Walking down the spiral staircase versus jumping off of it

"My blood sugar doesn't like to be less than (200-250) so don't give me that damned insulin!"

Have you ever met that patient? The one who fusses when you get their blood sugar "too low"??

Here is how I teach to that:

First, I have visual printouts of what the symptoms look like for Hyperglycemia (high blood sugar) and Hypoglycemia (low blood sugar). Patients benefit from pictures, not words. I set something like this on the table.

"Here is the deal. Your body likes this state we call "homeostasis." In a nutshell, it means your body wants to be at all times. Sameness. If one thing moves - other things have to move too" I draw this on the whiteboard:

What that looks like: (Pointing to the hyperglycemia chart) "Your blood sugar begins to rise and other systems compensate to keep adapt. Around sugars of 250, your body starts pulling water from here there and everywhere to push that sugar off by your kidneys. You get thirsty, you might be peeing all the time, you may be constantly hungry or you may be tired all the time and feel like you just can't get stuff done."

Patient agrees or disagrees with these statements. I adapt my approach to the ones they identify. 

"Also, you can have trouble seeing things and you might have a small wound that just won't heal - or worse yet gets infected like crazy! Why? Because bacteria like to eat sugar so your body is like Daytona Beach during Spring Break!"

Patient usually laughs - then becomes a bit uncomfortable.

"You didn't get this way over night. You aren't going to have "normal" blood sugars overnight either. We need to walk your blood sugar down, like walking down a spiral staircase to a less dangerous level of blood sugar."

Patient may argue about how their body doesn't like below ___ blood sugar. 

What are we worried about? (Pointing to the hypoglycemia chart) "Your body has gotten USED TO these blood sugars. If we immediately try to bring you down to "normal" your body doesn't have time to adjust. You will have the SYMPTOMS of low blood sugar, even though your blood sugar IS NOT LOW. So, when you hit 250 (down from 500) you feel like crap! You're shaking, your heart is beating, maybe you are sweating and you feel like you're going to fall out. You are starving and ready to chew off your own arm, you have a headache and you are ready to kill the first person who looks sideways at you. Sound familiar?"

Generally the patient is nodding emphatically.

"Well, this is not ACTUALLY hypoglycemia - but it feels that way. If your blood sugar was...say...under 100 - I'd be getting you a full meal together. If your blood sugar is, say 250 and you feel like this - I'd say you are not in immediate danger - but I also know you still feel like crap. For that, I'd get you a small snack, to help you feel better, but not to jack your blood sugar right back up through the roof."

A glimmer of understanding begins to fuel itself. 

So, think about bringing your blood sugar like walking down a spiral staircase. We want to take it one step at a time. You would feel a lot better walking down that staircase, than jumping off of it - wouldn't you?

Planning the new diabetic regimen begins. 

PS: If any of this works for you - please use it! The talk about homeostasis and "feeling" crummy when we overshoot our mark can be adapted to talking to a patient about their hypertension medications as well. 

Why you want to work with the most difficult patient on the unit

I talked about the concept of "othering" and how I would work with this as a nurse or charge nurse on a unit to tighten our team and help us all work together better. The same concepts are true when I apply them to the patients.

First of all, think about the following two questions:

What does the "other"do poorly?

What does the "other" do well? 

Find me a "familiar face" or "frequent flier" and please - oh please - let them be a loud troublemaker! These are so frequently our folks who are misunderstood. Of course, the more loud someone gets, the more I wonder about their underlying motivation, but I usually assume it is some sort of fear. When this loudness is in process, be quiet, listen. You are looking for subtext. Hear the fear, worry, frustration or motivation.

When I hear the subtext, personally, I often find myself tell them how much it sucks or how difficult this all must be. I don't have to agree with them. I don't have to feel that way. I often know I wouldn't necessarily have reacted that way. I just have to hear how they feel at this moment that brought them to this place, and they need to feel that I hear them.

I operate on the precept that when someone is mad 1) you aren't teaching them anything and 2) they can only rage for so long. Acknowledging how difficult this can be for them shifts gears or at least puts their transmission in neutral. This is a great place to be. In neutral, they may need some more time to vent - but you are helping the patient feel heard. The more they feel heard, the more they'll be more likely to tell you the worries on their mind. Don't be surprised if it does or does not perfectly fit your clinical scenario or what you are trying to accomplish - humans aren't always rational but you have to hear this if you want to cease the disruptive behavior.

Next helpful hint: If you really want to de-escalate this quickly, you have to let someone have an easy way to escape the corner they've backed themselves into. A scared, worried, frustrated person can make a real ass of themselves. They can say some nasty stuff. Once they are less screamy and more listeny, my response goes something like this:

"Hey, you were just having a MOMENT. It doesn't define you. This is all pretty stressful and you were upset. Everyone has a MOMENT, including me at times. We're past it now. I don't take it personal. Now let's try to do something that gets us where you are trying to go."

Then I focus helping develop a mutual plan of action. Why? They are engaged and they are open to what we are doing and need to do. I am pretty candid about what we can't do too. Patients don't hear the limits of our treatments, systems or facilities enough, then clinicians wonder why the patients have these unrealistic expectations.  This candid explanation of the limits of the system helps patients be more reasonable - more patient.


Bonus skill: 
Once you learn to speak to what someone does well and what they do poorly you can improve your game with your patients who are as sweet as pie. Why? because pleasant demeanor merely means they haven't gotten sideways of you or everyone else. It does not mean they are having their needs met. They still may not have revealed their fears or frustrations to you. I have learned that actively seeking my patients strengths and weaknesses helps me prepare them in ways that set them up for success and not failure (e.g. no unexpected re-admits).

If you can't say something nice about someone, then you're not done looking

‪On a floor of nursing staff, there will be personalities who conflict. It is not good for the patients or the staff. 

I wanted people to tell me what frustrated them (their barriers). Their feelings about this are real and need to be acknowledged. Often they would tell me something about a coworker that “drove them crazy." I would respond, "Ok, I know what they suck at, now tell me what they do well?" Rarely could they answer it. 

I would point out, this was a skill I had to learn myself but it was very useful. I'll admit, some days it was tough for me to find something nice about someone. I think there is value in having a place to admit that too.  At that point, I could suggest something minor that the "other person" could do well. No matter how minor the good thing was, my hope was it would be undeniable - even for the person complaining. Then I say, "If you can't say something nice about someone, then you are not done looking." 

My challenge to find more is because I've learned there is always more. I promise them if we know what they do well AND what they do poorly, then we can forge a more functional work day with them because we all can play to each others strengths and weaknesses.

I say all this because our team functioned more and more seamlessly on the floor after we all began to practice at this. It gave me some pride to hear the snarkiest of nurses asking another nurse "so, tell me what they do well?" from around the corner. 

This applies to your most difficult of patients. Find out what they do well and what they do poorly. Similarly, for your "sweet as pie" patients, you may find out what they do poorly and also reaffirm what they do well. I have found out this assessment of others resulted in more prepared discharges (read - reduced risk of unplanned re-admit). This whole exercise is one of assessment, and of meeting needs - plus it makes the workday suck less.