The 'NO' Man

It seems I have a new nickname at work.  A few nurses have been jokingly calling me this for awhile, but I actually heard our physician say this to me just a couple days ago.  I am evidently now known as...

The 'NO' Man.

I know from this and my blog that a 'NO' Man could be quite the funny.  But no, they don't know anything about Caitlyn or my femme proclivities.  No, what they're referring to is my capability to look a patient in the eye and simply tell him No.

Can I have some Tylenol?  No.  Can I have a bottom bunk detail?  No.  Can I have a base unit detail?  No.  Can I get some softer shoes?  No.  Can I see the doctor?  No.  Can I not be charged for this visit?  No.  Can I see a different nurse?  No.

No.

It's really quite simple to say, especially when it's not coming from a point of malice.  And I honestly don't work from a point of malice.  I don't want to hurt anybody or piss anybody off or not provide someone with medical care.  But I saw a facebook meme recently that seems to fit my work persona quite righteously:

In case you aren't aware, I'm a Registered Nurse in a prison.  All of my patients are convicted felons or parole violators (which just means they're convicted felons who got to go home early, but couldn't live by their new rules).  The general assumption for nurses in my position is that we're bad nurses and even bad people.  That we don't care for our patients and try to make them hurt as much as possible.  The truth is far more complex than that.  Note that I'm not saying those assumptions are entirely false.

There's several way that correctional nurses get that reputation.  Sometimes we get jaded.  I haven't been in this career long enough for that to be true for me, but I've seen it in some nurses.  They believe, at least on some level that their job is to make life miserable for the inmate's they're treating.  Or at the very least to deny them as much care as possible without causing more harm.  Another way is that it's difficult to be a correctional nurse.  It's nowhere near an ideal working environment and many well qualified nurses simply can't do it.  The department I work for currently has about a 20% job vacancy rate.  We need dozens if not hundreds of nurses.  Sadly that means nurses who aren't the best people will get hired because they meet the minimal legal standards.  And then there's the reason that I could be considered a bad person/nurse..... liars.

My patients lie.  Not all of them and not all the time, but that just pisses us off even more.  They lie for all manner of reasons including a desire for drugs, a desire for treatments they don't seek while on the outside, a desire for a 'vacation' (a trip to the emergency room is a vacation when your everyday life is inside a prison), or even just a very human desire for attention and compassion.  Instead of simply providing healthcare to my patients I first have to assess them to see if they're telling the truth.  I get lied to so often that it's more likely that the person in front of me IS lying rather than telling the truth.

And let me tell you, no where in the training and education I or anybody else gets as a nurse readies us to NOT treat someone who believes they need treatment.  You hurt?  I want to make that pain go away.  You feel sick?  I want to make you feel better.  You fear for your safety or life?  I want to protect you.  Many inmates know damned well that that's a nurse's default position and they take advantage of us.  So I and my colleagues have to be constantly on guard to protect ourselves from these liars.  You hurt?  But do you REALLY hurt?  You feel sick?  Do you REALLY feel sick?  You fear for your safety or life?  Do you REALLY fear for those things?

It's not easy.  I think it qualifies as difficult.  As hard.

But evidently I'm good at it.  You see, it's easy to just say yes all the time.  Give appointments to the doctor or give Tylenol or give permission to not work or send them to the ER or let them come up to the clinic whenever they want.  But that's not doing our entire job.  Yes, we're nurses and provide healthcare, but we're also employees of the Department of Corrections and everybody's job there is to show inmates what good citizens act like.  And good citizens don't lie and cheat to get what they want so we shouldn't let them lie and cheat to us.  It's just as easy to say no all the time.  There are several nurses that I work with that can say no with the best of them... but they tend to lean heavily on the 'no is always the answer' side of the equation.  I try my very best to stay grounded in the middle of that same equation.  No, when it's appropriate to be no.  Yes, when it's appropriate to be yes.

It takes a lot of assessing.  I don't simply assume they are telling me the truth and I don't simply assume they are lying.  I have to do a full assessment to see what treatment is appropriate and then give that and only that treatment.

The asshole part comes in with the liars.  I'm not an asshole, I just irritate assholes.  A perfect example of my 'specialty' came in yesterday at work.  We have several 'magic words' that the inmates can say that earn immediate attention.  One of them is 'Chest Pain'. If they complain about having chest pain we MUST bring them to the clinic and assess them for cardiac or pulmonary problems.  So an inmate told that to an officer and the officer called us.  I and another nurse took the wheelchair down to the unit and picked him up.  We brought him to the clinic.... and all he wanted to talk about was the pain in his neck.  This is a condition that he's seen nursing about four or five times and seen the medical provider about twice (that's all in just three weeks).  I was the second nurse on that trip so once he got to the clinic I stood back and let the other nurse take him in for his assessment.  That other nurse took the easy route and let the inmate talk to him about his neck pain, gave him some Tylenol and an appointment with the medical provider on Monday.

Now I have no problem with the nurse giving the inmate treatment for his neck pain condition.  As a nurse I don't ignore pain.  But any cry of pain doesn't immediately mean I have to rush him off to the ER to get some morphine or dilaudid.  I assess the pain.  In this case, the inmate showed no objective signs of pain.  He could stand up, he could move his neck without facial grimace, he wasn't using any guarding behavior, he winced inconsistently to physical assessment, he favored moving his neck in one direction but only when under direct observation (he moved his neck freely when he thought he wasn't being watched), he was breathing easy, his vital signs were all in the normal range, and he was speaking clearly and in full sentences.  He may well be in pain, but it's not major pain and like anybody with pain can be treated with over the counter medication and be given an appointment with the medical provider.  Plus in addition to all of that assessment is the history that he's been seen many times for this issue and has been assessed by the medical provider as not requiring further treatment.  So again, the treatment plan that the other nurse gave him was appropriate.

But he lied about the chest pain to get in to see us for free.  You see, the inmates don't pay for medical treatment.  If they need blood pressure medications every single day they are incarcerated, they get that at no cost.  They don't pay to see the medical provider, they don't pay for physical therapy, they don't pay for surgery.  Even I, with my good health insurance, have a co-pay for my medications in addition to paying for the insurance and the doctor's visit and the deductibles.  The ONLY payment for medical service inmate's can incur is for requesting medical service.  If an inmate is feeling sick, he puts in a request for healthcare form (oddly enough called a KITE).  That kite gets him an appointment with a nurse who assesses him and either treats him or gets him an appointment with a medical provider (sometimes I can get the medical provider to come in right at that moment, other times it waits for a day).  That appointment with the nurse costs five dollars.  $5.

Understand, that's the only cost.  So you see the nurse and get charged $5.  The nurse sends you to the doctor and that costs nothing.  The doctor sends you to get an X Ray and that costs nothing.  The X Ray comes back as a broken bone so you get a cast that costs you nothing.  The cast comes off and you didn't heal correctly so you get physical therapy and that costs you nothing.  The PT doesn't help so you go in for surgery and that costs you nothing.  Nothing for the pain medications, nothing for the post surgical care, no cost for all the required follow up appointments.  All of that treatment just cost $5 for the initial appointment.

And the whole reason we have that cost is to act as a deterrent.   If an inmate gets tired of being in his cell (and really, who wouldn't get tired of that!) it might be nice to get an appointment with a nurse in the nice air conditioned medical clinic.  It's worth it if there's no cost to it, but if it costs $5 you might not want to waste the money.  And before you even think about them only making a few dollars a week or think about the people who can't work and don't have money, understand that there are indigent funds for those without money that can be spent on healthcare.

So the guy that lied about the chest pain all so he could be seen about his ongoing and already treated neck pain?  He lied about it so that he wouldn't get charged the $5.  That's where I would have differed from the other nurse.  I would have assessed him for cardiac problems, reported to the medical provider his complaint and my recommendation (give him some Tylenol and send him back to the unit), and then told him point blank to put in a kite for his neck pain concerns.  The inmate would have been upset (his plan would have just failed... and yes it WAS a plan) but I would have sat there calmly and told him over and over that he could have a full appointment for his neck pain concerns but only after putting in a request to be seen for it.

I'm the 'No' Man.

Some of the nurses are so aware of this fact that they are now directing patients to me.  "Oh that's Mr Smith and he's probably lying about his (insert fake medical problem here), go ahead and give him to Calvin".  And now the medical providers are getting in on that action.  I haven't heard it directly but I can imagine it clearly... "Give him a follow up appointment with a nurse in three days, but make sure he sees Calvin."

I'm the 'No' Man.

I'm even getting it on another level now.  One thing an inmate can do if he believes he is being denied medical care is put in a Grievance.  A Grievance is the beginning of the legal process.  The first step is to be heard by a medical professional who will then see if his complaint is a legitimate one.  That's normally the job of the nursing supervisor.  The nursing supervisor talks to them, tries to understand what their complaint is, and then tries to explain how it isn't a legitimate complaint or fix the problem.  If they can't fix it and believe it to be an illegitimate complaint and the inmate won't sign off on it the grievance moves up to the health unit manger.  Well, my nursing supervisor is getting behind in her duties and both she and the health unit manger know I have my eye on being a supervisor one day... so now I'm getting to answer some of the grievances.  I say some because I can't answer grievances that involve my own care... and it turns out as the 'NO Man I get quite a few grievances filed against me.

<sigh>

Anyway, I now get to be the 'No' Man to an inmate who has already seen a nurse who already told them No.  I guess if I'm going to continue the naming structure, I'm now becoming the 'NoNo' Man?

I have a catch phrase.  I guess all named heroes should have one.

Mine is 'GetTheFuckOutOfMyClinic'.

It's said fast and with an angry lilt to my voice.  It's never said to the inmates... that's both rude and unprofessional and as someone who respects himself and the work he does, I won't lower myself to that level.  But I DO say it in joking with my fellow nurses.  When I say it, it's my shorthand way of saying I saw through an inmate's lie and told him calmly and cooly that he was not going to receive treatment for his supposed ailment and that he would have to kite if he would like to be seen again about it or wait until his next appointment with the medical provider.

But while the nurses applaud my ability to both give good and appopriate care while also stopping bullshit complaints... while the medical providers are jumping on the bandwagon and seem to be giving me the same accolades.... it's hard.  It's not easy to be right on the center of that line all the time.  It would be so easy to just give in and give the little bit of treatment I can and not argue with them.  It would be so easy to just give an appointment to the medical provider to any bullshit complaint that I no longer want to deal with.  It would be just as easy to literally tell them to GetTheFuckOutOfMyClinic.  NOT doing those things is giving me more stress than I'm able to handle on a day to day basis.  More often than not I'm getting home and not able to do anything else.  I just veg out in front of the TV as I try to shut off.  By the time I feel my shoulders relax and my back grow mobile again... it's bed time.  It's time to get a few hours of sleep and then start the process over again.  I can't log on to D+X.  I can't play a game.  I can't come here and share the good parts of my day.

I'm the 'No' Man.

And evidently the 'No Man doesn't get to do those things.