Two years ago, I went through the UCSF MEPN interview. It scared me silly and so I prepared for it in a variety of ways. Here are some ideas; my "brain storm", or more appropriately stated: "brain fart".
My understanding is that this year in the UCSF MEPN interview, y'all are doing a panel interview with a couple of interviewers. One will represent your specialty and will have a slightly more academic/administrative slant to their perspective. The other interviewer will be a clinical nurse and, logically, will be more concerned with clinical/bedside nursing than the advanced practice degree specialty. The panel interview differs than in years past, when we interviewed with the same people, but in two separate interviews. In any any event, these are, by and large, the questions you will be asked. My answers are there too, but clearly you shouldn't copy those.
INTERVIEW PREPARATION
Questions
• Why do you want to be a nurse?
• Why do you want to do critical care/trauma?
• How will you handle the stress?
• What do you think will be the most difficult thing about being a nurse?
• How do you intend on using your specialty in 5 & 10 years?
• Why not medical school?
• How will you prioritize your day?
• How will you know when you are being a good nurse?
• Give an example of a difficult/high stakes decision you’ve had to make and describe the thought process you went through
• Describe an ethical conflict that you’ve gone through
• Describe a frustrating experience at work and how you dealt with it
• Why no pediatric nursing?
• Describe your strengths and weaknesses.
Answers
-Q: Why do you want to be a nurse?
-A: Fundamentally I want to be able to help people—that’s a part of who I am. I’ve always worked with at risk or marginalized youth in a variety of settings because I feel it is the most necessary and practical work that can be done. In the same vein, I feel that in helping people, it is important to know how to treat the physical as well as the psychological, especially since the two are extensions of the same being. In my obsession with practical care, I realized that it was important for me to know how to care for the whole person, not just the mental aspects of care.
Furthermore, I have always worked in and around youth that are in crisis. The students at ___ and residents at _______were extremely violent and verbally abusive because of their past histories and troubles with their families. I thought it was extremely necessary to work with type of person because they absolutely needed some outside help to resolve some of their psychological issues. Sometimes that was as simple as having their meals prepared for them in a consistent manner. Often it involved de-escalating a child that was highly emotionally reactive.
Often, an emergency would take place where someone was injured and I wouldn’t have the knowledge to care for the people. That bothered me: not being of direct use in an emergency situation. So I started volunteering a year ago at _______ Emergency Department in order to see if the crisis management skills were at all applicable to working in the ED. I found that they were. Youth going through emotional crises are fundamentally similar to people going through a physical crisis—they just need several types of care within both the psychological and physical realms. I have been assigned to act as an information liaison in the ED at ______ where I announce my presence at the beginning of every shift to the patients and families that are waiting in the ED to see if I can be of use to them. Many patients will have been there for 3+ hours, so waiting time is often a concern and many people will be quite reactive to not having been taken care of within the time frame that they see fit. Maintaining a calm, consistent, and honest presence is of the essence in dealing with these situations. Occasionally I can use humor, but not until I have established professional rapport with the people in the ED.
Beyond the desire to help folks when they need it most, I also really enjoy the technical knowledge of nursing. I love to think systemically about patients and what is ailing them while I work in the ED. Using my basic knowledge of Anatomy, Physiology, and Chemistry I steal glances at charts, EKGs, x-rays, blood pressure readings, lab reports and CT scans and try to think critically about all the elements that are contributing to a persons illness. I like to ask a ton of questions to the RNs and MDs—especially about pharmacology, which I find fascinating.
Nurses in the ED have so much autonomy to care for the patients and they are always thinking on their feet and problem solving at all hours of the night. I like the challenge—the constant challenge of thinking about things that will help someone heal.
I also love the way nurses learn: it’s like an apprenticeship where clinical experience trumps all academic experience. Often times nursing is super physical and mechanical and demands refined expertise.
-Q: How will you handle the stress?
-A: I will handle it in that I am actively involved with how I experience stress. Some people appear to be impermeable to stressful situations. I don’t believe I am one of them. I get tired, irritable and my decision-making skills can become compromised unless I take consistent inventory of how I am experiencing stress. During a stressful situation I am usually so ensconced in working the problem that I am hardly aware of how I am physically feeling. Then, once home the fatigue and irritability sets in.
Techniques that I’ve learned to handle stress are
(1) Go running everyday
(2) Ask for help: Recognize that I am not the only person in the situation and that I can rely on others. I am extremely independent so this is often difficult for me.
(3) Take a break
(4) Eat all the time. I am somewhat hypoglycemic, so being aware of that is helpful.
(5) Breathe
(6) Honest with myself and others. Being clear and straightforward lets people know what expectations are and therefore doesn’t allow for unrealistic expectations to put added pressure on me.
-Q: What do you think the most difficult thing about being a nurse will be?
-A: I feel that the most difficult thing about being a nurse will be overcoming the inevitable process of habituation to the routine—and the “hardened” perspective that goes along with habituation. In working at the school for severely emotionally disturbed youth, I found that after about a year, I started to become too accustomed to being there and would, on occasion, let the routine take over rather than being actively involved with my students. This occurrence would make me a less aware/less perceptive/less skilled teacher. I think the same thing could happen in working with patients—I might become accustomed to being there and therefore less sympathetic and less aware of their plight. I think it is incredibly important to keep your assessment abilities sharp and acute no matter how long one has been there.
-Q: How will you know when you are being a good nurse?
-A: I’m pretty realistic about people’s behavior. I learned to have realistic expectations from working with SED youth. Frequently, I would be celebrating Ds and Cs and the fact that a student wouldn’t hit someone that week. It’s not that I’ve lowered my expectations—I want for them to be really successful and get As and be all that they can be. It’s just that I have realized that it is important to have realistic expectations. Being what they have gone through, it’s sometimes a miracle that they wanted to wake up. I have realistic expectations for patients that are in crisis and people in general. More often than not, people let you know when they are unhappy but will not let you know when they are content. Thus, if all of my patients are being quiet, it’s most likely that I am doing a good job. I’ll still be doing my rounds if they are quiet though.
-Q: Describe a frustrating experience at work and how you dealt with it
-A: Too personal, can you believe it???
-Q: How do you intend on using your specialty in 5 & 10 years?
-A: Upon graduating from UCSF with an advanced practice degree in nursing, my immediate plan is to gain outstanding clinical experience—humbling myself to the people that have knowledge and experience within the field and carry themselves with professionalism and a well-adjusted attitude. I plan on letting my clinical experiences be my guide as far as specialization in treatment. I am particularly interested in diagnosing internal injuries with non-specific symptoms, myocardial infarction, and severe wound management. Once I can gain enough expertise in an area of special interest, I would like to be a consultant in an ED/ICU for other nurses. Once I have tried my hand at teaching other nurses in a clinical setting, I would like to seriously consider getting my PhD in nursing and teaching clinical rotations within a nursing school such as UCSF. I could also very well wee myself working as a consultant in order to write legislation that would effect bills that would change health care. It’s up in the air in many respects, but my dedication and focus and quest for answers is second to none.
-Q: Give an example of a difficult/high stakes decision you’ve had to make and describe the thought process you went through
-A: There are two types of high stakes decisions: (1) those that require “from the gut” type decisions because there is some sort of emergency, or (2) those that give you a little leeway in terms of time.
If a decision requires an immediate response, I am not someone who sits back and does nothing. That’s part of the reason that I want to learn critical care/trauma nursing so that I can be of use in an emergency. An example of a time when I had to make a quick, high stakes decision is when: AC caught on fire, I heard it, nobody responded so I evacuated the house.
When a high stakes, life changing decision allows for a little time, I do research and talk to members of my “team”: my wife, my brother, my Mom & Dad, my friends, and my co-workers. Two high stakes decisions that I’ve had to make are (1) getting married, and (2) deciding to become a nurse. In deciding to become a nurse, I wanted to be sure that I knew what I was getting myself into, so I started voluntering weekly at ________ from 9-midnight so I could look before I leapt. There I observed, investigated, and absorbed as much as possible. I also spoke with my wife, to see if she would support the decision. Being that she is in law school and I was the primary earner in the household
Questions for her:
How did you get into nursing? Why? What is your specialization?
Do you do more administrative work than clinical work? Do you miss clinical work?
Strengths
-Moral: I believe in making the right decisions
-Honest:
-Work Ethic: second to none.
-caring & dutiful: I feel it is important to take care of people and feel that it is my duty to do so.
-perceptive: I enjoy observing situations and seeing nuances of behavior that give me insight as to how to deal with people.
-always willing to challenge myself: I like running up hills.
-independent: always thinking for myself and not within groupthink—allows me to be more objective.
Weaknesses
-rigid: Somewhat rigid when setting goals and pursuing them: difficult time shifting gears—result of me being a perfectionist.
-judgmental: used to making a lot of quick, split decision judgments in order to take care of people—this can affect how I treat people.
-too independent—sometimes have a hard time working with others.
-too dutiful: sometimes don’t take time for myself.
Showing posts with label UCSF. Show all posts
Showing posts with label UCSF. Show all posts
Wednesday, January 7, 2009
Thursday, November 6, 2008
New Nurse Insanity
REFLECING ON: Why working as a new RN is nuts on my floor. I can't believe a year ago I was a student.
I've been remiss in writing because, well, I've been absolutely going bonkers (in a good way) since getting hired as a new nurse on a cardiothoracic floor/telemetry unity. What's that mean? It means I get patients that are so sick that we monitor their heart and oxygenation 24/7. It means that our patients are WICKED unstable: recent/ongoing heart attacks/unstable angina, unstable heart rhythms (including V-Tach/Rapid uncontrolled A-Fib, heart block, and pacemakers), heart transplants, lung transplants, double heart/lung transplants, profound vascular disease requiring amputation, and a general hodge podge of rare diseases that academic hospitals get sent because nobody else has the resources to treat them. People code on my floor. We send a lot of folks to the ICU. We get a lot of folks from the ICU. I work 3 12-hour shifts a week, which I realize initially sounds pretty cush, but when you see the actual schedule and do the actual work, it's more like a 16-hour day of non-stop running. Here's my day:
*0400:
-Wake up and stumble to coffee maker.
*0430:
-Become conscious, realize have clothes on; don't remember dressing. "Neat", I think, "I'm efficient even when I'm semi-conscious." Double check that I have stethoscope, ID, PALM, a couple of power bars. Double check that I actually have pants on. Kiss wife. She murmurs through morning breath that she loves me. I tuck her in again and make sure her alarm is set for 0500. She will get up as I leave to study for the BAR. I want a day off. "It's okay", I remind myself, "I love my job."
*0430-0500:
-Review lab values/pharm/diseases that I've never heard before but nonetheless will be required to manage and speak intelligently on to patients, their families, fellow nurses, MDs (R1-R3, and maybe an attending), RTs, OTs, PTs, PCAs, PSAs, radiologists, and of course, my boss and nursing students. I drink a Liter of protein-shake straight from the blender while doing this.
*0500-0545 :
-Drive to SF, find parking in one of the neighborhoods around the hospital that ISN'T 2-hour, so that I can save $20. Remind myself that the 15 minute walk to the hospital is worth it. I may be finally making a paycheck, but I also remind myself that I'm still $75,000 in school debt.
*0545-0600:
-Walk to hospital, listen to iPod, consider second cup of coffee and perhaps going to Mexico where ephedrine is still legal (kidding). Try to breathe. Get semi-religious and pray a bit. The prayer is always the same: "Please Gods (I pray to all of them to cover my bases), give me the strength to act in the best interests of my patients. Allow me to act decisively when I know and ALWAYS seek help when I don't. Keep me and my team safe. Thank you. Word. One love. Amen." I breathe in fresh air one last time before entering into the hospital. It is usually smoky because the entrance is next to the smoking shelter.
*0600:
-Arrive on hospital unit and sympathize with my night shift homies. They all are bug-eyed and slightly delirious. They openly wonder why the hell I'm there so early. They then get scared and start doing what they need to do before end of the shift. They don't understand why I am so early. I've been an hour early every shift since Janurary when I was a student on this floor. I am still early after working for 3 months. I don't intend on changing. This is my way. Don't knock it.
"No, but seriously, Nat, why?", they ask.
"This is what I do, don't worry about it and dismiss me as nuts", I say.
-I need to catch up on my patients and read new admission histories. I get to the computer and start reading about my assignment. (I am going to write the hospital jargon abbreviations next to the common ones so you can learn to interpret medical-ease) I review the assignment. It's heavy. I look at other folks assignments. They're all heavy. Okay, here we go:
-Patient (Pt.) #1: 47 year old (yo) female, status post (s/p) lung transplant (lung tx) 2/2 pulmonary fibrosis (PF) presenting with (p/w) shortness of breath (SOB)/wheezing/Chest Pain (CP) secondary to (2/2) Cytomegalovirus (CMV) infection. Right upper lobe (RUL) has SERIOUS wheezing. Pt. refuses oxygenation because prior to her tx, she was on a high flow mask that covered her face for 6 months while she was waiting for the lungs. @ 0900 she will be receiving a $35,000/dose immunoglobulin (Ig) that I will eventually have to do battle with pharmacy to get in on time, and then figure out how to administer because even veteran RNs have only given it once in their careers. I pray I don't drop the bottle. Later, after successfully administering it, I kid the patient and tell her that she is $35,000 richer. She laughs and thanks god for health insurance. I think of folks that don't have it. I then call pharmacist and kid that I dropped the bottle. Pharmacist takes me seriously. I let moments of awkward tense silence pass on the phone, and then admit I am joking. "That was REALLY not funny", she groans. On paper this is my least stable patient, but in reality, is my most stable patient because she knows SO much about her own treatment. I listen to her and try to coordinate appointments and medication administration around her work, which she still manages to do from her hospital room. She had had 7 hospitalization in the last 11 months, some lasting more than 2 months.
-Patient #2: 80 y.o. male s/p right lower lobe lobectomy (RLL lobectomy) 2/2 adenocarcinoma metastasis. Right Chest Tube (CT) in place draining 10 mL of serosanguinous (SS) fluid/12 hours. She's post-operation day (POD) #3. CT will probably be pulled today. Pt. also has history of (h/0) going into rapid uncontrolled atrial-fibrilation (A-FIB) (HR 180s) and becoming hemodynamically unstable (BPs: 70s-140s/40s-100s). This is in the context of NO prior cardiac history. Apparently when you mess with the bull (lungs) you get the horns (heart). The heart does not like major surgery anywhere near it. According to the literature, the heart will sometimes become irritated in 30% of thoracic surgery patients and convert from Normal sinus Rhythm (NSR) to A-Fib. Basically the heart decides to suddenly do the mambo and not pump blood so efficiently. Pain management and oxygenation are MAJOR issues with this patient because she's never NOT in pain. Epidural (pain medication that infuses directly into space around spine) has just been stopped. Nervous family watching my EVERY move. I learn to earn their trust by effectively managing her hemodynamic instability with fluid boluses and IV metoprolol. I learned that from my preceptor, Bill. He is not there today, but I remember hanging on his every word through the 10 weeks of orientation. I quietly think to myself, "I wish I still had a preceptor." Nope. Time to "nurse" up.
-Patient #3: 27 y.o. male p/w elevated troponins (heart muscle fibers) that indicate he's had a myocardial infarction (MI) 2/2 methamphetamine use. Pt. p/w CP and assaultive/aggresive behavior that requires restraints in the Emergency Department (ED). Pt. also in complete congestive heart failure (CHF) 2/2 profound substance abuse (SU). Pt. continues to be actively psychotic and later, we learn, has escaped from a lock-down psych facility after being brought in on 5150 hold for assaulting folks in the streets. Pt. complains of (c/0) dragons outside room. Pt. will eventually take off his cardiac monitor, insist we are sucking his soul away through the wires and inform me that despite the fact that I am good, that I am "dying" in my eyes. I must look tired. Good rapport established, he begins to trust me but will eventually rip out his own IV, shoot blood all over the floor, and begin sucking his own blood out. Before the day is through, he will also assault a secure officer with an ice-cream sandwich, try to escape multiple times, and require an amazing amount of anti-psychotic medication (seroquel, thorazine, ativan) before taking a nap. Because the patient trusts me, he takes medication by mouth (PO) but refuses another IV, which he also told me was sucking away his soul. I will have to monitor for extrapyramidal side effects (EPS--abnormal motor/neurological movement), neuroleptic malignant syndrome (NMS-sudden reaction/fever to some psych meds), and oversedation AND be extremely concerned about the condition of his heart. Pt. will eventually be restrained for assaulting another security guard. This time with his dinner tray.
-Patient #4. 56 yo male p/w increasing SOB and CP 2/2 CHF 2/2 genetic dilated cardiomyopathy (DCM). He will be initiated on a dobutamine drip that will keep his heart pumping until he can get a transplant. Dobutamine is calculated to the microgram and requires some serious attention when you've never managed before. I've only studied about it for the NCLEX and in my patho class with Pam ("let's get it started"), my favorite nurisng professor. I'm glad I studied so hard for the NCLEX. I'm even "gladder" I have time to read about how to administer this drug before giving it, monitor for side effects, and initiate proper hospital monitoring policy/protocol for this patient. This amounts to HELLA paperwork. Glad I arrived an hour early.
*0700-0730:
-Take report from night shift. Quietly wonder if this is manageable. Update resource nurse about my patients and who will be "heavy". I kind of think they're all heavy.
*0730-1900
-Run my ASS off managing everything from hypochondrical family members to a patient crashing and almost needing to go to ICU. Frequent re-assessment for patients 1-4 because, well, they are not all that stable. Throw in a smattering of moody sleep-deprived residents and helpful residents. Everything is a blur and every monitor is beeping, calling my name for attention and assessment. My work cell-phone rings off the hook. I wash my hands at least 200 times. I try to be calm when 25% of my medications aren't available because pharmacy is backed up. I make friends with the pharmacist so that I can get things on-time for the rest of the day. I remind myself not to give patient #3 any more ice-cream sandwiches. I occasionally wonder how I am managing to not go insane as this actively psychotic patient. I call in support from veteran nurses but frequently realize that I need to act decisively and independently so as not to burden them from taking care of their own patients. Then the $35,000 medication comes and I need to administer it immediately. That's when Pt.#2 almost crashes. I am suddenly and inexplicably less overwhelmed right now because I know the crashing patient takes priority. I am now doing one thing and not a million things. I hand the $35,000 medication to the resource nurse and ask her, "Can you find out how to give this? I'll be right back (white lie), I need to call rapid response (team of nurses that respond to REALLY unstable patients)". Pt.#2 become stable after an hour of work. I am now REALLY behind. I become overwhelmed at one point because 2 pages of orders suddenly appeared in the chart that weren't there a minute ago. The orders were back-timed by a sneaky MD to read as if they were written @ 0800 and it is currently 1000 so I look like I neglected to execute important orders. Talk to resident about not doing that again. A different, helpful resident (R3 no less) gets excited about doing a Guiac Test on pt. #1 that now has been diagnosed with a upper gastrointestinal UGI bleed. I am happy to delegate a poop test to an excited doctor. I kind of love him for that. Now reader, I urge you, to never breathe deeply while handling melena (look it up and you will know it's definition: black, bloody, tarry poo. Smell it once and you will never be the same).
-At one point I will have to change my scrubs because, while helping a colleague, explosive diarrhea covers my scrubs, and I need to change. There's no washing this out. We call it a "code brown". After disgusting some folks on the elevator, and getting a new pair of scrubs from the basement, I take this opportunity to eat a power bar. After changing of course. And washing my hands for the 300th time. I get back to the patients and more of the same onslaught ensues. Constant reorganization and re-prioritization. Somehow it's all getting done. Thank GOD for the team. Blur. Blur. Triple Blur. I look up and it's almost time to go. I should probably chart more than vitals. Damn. I've got a half hour.
*1930
-Give report to newly refreshed night nurses. It is then that I remember that I didn't eat anything but the power bar or pee the whole day. After report, I then have the most satisfying pee of my whole life. It lasts an abnormally long time. I wonder if I've given myself prostitis or a UTI. Will find out next week.
*2000
-Leave hospital after tying up loose ends.
*2015
-Arrive @ car and assess whether I will fall asleep on way home. No.
*2045
-Arrive home and take a LONG shower.
*2115
-Wife now accepts kiss because she now is no longer concerned about poo/blood on me.
*2130-2200
-Catch up with wife while eating Cheerios.
*2201
-CRASH.
*0400
-Time to do it again.
I've been remiss in writing because, well, I've been absolutely going bonkers (in a good way) since getting hired as a new nurse on a cardiothoracic floor/telemetry unity. What's that mean? It means I get patients that are so sick that we monitor their heart and oxygenation 24/7. It means that our patients are WICKED unstable: recent/ongoing heart attacks/unstable angina, unstable heart rhythms (including V-Tach/Rapid uncontrolled A-Fib, heart block, and pacemakers), heart transplants, lung transplants, double heart/lung transplants, profound vascular disease requiring amputation, and a general hodge podge of rare diseases that academic hospitals get sent because nobody else has the resources to treat them. People code on my floor. We send a lot of folks to the ICU. We get a lot of folks from the ICU. I work 3 12-hour shifts a week, which I realize initially sounds pretty cush, but when you see the actual schedule and do the actual work, it's more like a 16-hour day of non-stop running. Here's my day:
*0400:
-Wake up and stumble to coffee maker.
*0430:
-Become conscious, realize have clothes on; don't remember dressing. "Neat", I think, "I'm efficient even when I'm semi-conscious." Double check that I have stethoscope, ID, PALM, a couple of power bars. Double check that I actually have pants on. Kiss wife. She murmurs through morning breath that she loves me. I tuck her in again and make sure her alarm is set for 0500. She will get up as I leave to study for the BAR. I want a day off. "It's okay", I remind myself, "I love my job."
*0430-0500:
-Review lab values/pharm/diseases that I've never heard before but nonetheless will be required to manage and speak intelligently on to patients, their families, fellow nurses, MDs (R1-R3, and maybe an attending), RTs, OTs, PTs, PCAs, PSAs, radiologists, and of course, my boss and nursing students. I drink a Liter of protein-shake straight from the blender while doing this.
*0500-0545 :
-Drive to SF, find parking in one of the neighborhoods around the hospital that ISN'T 2-hour, so that I can save $20. Remind myself that the 15 minute walk to the hospital is worth it. I may be finally making a paycheck, but I also remind myself that I'm still $75,000 in school debt.
*0545-0600:
-Walk to hospital, listen to iPod, consider second cup of coffee and perhaps going to Mexico where ephedrine is still legal (kidding). Try to breathe. Get semi-religious and pray a bit. The prayer is always the same: "Please Gods (I pray to all of them to cover my bases), give me the strength to act in the best interests of my patients. Allow me to act decisively when I know and ALWAYS seek help when I don't. Keep me and my team safe. Thank you. Word. One love. Amen." I breathe in fresh air one last time before entering into the hospital. It is usually smoky because the entrance is next to the smoking shelter.
*0600:
-Arrive on hospital unit and sympathize with my night shift homies. They all are bug-eyed and slightly delirious. They openly wonder why the hell I'm there so early. They then get scared and start doing what they need to do before end of the shift. They don't understand why I am so early. I've been an hour early every shift since Janurary when I was a student on this floor. I am still early after working for 3 months. I don't intend on changing. This is my way. Don't knock it.
"No, but seriously, Nat, why?", they ask.
"This is what I do, don't worry about it and dismiss me as nuts", I say.
-I need to catch up on my patients and read new admission histories. I get to the computer and start reading about my assignment. (I am going to write the hospital jargon abbreviations next to the common ones so you can learn to interpret medical-ease) I review the assignment. It's heavy. I look at other folks assignments. They're all heavy. Okay, here we go:
-Patient (Pt.) #1: 47 year old (yo) female, status post (s/p) lung transplant (lung tx) 2/2 pulmonary fibrosis (PF) presenting with (p/w) shortness of breath (SOB)/wheezing/Chest Pain (CP) secondary to (2/2) Cytomegalovirus (CMV) infection. Right upper lobe (RUL) has SERIOUS wheezing. Pt. refuses oxygenation because prior to her tx, she was on a high flow mask that covered her face for 6 months while she was waiting for the lungs. @ 0900 she will be receiving a $35,000/dose immunoglobulin (Ig) that I will eventually have to do battle with pharmacy to get in on time, and then figure out how to administer because even veteran RNs have only given it once in their careers. I pray I don't drop the bottle. Later, after successfully administering it, I kid the patient and tell her that she is $35,000 richer. She laughs and thanks god for health insurance. I think of folks that don't have it. I then call pharmacist and kid that I dropped the bottle. Pharmacist takes me seriously. I let moments of awkward tense silence pass on the phone, and then admit I am joking. "That was REALLY not funny", she groans. On paper this is my least stable patient, but in reality, is my most stable patient because she knows SO much about her own treatment. I listen to her and try to coordinate appointments and medication administration around her work, which she still manages to do from her hospital room. She had had 7 hospitalization in the last 11 months, some lasting more than 2 months.
-Patient #2: 80 y.o. male s/p right lower lobe lobectomy (RLL lobectomy) 2/2 adenocarcinoma metastasis. Right Chest Tube (CT) in place draining 10 mL of serosanguinous (SS) fluid/12 hours. She's post-operation day (POD) #3. CT will probably be pulled today. Pt. also has history of (h/0) going into rapid uncontrolled atrial-fibrilation (A-FIB) (HR 180s) and becoming hemodynamically unstable (BPs: 70s-140s/40s-100s). This is in the context of NO prior cardiac history. Apparently when you mess with the bull (lungs) you get the horns (heart). The heart does not like major surgery anywhere near it. According to the literature, the heart will sometimes become irritated in 30% of thoracic surgery patients and convert from Normal sinus Rhythm (NSR) to A-Fib. Basically the heart decides to suddenly do the mambo and not pump blood so efficiently. Pain management and oxygenation are MAJOR issues with this patient because she's never NOT in pain. Epidural (pain medication that infuses directly into space around spine) has just been stopped. Nervous family watching my EVERY move. I learn to earn their trust by effectively managing her hemodynamic instability with fluid boluses and IV metoprolol. I learned that from my preceptor, Bill. He is not there today, but I remember hanging on his every word through the 10 weeks of orientation. I quietly think to myself, "I wish I still had a preceptor." Nope. Time to "nurse" up.
-Patient #3: 27 y.o. male p/w elevated troponins (heart muscle fibers) that indicate he's had a myocardial infarction (MI) 2/2 methamphetamine use. Pt. p/w CP and assaultive/aggresive behavior that requires restraints in the Emergency Department (ED). Pt. also in complete congestive heart failure (CHF) 2/2 profound substance abuse (SU). Pt. continues to be actively psychotic and later, we learn, has escaped from a lock-down psych facility after being brought in on 5150 hold for assaulting folks in the streets. Pt. complains of (c/0) dragons outside room. Pt. will eventually take off his cardiac monitor, insist we are sucking his soul away through the wires and inform me that despite the fact that I am good, that I am "dying" in my eyes. I must look tired. Good rapport established, he begins to trust me but will eventually rip out his own IV, shoot blood all over the floor, and begin sucking his own blood out. Before the day is through, he will also assault a secure officer with an ice-cream sandwich, try to escape multiple times, and require an amazing amount of anti-psychotic medication (seroquel, thorazine, ativan) before taking a nap. Because the patient trusts me, he takes medication by mouth (PO) but refuses another IV, which he also told me was sucking away his soul. I will have to monitor for extrapyramidal side effects (EPS--abnormal motor/neurological movement), neuroleptic malignant syndrome (NMS-sudden reaction/fever to some psych meds), and oversedation AND be extremely concerned about the condition of his heart. Pt. will eventually be restrained for assaulting another security guard. This time with his dinner tray.
-Patient #4. 56 yo male p/w increasing SOB and CP 2/2 CHF 2/2 genetic dilated cardiomyopathy (DCM). He will be initiated on a dobutamine drip that will keep his heart pumping until he can get a transplant. Dobutamine is calculated to the microgram and requires some serious attention when you've never managed before. I've only studied about it for the NCLEX and in my patho class with Pam ("let's get it started"), my favorite nurisng professor. I'm glad I studied so hard for the NCLEX. I'm even "gladder" I have time to read about how to administer this drug before giving it, monitor for side effects, and initiate proper hospital monitoring policy/protocol for this patient. This amounts to HELLA paperwork. Glad I arrived an hour early.
*0700-0730:
-Take report from night shift. Quietly wonder if this is manageable. Update resource nurse about my patients and who will be "heavy". I kind of think they're all heavy.
*0730-1900
-Run my ASS off managing everything from hypochondrical family members to a patient crashing and almost needing to go to ICU. Frequent re-assessment for patients 1-4 because, well, they are not all that stable. Throw in a smattering of moody sleep-deprived residents and helpful residents. Everything is a blur and every monitor is beeping, calling my name for attention and assessment. My work cell-phone rings off the hook. I wash my hands at least 200 times. I try to be calm when 25% of my medications aren't available because pharmacy is backed up. I make friends with the pharmacist so that I can get things on-time for the rest of the day. I remind myself not to give patient #3 any more ice-cream sandwiches. I occasionally wonder how I am managing to not go insane as this actively psychotic patient. I call in support from veteran nurses but frequently realize that I need to act decisively and independently so as not to burden them from taking care of their own patients. Then the $35,000 medication comes and I need to administer it immediately. That's when Pt.#2 almost crashes. I am suddenly and inexplicably less overwhelmed right now because I know the crashing patient takes priority. I am now doing one thing and not a million things. I hand the $35,000 medication to the resource nurse and ask her, "Can you find out how to give this? I'll be right back (white lie), I need to call rapid response (team of nurses that respond to REALLY unstable patients)". Pt.#2 become stable after an hour of work. I am now REALLY behind. I become overwhelmed at one point because 2 pages of orders suddenly appeared in the chart that weren't there a minute ago. The orders were back-timed by a sneaky MD to read as if they were written @ 0800 and it is currently 1000 so I look like I neglected to execute important orders. Talk to resident about not doing that again. A different, helpful resident (R3 no less) gets excited about doing a Guiac Test on pt. #1 that now has been diagnosed with a upper gastrointestinal UGI bleed. I am happy to delegate a poop test to an excited doctor. I kind of love him for that. Now reader, I urge you, to never breathe deeply while handling melena (look it up and you will know it's definition: black, bloody, tarry poo. Smell it once and you will never be the same).
-At one point I will have to change my scrubs because, while helping a colleague, explosive diarrhea covers my scrubs, and I need to change. There's no washing this out. We call it a "code brown". After disgusting some folks on the elevator, and getting a new pair of scrubs from the basement, I take this opportunity to eat a power bar. After changing of course. And washing my hands for the 300th time. I get back to the patients and more of the same onslaught ensues. Constant reorganization and re-prioritization. Somehow it's all getting done. Thank GOD for the team. Blur. Blur. Triple Blur. I look up and it's almost time to go. I should probably chart more than vitals. Damn. I've got a half hour.
*1930
-Give report to newly refreshed night nurses. It is then that I remember that I didn't eat anything but the power bar or pee the whole day. After report, I then have the most satisfying pee of my whole life. It lasts an abnormally long time. I wonder if I've given myself prostitis or a UTI. Will find out next week.
*2000
-Leave hospital after tying up loose ends.
*2015
-Arrive @ car and assess whether I will fall asleep on way home. No.
*2045
-Arrive home and take a LONG shower.
*2115
-Wife now accepts kiss because she now is no longer concerned about poo/blood on me.
*2130-2200
-Catch up with wife while eating Cheerios.
*2201
-CRASH.
*0400
-Time to do it again.
Wednesday, February 6, 2008
Stress and Tachycardic, Psychedelic Dreams
Reflecting on: Nursing, stress, and psychedelic dreams…
Lately, I’ve come to the conclusion that MEPN, for me, is like running a race where the finish line is gradually being pulled further away from me. Sometimes I feel like I’m gaining ground—most of the time, really—but then there are the times where my legs are cycling in a sick, nightmarish pantomime that approximates running, but gets me exactly nowhere—as if I’m stuck on a quicksandish treadmill and the finish line disappears into the horizon.
I’ve actually had this dream before and it sucks every time.
The key to overcoming such nightmares, I’ve found out, is to become self-aware while still in the dream. It doesn’t happen as much as I would like.
In the nightmare, I spin my legs so fast and become so agitated and over-rot with emotion that I actually wake myself up—heart beating as though I actually were running an endless mile. I can hear the blood pounding in my ears…I take a moment to soak up the relief that I am not actually stuck—that I am in my bed with my ridiculous cat and beautiful wife and that everything will be alright. My wife snorts and shifts her pillow. The cat rouses and looks at me as if I were crazy. Possibly. But not so far gone that I’m afraid to go back to sleep. I look around and slow my breathing. I close my eyes…
…I fall back asleep and drift off into the same dream.
Given a second chance, I become self-aware—“lucid dreaming” I think professionals call it. The sensation of lucid dreaming is akin to the same relief that I had when I woke, but quickly transitions into being exceedingly tickled that I can laugh at the ground I was once stuck on. Chuckling to myself, solid matter blurs into sky and I fly off through clouds and over towns I vaguely I recognize. Total exhilaration of the dream fuzz flies past my face. I feel victorious that I have overcome physical boundaries. But then, while flying, I sometimes am bothered by the notion that “this isn’t real” and will falter—even fall. Gravity regains its hold on me and I plummet. As I rush towards the earth, I am reminded that I am still dreaming, and go into my best dive formation. Hurdling towards the ground, there is no impact because I dive into the earth’s crust and through the center of the earth. I am now in an entirely new dimension.
I want to do it again. And again…
Sometimes my dreams mean something and sometimes they don’t.
Sometimes I don’t wanna know (seriously).
This one, however, has some pretty obvious symbols.
Clearly, I’m racing my ass off to be the best damn nurse I can be in one year. It’s kind of ridiculous when I say it out loud, but since that is what I am, in fact, doing, it’s better to be clear about my intentions. The overall experience is a lovely mélange of being completely overwhelmed but, now faced with a challenge, exhilarated that I am alive and in the middle of something meaningful and stimulating.
Baptism by fire.
The finish line is nonsense though; it is nothing more than a self-imposed limit that I created because this accelerated RN experience is done in one year. Time to laugh and become self-aware: I am built for this. I love doing this. So why would I ever stop? Why would I even want a finish line? I think I’d rather keep on running, jump in a limo, get out, and, I don’t know, do the freaking running man or something. I mean, let’s evolve, right?
Right.
The endless, never ending run that doesn’t allow me to move anywhere: that’s my battle with perfectionism—a huge limitation. I am operating under the incredibly unrealistic notion that I have to be perfect in 6 weeks. Ridiculous. More ridiculous than my cat. So what do I do? Let’s challenge those expectations…let’s laugh at them—or rather, laugh with them! Maybe I’ll fly. Maybe I’ll forget…more than likely I’ll do both…but whatever…let’s breakdown and build up and get back to basics. Let’s evolve. I said that already. How about relative perfectionism instead? How about I be as good as I can be in 6 weeks without losing my mind and making my quicksand treadmill a reality? How about a little reminder that I can continue to reform and dive into the challenges that present themselves to me…
It’s a beautiful thing to be stressed and overworked and running with your pants around your ankles because although it makes me crazy, it forces me to think and learn: it is here that I am reminded that I can fly and that I will fly again.
Lately, I’ve come to the conclusion that MEPN, for me, is like running a race where the finish line is gradually being pulled further away from me. Sometimes I feel like I’m gaining ground—most of the time, really—but then there are the times where my legs are cycling in a sick, nightmarish pantomime that approximates running, but gets me exactly nowhere—as if I’m stuck on a quicksandish treadmill and the finish line disappears into the horizon.
I’ve actually had this dream before and it sucks every time.
The key to overcoming such nightmares, I’ve found out, is to become self-aware while still in the dream. It doesn’t happen as much as I would like.
In the nightmare, I spin my legs so fast and become so agitated and over-rot with emotion that I actually wake myself up—heart beating as though I actually were running an endless mile. I can hear the blood pounding in my ears…I take a moment to soak up the relief that I am not actually stuck—that I am in my bed with my ridiculous cat and beautiful wife and that everything will be alright. My wife snorts and shifts her pillow. The cat rouses and looks at me as if I were crazy. Possibly. But not so far gone that I’m afraid to go back to sleep. I look around and slow my breathing. I close my eyes…
…I fall back asleep and drift off into the same dream.
Given a second chance, I become self-aware—“lucid dreaming” I think professionals call it. The sensation of lucid dreaming is akin to the same relief that I had when I woke, but quickly transitions into being exceedingly tickled that I can laugh at the ground I was once stuck on. Chuckling to myself, solid matter blurs into sky and I fly off through clouds and over towns I vaguely I recognize. Total exhilaration of the dream fuzz flies past my face. I feel victorious that I have overcome physical boundaries. But then, while flying, I sometimes am bothered by the notion that “this isn’t real” and will falter—even fall. Gravity regains its hold on me and I plummet. As I rush towards the earth, I am reminded that I am still dreaming, and go into my best dive formation. Hurdling towards the ground, there is no impact because I dive into the earth’s crust and through the center of the earth. I am now in an entirely new dimension.
I want to do it again. And again…
Sometimes my dreams mean something and sometimes they don’t.
Sometimes I don’t wanna know (seriously).
This one, however, has some pretty obvious symbols.
Clearly, I’m racing my ass off to be the best damn nurse I can be in one year. It’s kind of ridiculous when I say it out loud, but since that is what I am, in fact, doing, it’s better to be clear about my intentions. The overall experience is a lovely mélange of being completely overwhelmed but, now faced with a challenge, exhilarated that I am alive and in the middle of something meaningful and stimulating.
Baptism by fire.
The finish line is nonsense though; it is nothing more than a self-imposed limit that I created because this accelerated RN experience is done in one year. Time to laugh and become self-aware: I am built for this. I love doing this. So why would I ever stop? Why would I even want a finish line? I think I’d rather keep on running, jump in a limo, get out, and, I don’t know, do the freaking running man or something. I mean, let’s evolve, right?
Right.
The endless, never ending run that doesn’t allow me to move anywhere: that’s my battle with perfectionism—a huge limitation. I am operating under the incredibly unrealistic notion that I have to be perfect in 6 weeks. Ridiculous. More ridiculous than my cat. So what do I do? Let’s challenge those expectations…let’s laugh at them—or rather, laugh with them! Maybe I’ll fly. Maybe I’ll forget…more than likely I’ll do both…but whatever…let’s breakdown and build up and get back to basics. Let’s evolve. I said that already. How about relative perfectionism instead? How about I be as good as I can be in 6 weeks without losing my mind and making my quicksand treadmill a reality? How about a little reminder that I can continue to reform and dive into the challenges that present themselves to me…
It’s a beautiful thing to be stressed and overworked and running with your pants around your ankles because although it makes me crazy, it forces me to think and learn: it is here that I am reminded that I can fly and that I will fly again.
Saturday, January 5, 2008
Feathers, Harpoons, Livers, & Transplants
REFLECTING ON: Ethical issues of transplanting a new liver into a "recovered" alcoholic. Martha's name is real and written with her permission.
In post-conference on Friday, a fellow MEPN ruffled my feathers. You see, in our clinical rotations, we were discussing the hospital policy to transplant new livers into “recovered” alcoholics and the ethical issues contained therein. When somebody informed me that the hospital's policy required a transplantee to be sober for a mere 3 months, I stated aloud, “That just doesn’t sit right with me.” There were some murmurings of agreement and some quiet dissent.
The feather ruffler, Martha, then coolly dealt her reply, “Oh those alcoholics, they don’t deserve livers, do they?”
Ire now raised, I took the bait, “That’s exactly what I’m saying.”
With what I perceived to be silent judgment, Martha looked me coolly, and said, “I know.”
Discussion ensued amongst the other students, but my mind was fixated on Martha’s words; they had jarred me. I was mad at the implication that my judgment of alcoholics was inappropriate or unfounded. I remained silent though. You see, one of the few things that I’ve learned in my thirty years is that when I am full of emotion, I try to keep my cards to myself for fear of revealing a bad hand. I don’t enjoy becoming overheated; it’s a sure-fire recipe for saying ridiculous things and becoming illogical.
As the discussion continued, Martha solidified her seat in court, “And those queers, should we give them livers too?”
Fine Martha. I see your point. Where do we draw the ethical line regarding who is eligible for a transplant and who is not? A fair point: we need to maintain objectivity or else slip down that slope of judgment that can ultimately lead to prejudice and discrimination. And although I concede this point, it was presented with the delicacy of a harpoon thrower. Of course, perhaps I need a harpoon now and then so that I can re-examine issues like these. So, in all honesty, thank you for the harpoon, and for the record, I do believe that gay people do deserve livers.
Alcoholics though? I just don’t know.
Where I take issue with most alcoholics is theirs is an affliction of the mind. While the non-addicted brain maintains its status as an efficient conductor of the organ systems that supply and maintain life, the addict’s mind will gladly sell the piano that it feebly pounds out chopsticks on in order to continue its own selfish, self-annihilation. Replacing the liver is a like putting a tiny band-aid on a huge gash that will continue to expand, ooze, and bleed until the actual cause is effectively managed and treated. The perpetrator of this deep cut is not the liver; it is the mind, and all of the complex and ever evolving layers and patterns that it alternates influencing and being influenced by. I maintain, as in triage, the most serious and life-threatening problems should be treated first. Since the origins of an alcoholic’s liver failure are routed in their addiction, a mental illness, the mind should therefore be prioritized for treatment. And although I am open to it, I have never witnessed a recovery from addiction in just 3 short months.
I ask, what is the point of extending a person’s life that is hell-bent on drinking him or herself to death? Unless that individual shows sincere and real progress towards treating their addiction, their true disease, fixing a diseased liver merely buys them time in the off-chance that they have an epiphany—and what is the likelihood that a person will suddenly shift to a pattern of making healthy decisions after a lifetime of making it’s bad ones? It’s like waiting for lightening to strike.
And in the meantime, while we’re waiting for lightening to strike, what do we actually witness? In my experience working at a group home for emotionally disturbed boys, most of whom were the products of parents that were abusive addicts, I watched how alcoholism continually disappoints, hurts, and self-destructs. One child, Steven, comes to mind. At 14, Steven appeared as if he was in early grade school. His physical and mental stature had been severely retarded by his mother’s drinking. His face and head revealed all the classic physical manifestations of Fetal Alcohol Syndrome: small head, low, misshapen ears, an unnaturally flat face, almost no jaw, thin lips, and incredibly small eyes. Steven read at maybe a 2nd grade level on a good day but cursed like a sailor when he was angry, which was almost all the time. When he got mad, he would often run away in a manner that resembled what a second grader would do: run three or four blocks, and then return home. Until he began to express suicidal ideation, the staff at the facility where I worked would let him run, knowing full well that he would soon return. One day, after Brent Steven expressed committing suicide, I was chasing him during one of his efforts at going AWOL. When I caught up with him, I just stood beside him. I had learned early on that grabbing someone that wants to leave is a sure way of making them dislike you. So I just stood, and then walked beside him, away from the group home. Steven was clearly frustrated—his brow was furrowed and he walked with fists at his sides. Then he stopped and looked up at me. I looked down and asked the kind of question that you only ask after you’ve chased a kid a hundred times, “Why don’t you ever just go for it? Why do you always stop?” Steven turned around and began returning home. We walked side-by-side. He walked silently for a bit, and then answered my question, “If I only just had a piece of paper, that I could draw a map on, then maybe I could draw a map and figure out how to get out of here.”
Now Steven had been in cars and even hikes that lead him off the facility’s premises a thousand times. It was only in that moment that I became acutely aware of how damaging the alcohol had been to his brain: he couldn’t keep his surrounding or even where he was in his mind for long enough to leave. He wanted to draw a map, one that he could keep in his mind, so that he could escape. In his distorted thinking, he hadn’t thought to consult an already existing map.
So there it is: why I resent and am so unforgiving of alcoholics. How can 3 months of drying out correct for Steven's lifetime of depression and frustration? It can’t. And it’s not fair. It’s not fair to Steven and it’s not fair to someone on the transplant list who, in all honesty, shows a hell of a lot more promise than a 3-month “recovered” alcoholic. Does Steven's mother deserve a new liver? I think not. And though it may sound harsh, I’m fine with that. Why? Because both within my personal and professional life, I’ve seen and felt the wake of mayhem and hurt left behind by alcoholics.
I realize that Steven is a dramatic illustration of the consequences of someone’s addiction. But it is real, and although most that are affected by alcoholism do not bare Steven's physical abnormalities, they are nonetheless affected in a manner that is similar to Steven; they bare internal scars and pain that they will carry with them for the rest of their lives. Call it what you will: a bias, a stereotype, or even prejudice. Judgment based on experience is what I prefer to call wisdom. Oh Jesus Christ I sound like a televangelist. Sorry. Just let me have my televangelist moment though and I will go back to trying to be well adjusted.
Here’s where it starts and ends for me: I’m absolutely willing to give the next recovering alcoholic a fair shake—just not after three months. How can an individual consider himself or herself cured when they’ve spent a much longer period of time slowly poisoning themselves? They’ve proved time and time again that they are not competent to make healthy choices, so why would we prolong that process? I don’t have time in my life to wait for the lightening to strike. Someone who deserves a new liver, in my mind, would be hit by that lightening, bottle it up, and bring it to the god damn hospital and show everyone that they deserve a new liver. That’s just me though.
I’m sure I sound like a pessimist right now. Rest assured, I’m not. I’m a horribly sensitive, bleeding heart optimist. You know how I know? Because despite my animosity towards alcoholics that have caused pain everywhere, I will still do my best, as a student and nurse-to-be, to provide quality nursing care to that alcoholic--even to Steven's mother. Why? Part of me is still invested in the hope that a person can change, even though the odds are against it. Pragmatic optimism? I don’t know what to call it. Most of me, however, just knows it’s the right thing to do.
In post-conference on Friday, a fellow MEPN ruffled my feathers. You see, in our clinical rotations, we were discussing the hospital policy to transplant new livers into “recovered” alcoholics and the ethical issues contained therein. When somebody informed me that the hospital's policy required a transplantee to be sober for a mere 3 months, I stated aloud, “That just doesn’t sit right with me.” There were some murmurings of agreement and some quiet dissent.
The feather ruffler, Martha, then coolly dealt her reply, “Oh those alcoholics, they don’t deserve livers, do they?”
Ire now raised, I took the bait, “That’s exactly what I’m saying.”
With what I perceived to be silent judgment, Martha looked me coolly, and said, “I know.”
Discussion ensued amongst the other students, but my mind was fixated on Martha’s words; they had jarred me. I was mad at the implication that my judgment of alcoholics was inappropriate or unfounded. I remained silent though. You see, one of the few things that I’ve learned in my thirty years is that when I am full of emotion, I try to keep my cards to myself for fear of revealing a bad hand. I don’t enjoy becoming overheated; it’s a sure-fire recipe for saying ridiculous things and becoming illogical.
As the discussion continued, Martha solidified her seat in court, “And those queers, should we give them livers too?”
Fine Martha. I see your point. Where do we draw the ethical line regarding who is eligible for a transplant and who is not? A fair point: we need to maintain objectivity or else slip down that slope of judgment that can ultimately lead to prejudice and discrimination. And although I concede this point, it was presented with the delicacy of a harpoon thrower. Of course, perhaps I need a harpoon now and then so that I can re-examine issues like these. So, in all honesty, thank you for the harpoon, and for the record, I do believe that gay people do deserve livers.
Alcoholics though? I just don’t know.
Where I take issue with most alcoholics is theirs is an affliction of the mind. While the non-addicted brain maintains its status as an efficient conductor of the organ systems that supply and maintain life, the addict’s mind will gladly sell the piano that it feebly pounds out chopsticks on in order to continue its own selfish, self-annihilation. Replacing the liver is a like putting a tiny band-aid on a huge gash that will continue to expand, ooze, and bleed until the actual cause is effectively managed and treated. The perpetrator of this deep cut is not the liver; it is the mind, and all of the complex and ever evolving layers and patterns that it alternates influencing and being influenced by. I maintain, as in triage, the most serious and life-threatening problems should be treated first. Since the origins of an alcoholic’s liver failure are routed in their addiction, a mental illness, the mind should therefore be prioritized for treatment. And although I am open to it, I have never witnessed a recovery from addiction in just 3 short months.
I ask, what is the point of extending a person’s life that is hell-bent on drinking him or herself to death? Unless that individual shows sincere and real progress towards treating their addiction, their true disease, fixing a diseased liver merely buys them time in the off-chance that they have an epiphany—and what is the likelihood that a person will suddenly shift to a pattern of making healthy decisions after a lifetime of making it’s bad ones? It’s like waiting for lightening to strike.
And in the meantime, while we’re waiting for lightening to strike, what do we actually witness? In my experience working at a group home for emotionally disturbed boys, most of whom were the products of parents that were abusive addicts, I watched how alcoholism continually disappoints, hurts, and self-destructs. One child, Steven, comes to mind. At 14, Steven appeared as if he was in early grade school. His physical and mental stature had been severely retarded by his mother’s drinking. His face and head revealed all the classic physical manifestations of Fetal Alcohol Syndrome: small head, low, misshapen ears, an unnaturally flat face, almost no jaw, thin lips, and incredibly small eyes. Steven read at maybe a 2nd grade level on a good day but cursed like a sailor when he was angry, which was almost all the time. When he got mad, he would often run away in a manner that resembled what a second grader would do: run three or four blocks, and then return home. Until he began to express suicidal ideation, the staff at the facility where I worked would let him run, knowing full well that he would soon return. One day, after Brent Steven expressed committing suicide, I was chasing him during one of his efforts at going AWOL. When I caught up with him, I just stood beside him. I had learned early on that grabbing someone that wants to leave is a sure way of making them dislike you. So I just stood, and then walked beside him, away from the group home. Steven was clearly frustrated—his brow was furrowed and he walked with fists at his sides. Then he stopped and looked up at me. I looked down and asked the kind of question that you only ask after you’ve chased a kid a hundred times, “Why don’t you ever just go for it? Why do you always stop?” Steven turned around and began returning home. We walked side-by-side. He walked silently for a bit, and then answered my question, “If I only just had a piece of paper, that I could draw a map on, then maybe I could draw a map and figure out how to get out of here.”
Now Steven had been in cars and even hikes that lead him off the facility’s premises a thousand times. It was only in that moment that I became acutely aware of how damaging the alcohol had been to his brain: he couldn’t keep his surrounding or even where he was in his mind for long enough to leave. He wanted to draw a map, one that he could keep in his mind, so that he could escape. In his distorted thinking, he hadn’t thought to consult an already existing map.
So there it is: why I resent and am so unforgiving of alcoholics. How can 3 months of drying out correct for Steven's lifetime of depression and frustration? It can’t. And it’s not fair. It’s not fair to Steven and it’s not fair to someone on the transplant list who, in all honesty, shows a hell of a lot more promise than a 3-month “recovered” alcoholic. Does Steven's mother deserve a new liver? I think not. And though it may sound harsh, I’m fine with that. Why? Because both within my personal and professional life, I’ve seen and felt the wake of mayhem and hurt left behind by alcoholics.
I realize that Steven is a dramatic illustration of the consequences of someone’s addiction. But it is real, and although most that are affected by alcoholism do not bare Steven's physical abnormalities, they are nonetheless affected in a manner that is similar to Steven; they bare internal scars and pain that they will carry with them for the rest of their lives. Call it what you will: a bias, a stereotype, or even prejudice. Judgment based on experience is what I prefer to call wisdom. Oh Jesus Christ I sound like a televangelist. Sorry. Just let me have my televangelist moment though and I will go back to trying to be well adjusted.
Here’s where it starts and ends for me: I’m absolutely willing to give the next recovering alcoholic a fair shake—just not after three months. How can an individual consider himself or herself cured when they’ve spent a much longer period of time slowly poisoning themselves? They’ve proved time and time again that they are not competent to make healthy choices, so why would we prolong that process? I don’t have time in my life to wait for the lightening to strike. Someone who deserves a new liver, in my mind, would be hit by that lightening, bottle it up, and bring it to the god damn hospital and show everyone that they deserve a new liver. That’s just me though.
I’m sure I sound like a pessimist right now. Rest assured, I’m not. I’m a horribly sensitive, bleeding heart optimist. You know how I know? Because despite my animosity towards alcoholics that have caused pain everywhere, I will still do my best, as a student and nurse-to-be, to provide quality nursing care to that alcoholic--even to Steven's mother. Why? Part of me is still invested in the hope that a person can change, even though the odds are against it. Pragmatic optimism? I don’t know what to call it. Most of me, however, just knows it’s the right thing to do.
Tuesday, December 11, 2007
A Day at an Abortion Clinic
REFLECTING ON: Observing at an abortion clinic and confronting my previously unchallenged ideas on the subject...
Having not donned my forest-green scrub top in a while, at 5:30 yesterday morning, I found myself again feeling like a complete fraud as I dressed up to “play nurse”. I moved slowly as I pulled up my multi-pocketed, khaki scrub pants, and closed my eyes for long periods of time. At the end of one sleepy head nod, I opened my eyes to stare down at my left sleeve: the iron-on UCSF patch—my official sponsor. I wondered if or when I ever was ever going to feel confident or competent as a nurse. Such is the life, I suppose, of a student in an accelerated program.
My destination was a San Francisco abortion clinic where they perform abortions for patients in their first and second trimesters (up to 22 weeks). As someone who had never been to an abortion clinic in any part of my personal or professional life, my expectations were distorted by the vague abstractions of what I had heard in lectures, seen in the news, and read in books. Though it was vacation, I had chosen to volunteer at this clinic for this very reason: my total lack of actual experience with the subject. In addition to educating myself, my decision to volunteer was intended to confront my fears regarding abortion. In being totally honest with myself, I realized that I wanted nothing to do with the abortion process. My natural inclination is to run away from situations like these due to some misplaced instinct to survive. I have quickly realized, however, that being a nurse often requires me to walk towards these less-than-comfortable situations in order that I better serve my patients. How can I be objective and caring if the greater part of my brain is sorting through basic instincts? So I take a deep breath and take a step closer to my fears.
Although these greater, mostly inexpressible thoughts were swirling around my gray matter as I got ready, I could verbalize one constant preoccupation: I was nervous and concerned that I wouldn’t be of any use. I suppose “being of use” isn’t so much the point during a day of observation, but I always like to show that I can be helpful. Part of the “disease to please” I suppose, where I always try to find someway to help. Later, after I had observed eight abortions, I was glad to just sort through my thoughts.
While on BART and Muni, I spent my time reviewing pregnancy and abortion terminology as well as the pharmacological actions of Mifeprestone, Misoprostate, and Methotrexate—drugs used in medically induce abortions. Memorizing things like these is a part of my “comfort-routine”, where I control for as many variables as possible. Memorizing facts, though challenging and requiring discipline, is easier than wrestling with the swirling and unpredictable emotional variables. I can memorize what is known and understood. In contrast, I can only blankly repeat sentences when something is beyond my mind’s grasp. As much as I crammed, there was no way I could prepare myself for truly understanding the mechanics of abortion.
I foggily made my way through the hospital’s labyrinth of hallways and, after ringing a doorbell, stepped into the clinic. Luz, another nursing student in UCSF’s MEPN program, was already there. Everyone was friendly and this surprised me somehow. I even heard one of the nurses say, “Oh good, the students are here.” Reflecting back, my surprise was the first clue to my true, thoughts on abortion. If I had been completely honest with myself, I halfway expected that everyone in the clinic would be quiet and forlorn, perhaps in constant state of mourning, because after all, weren’t they killing babies here?
And with that flash of thought, I was truly taken back. Floored really. Completely and totally shocked. Did I really just think that? But I had always flown the pro-choice flag…and now…shit…was all my talk just lip-service and yet another unchallenged idea in my personal cache of thoughts that define me as liberal and open-minded? Am I really that naïve? In the abstract, I had somehow rationalized that there was a clear delineation as to the point where life began and ended such that each of these medical professionals, with exacting precision, were able to determine beyond a shadow of a doubt when and how life began so as not to destroy any potential, any thought, any love, or any laughter…as if the next great Mozart or Martin Luther King might be at the clinic in fetal form, or perhaps just a really good kid. I don’t know…starting out with thoughts like these, I knew it was going to be one hell of a day.
At the nurse’s station, I stood next to Luz, blankly repeating words and sentences to myself. Luz seemed more at ease than I. Madison, an experienced nurse at the clinic, approached us while tossing up a coin, which I knew had something to do with me. Without asking, I called heads, won the toss, and was asked to choose my preceptor: Madison or some other woman. As I hadn’t met the other woman and I liked Madison’s style—direct, thorough, and smart—I chose Madison.
Madison shot out a million words a minute and walked about just as fast. Talking while walking seemed to synergize her speed, making her blurry on any photograph. One minute we were in the med room drawing up a cocktail of fentanyl, versed, and atropine and the next we were whirling passed the nurse’s station and reviewing patient information. She explained that the fentanyl, an opiate, is for stopping pain; versed is a central nervous system depressant used to relax the patient; and the atropine, a parasympatholytic, is employed in order to maintain the patient’s heart and breathing rate, as well as for prophylaxis against a vasovagal response. Madison had not only told me the pharmacological action and reason for each drug, but she had also managed to summarize the procedure, and even began to discuss abortion complications—all in about 3 minutes. My head was spinning when we entered the procedure room where there was a already a patient prepped and ready to go. I would need more time to take it all in.
As I learned and asked questions, twenty-three abortions would take place that day. The patients ranged in ages from 14 to 30 years and their fetus’ gestational age ranged from 7 to 14 weeks. I observed no immediate complications.
Ella was our first client. She was thirty-three, married with two kids and didn’t want another. She told me as much while I sat with her during the pre-procedure counseling session. She had had this procedure once before and somehow seemed cheerfully resolved to go through it again. Her “cheerfulness”, I admit, was my bias, but I can only report what I see. Who knows how she really felt?
In Ella’s chart, we would write that she was a G4P2—gravida 4, para 2, indicating that she had been pregnant a total of four times, and had carried two of them to at least 20 weeks. This fetus was 14 weeks. Ella’s confident body language and willingness to look at medical personnel in the eye seemed to indicate that she was at peace with her decision. Somehow that put me at ease, too, which allowed me to pay close attention to the tools and mechanics of her abortion.
The procedure took place in an older operating room with wall-to-wall tile. The room was extremely cold and in the center of the room was Ella, lying on the operating table with her legs propped up, spread, and secured by the stirrups. She was draped with the infamously small hospital gown, but probably didn’t care about the cold because of the fentanyl. Behind the table sat the equipment that monitors each patient’s oxygen saturation, respiration rate, heart rate, and blood pressure. At the foot of the table was a draped cart of sterile tools. Under the drape was a bowl for betadyne, which is used to clean each patient’s vagina inside and out. Near the bowl was the speculum, a vice-like tool that is inserted into the vaginal canal so that the clinician may have direct access to the cervical canal and uterus, where the fetus is developing. Next to the speculum was a wrapped sterile cloth that contained several sterile dilators—10-inch metal rods of increasing diameter that would probe from the external to the internal os of the cervix, allowing for full access to the uterine cavity. Depending on the age of the fetus, the clinician will use either a manual or electric vacuum, either of which would require a plastic tube, the cannula, to be attached to it. The cannula is inserted through the cervical canal and into the uterus. One one end that is insertedinto the uterus, the cannula is beveled and the other is attached to the vacuum. The cannula serves as the primary tool for terminating the fetus and is guided into the uterus via an ultrasound image. The ultrasound is live, essentially showing a video of the procedure’s main event: destruction of the fetus. The amniotic sac is more salient in earlier pregnancies, with a small but distinguishable fetus growing at one side of the placenta. The head is just barely visible, as well as small arms and legs. If the fetus is in the second trimester, like Ella’s, the fetus’ spine is obvious, and upon careful examination, one can even see a tiny fluctuating blur of black and white: the beating fetal heart. The plastic cannula would normally be invisible on an ultrasound image, but is obvious because of its barium coating. Once the cannula is placed into the uterine cavity next to the fetus, it is twisted and pumped up and down while connected to suction. The fetus, placenta, and amntiotic sac are being speared, broken apart, and then sucked into the vacuum container. The clinician performing the procedure will make several passes with the cannula in order to ensure that all of the contents are aspirated. Then, to further ensure that there are no more fetal contents within the uterus, another tool, the curette, will be employed. The curette has a handle similar to a screw-driver with a long metal rod extending from it. At the end of the rod is a metal loop that is used to gently scrape the uterine walls to ensure all fetal material has been removed. Both of the physicians that I observed carry out this part of the procedure described the sensation of scraping the empty uterus as “grainy”. Once empty, the uterus shrinks back into its flattened position, the walls of which are now flush unto themselves, with no fetus present. On the ultrasound, the physicians described the flattened uterus as having two parallel “silver” lines that represent the uterine endometrium.
Ella’s abortion followed this precise operation. No complications. No pain. She was groggy from the medicine, but after recovering from the procedure, she left the hospital and was driven home by her sister. In the recovery room, she smiled at me, ate crackers, and talked easily with the nurses and other patients. Again, I found myself surprised by the ease in which she and everyone around her had adapted to the events I had just witnessed. This included myself. I did keep my surprise quiet for fear of being branded a heretic. I suppose if I had I been injected with a fentanyl cocktail, I could have watched a train wreck while singing “Frère Jacques”, but I hadn’t, and nor did I have the years of experience that could allow me to fully gain professional distance and objectify the patient while sinking into a rhythm of automaticity.
I had a strong emotional reaction. What I had observed was this: one minute there was an observable human figure on the ultrasound and the next there was not. In the interim I observed blood being suctioned from Ella’s uterus and into glass jar that had a cheesecloth filter for catching solid tissue. At one point, the electric vacuum became clogged and the doctor had to withdraw the cannula from Ella. A scant amount of blood dripped from Ella’s vagina to the blue drape beneath her. Clearly, there was tissue obstructing the beveled end of the cannula. The doctor brought it to a bowl and tapped the cannula twice on the bowl’s edge. A clump of tissue loosened and fell; the doctor returned to the procedure and all eyes were back on Ella except for mine. My gaze remained fixed on the bowl where saw a small, dismembered arm with a hand. I counted five fingers and noticed the arm was bent at the elbow.
I strained to hide a flash of grimace. My eyes watered for a second and would have betrayed me had I not looked with feigned interest at the vacuum. Ella had her eyes closed anyway. Nobody in the room was looking at me. My nostrils flared and I thirstily inhaled air. All I could think was, “Get it together Nat…we’ll work this out later,” which I repeated at least seventeen times. My eyes returned to the arm and I noted veins below translucent skin. It was the left arm. I thought I could see the head of the humerus. It was approximately 5 cm long.
The facts were comforting to me. I looked around and noted instruments and where we were in the procedure. And with that, I moved from being emotion-filled to diagnostic-filled, which I found as alarming as first seeing the arm. The sting of what I had just seen was still with me, but was sublimated into fascination by examining the anatomy of the fetal remnants. My head was in two places at once.
Upon leaving the operating room, the emotional pull returned, forcing me to bend my mind around what I had just seen. This was heavy, heavy stuff but there was no time to think; there was another procedure to perform. I was on Madison’s schedule now. The rest of the abortions were for fetuses 8 weeks or less, which somehow seemed more acceptable to me. I couldn’t see the fetus as well, and they weren’t as developed as the 14 weeker, so it wasn’t as hard to watch. There were no more tissue obstructions either.
In between patients, Madison and some of the other nurses expressed their disbelief that some of their patients actually wanted to take the fetal remnants home with them for a funeral. Madison was clearly frustrated, “I mean, I can see wanting to have a funeral if it is a medically necessary abortion and you wanted the child to begin with, but for an elective abortion? I just don’t get it. And besides, most of our girls are on Medicaid…so you’re telling me you can’t afford an abortion, but you can afford a funeral?”
“Maybe they’re trying to show somebody,” I said, surprising myself. I had turned a corner and tried to picture the life of the person who had been on the operating table outside of the procedure. “Maybe they’re trying to let someone know that this is what they had to go through.”
“True,” Madison said, “there’s a million reasons to get an abortion, and we only see part of it. I guess the bottom line is that everyone should have access to it, regardless of their reason or means so they can be safe—it’s going to happen no matter what. I know we sound callous, but don’t think for a second that we don’t love what we do. It’s important. Women need to be bale to safely choose this procedure.”
Clearly, the day one decides to have an abortion shouldn’t be a happy day in anyone’s life. But for Luther, it clearly was. Although all the nurses had discouraged Susan from having her partner in the room while the procedure was taking place, she was adamant about having him there. “I didn’t get pregnant by myself,” she insisted. At with this, everyone acquiesced, and he was fetched from the waiting room. It was late in the day and this was the next to last procedure. When Luther came into the operating room, Susan was already laying back on the table. Her face had changed as soon as he entered the room: passionate to impassive in two seconds flat.
When I first saw Luther, all I could think was that he was a grubby little boy. Mannish in stature and size, I suppose, but his body language put him at 17 tops. His sweats were crusted up with dirty liquid stains and a distinct odor followed him into the room. I recognized the smell immediately—that of a dirty, neglected home. I had been in hundreds during my days as a social worker and group home counselor, and most of them smelled the same: stale cigarette smoke, dirt, must, and sweat all combined to create one of the most pungent smells in my memory.
Luther was taking off his hat as he entered, which I offered to take from him. He handed it to me and was signaled to sit down next to Susan. When he spoke, his words were saccharine, “It’s gonna be alright baby, baby—you’ll see. All these people are gonna take real good care of you.”
It sounded like bullshit to me. His words were hollow and unconvincing like those of a bad actor. Luther looked around at the staff after each sentence, as if looking for approval, and spent very little time looking at Susan. As the procedure progressed and the staff would offer encouraging words, he would mimic them like a myna bird, “It’s going alright baby, baby…just breathe baby, baby.” And although he said all the right things, I couldn’t help but think he was quietly celebrating because I could see him smile. A new feeling overwhelmed me during Susan’s procedure: that she was brave.
Perhaps Luther was relieved to not be a father at such a young age. God knows I was relieved to hear that an old girlfriend’s pregnancy test came back negative when a much younger Nat went through a pregnancy scare at age 18. So perhaps he was happy, but Susan was clearly not, and I think she wanted him to see that. Later, Madison told me she noticed the same thing, “I hate it when they perform like that.”
While Susan was in recovery, I realized that I had not given Luther back his hat. I went to find Luther in an otherwise empty waiting room and before I even got to the door, I noticed a new smell: the small room reeked of marijuana. Nobody had been smoking in the room, otherwise there would have been smoke, but somebody had clearly smoked recently and brought the smell in with them. When I looked at Luther, his eyes were bloodshot. I held up the hat, and said, “I have your hat.” Luther stood up, breathed heavily, and then sat back down, clearly overwhelmed. I tossed him the hat and said, “Good luck. Take care of Susan.” His head darted back to the television without another word. Stoned was no way to start out as a father.
Now I was relieved that Susan had the abortion. She knew she was doing what was best for her, Luther, and her unborn child. Having seen the situations that unwanted children can be born into, and the havoc that being brought up in a poor, neglectful, and/or abuse-ridden home can do to a child, I am certain that some people are better off not having been born. It hurts me to say it, but I think it’s true.
The gross reality of the abortion procedure leaves a lot for me to reconcile. Am I justifying a form of murder? Perhaps, but when exactly does life begin? Is it with the first mitotic cell division or the first heart beat? Is it the first lucid thought? A lot of unknowns. And what would happen if the child were to be born? Have I grown so self-absorbed to think that humans are so important that every single hint at a life should be preserved when there are millions of already born humans that don’t even get their basic needs met? More unknowns, though I’m inclined to answer yes to that last question.
I suppose it doesn’t really matter how I answer any question, because the reasons that a woman has to get an abortion are her own, and determining their “validity” is as difficult to ascertain as determining when life begins. The reality of the situation is that the procedure will continue to take place, whether legal or not, and to provide women with safe options is of the utmost importance.
My head was still spinning when I got on the bus to go home. It still is.
Having not donned my forest-green scrub top in a while, at 5:30 yesterday morning, I found myself again feeling like a complete fraud as I dressed up to “play nurse”. I moved slowly as I pulled up my multi-pocketed, khaki scrub pants, and closed my eyes for long periods of time. At the end of one sleepy head nod, I opened my eyes to stare down at my left sleeve: the iron-on UCSF patch—my official sponsor. I wondered if or when I ever was ever going to feel confident or competent as a nurse. Such is the life, I suppose, of a student in an accelerated program.
My destination was a San Francisco abortion clinic where they perform abortions for patients in their first and second trimesters (up to 22 weeks). As someone who had never been to an abortion clinic in any part of my personal or professional life, my expectations were distorted by the vague abstractions of what I had heard in lectures, seen in the news, and read in books. Though it was vacation, I had chosen to volunteer at this clinic for this very reason: my total lack of actual experience with the subject. In addition to educating myself, my decision to volunteer was intended to confront my fears regarding abortion. In being totally honest with myself, I realized that I wanted nothing to do with the abortion process. My natural inclination is to run away from situations like these due to some misplaced instinct to survive. I have quickly realized, however, that being a nurse often requires me to walk towards these less-than-comfortable situations in order that I better serve my patients. How can I be objective and caring if the greater part of my brain is sorting through basic instincts? So I take a deep breath and take a step closer to my fears.
Although these greater, mostly inexpressible thoughts were swirling around my gray matter as I got ready, I could verbalize one constant preoccupation: I was nervous and concerned that I wouldn’t be of any use. I suppose “being of use” isn’t so much the point during a day of observation, but I always like to show that I can be helpful. Part of the “disease to please” I suppose, where I always try to find someway to help. Later, after I had observed eight abortions, I was glad to just sort through my thoughts.
While on BART and Muni, I spent my time reviewing pregnancy and abortion terminology as well as the pharmacological actions of Mifeprestone, Misoprostate, and Methotrexate—drugs used in medically induce abortions. Memorizing things like these is a part of my “comfort-routine”, where I control for as many variables as possible. Memorizing facts, though challenging and requiring discipline, is easier than wrestling with the swirling and unpredictable emotional variables. I can memorize what is known and understood. In contrast, I can only blankly repeat sentences when something is beyond my mind’s grasp. As much as I crammed, there was no way I could prepare myself for truly understanding the mechanics of abortion.
I foggily made my way through the hospital’s labyrinth of hallways and, after ringing a doorbell, stepped into the clinic. Luz, another nursing student in UCSF’s MEPN program, was already there. Everyone was friendly and this surprised me somehow. I even heard one of the nurses say, “Oh good, the students are here.” Reflecting back, my surprise was the first clue to my true, thoughts on abortion. If I had been completely honest with myself, I halfway expected that everyone in the clinic would be quiet and forlorn, perhaps in constant state of mourning, because after all, weren’t they killing babies here?
And with that flash of thought, I was truly taken back. Floored really. Completely and totally shocked. Did I really just think that? But I had always flown the pro-choice flag…and now…shit…was all my talk just lip-service and yet another unchallenged idea in my personal cache of thoughts that define me as liberal and open-minded? Am I really that naïve? In the abstract, I had somehow rationalized that there was a clear delineation as to the point where life began and ended such that each of these medical professionals, with exacting precision, were able to determine beyond a shadow of a doubt when and how life began so as not to destroy any potential, any thought, any love, or any laughter…as if the next great Mozart or Martin Luther King might be at the clinic in fetal form, or perhaps just a really good kid. I don’t know…starting out with thoughts like these, I knew it was going to be one hell of a day.
At the nurse’s station, I stood next to Luz, blankly repeating words and sentences to myself. Luz seemed more at ease than I. Madison, an experienced nurse at the clinic, approached us while tossing up a coin, which I knew had something to do with me. Without asking, I called heads, won the toss, and was asked to choose my preceptor: Madison or some other woman. As I hadn’t met the other woman and I liked Madison’s style—direct, thorough, and smart—I chose Madison.
Madison shot out a million words a minute and walked about just as fast. Talking while walking seemed to synergize her speed, making her blurry on any photograph. One minute we were in the med room drawing up a cocktail of fentanyl, versed, and atropine and the next we were whirling passed the nurse’s station and reviewing patient information. She explained that the fentanyl, an opiate, is for stopping pain; versed is a central nervous system depressant used to relax the patient; and the atropine, a parasympatholytic, is employed in order to maintain the patient’s heart and breathing rate, as well as for prophylaxis against a vasovagal response. Madison had not only told me the pharmacological action and reason for each drug, but she had also managed to summarize the procedure, and even began to discuss abortion complications—all in about 3 minutes. My head was spinning when we entered the procedure room where there was a already a patient prepped and ready to go. I would need more time to take it all in.
As I learned and asked questions, twenty-three abortions would take place that day. The patients ranged in ages from 14 to 30 years and their fetus’ gestational age ranged from 7 to 14 weeks. I observed no immediate complications.
Ella was our first client. She was thirty-three, married with two kids and didn’t want another. She told me as much while I sat with her during the pre-procedure counseling session. She had had this procedure once before and somehow seemed cheerfully resolved to go through it again. Her “cheerfulness”, I admit, was my bias, but I can only report what I see. Who knows how she really felt?
In Ella’s chart, we would write that she was a G4P2—gravida 4, para 2, indicating that she had been pregnant a total of four times, and had carried two of them to at least 20 weeks. This fetus was 14 weeks. Ella’s confident body language and willingness to look at medical personnel in the eye seemed to indicate that she was at peace with her decision. Somehow that put me at ease, too, which allowed me to pay close attention to the tools and mechanics of her abortion.
The procedure took place in an older operating room with wall-to-wall tile. The room was extremely cold and in the center of the room was Ella, lying on the operating table with her legs propped up, spread, and secured by the stirrups. She was draped with the infamously small hospital gown, but probably didn’t care about the cold because of the fentanyl. Behind the table sat the equipment that monitors each patient’s oxygen saturation, respiration rate, heart rate, and blood pressure. At the foot of the table was a draped cart of sterile tools. Under the drape was a bowl for betadyne, which is used to clean each patient’s vagina inside and out. Near the bowl was the speculum, a vice-like tool that is inserted into the vaginal canal so that the clinician may have direct access to the cervical canal and uterus, where the fetus is developing. Next to the speculum was a wrapped sterile cloth that contained several sterile dilators—10-inch metal rods of increasing diameter that would probe from the external to the internal os of the cervix, allowing for full access to the uterine cavity. Depending on the age of the fetus, the clinician will use either a manual or electric vacuum, either of which would require a plastic tube, the cannula, to be attached to it. The cannula is inserted through the cervical canal and into the uterus. One one end that is insertedinto the uterus, the cannula is beveled and the other is attached to the vacuum. The cannula serves as the primary tool for terminating the fetus and is guided into the uterus via an ultrasound image. The ultrasound is live, essentially showing a video of the procedure’s main event: destruction of the fetus. The amniotic sac is more salient in earlier pregnancies, with a small but distinguishable fetus growing at one side of the placenta. The head is just barely visible, as well as small arms and legs. If the fetus is in the second trimester, like Ella’s, the fetus’ spine is obvious, and upon careful examination, one can even see a tiny fluctuating blur of black and white: the beating fetal heart. The plastic cannula would normally be invisible on an ultrasound image, but is obvious because of its barium coating. Once the cannula is placed into the uterine cavity next to the fetus, it is twisted and pumped up and down while connected to suction. The fetus, placenta, and amntiotic sac are being speared, broken apart, and then sucked into the vacuum container. The clinician performing the procedure will make several passes with the cannula in order to ensure that all of the contents are aspirated. Then, to further ensure that there are no more fetal contents within the uterus, another tool, the curette, will be employed. The curette has a handle similar to a screw-driver with a long metal rod extending from it. At the end of the rod is a metal loop that is used to gently scrape the uterine walls to ensure all fetal material has been removed. Both of the physicians that I observed carry out this part of the procedure described the sensation of scraping the empty uterus as “grainy”. Once empty, the uterus shrinks back into its flattened position, the walls of which are now flush unto themselves, with no fetus present. On the ultrasound, the physicians described the flattened uterus as having two parallel “silver” lines that represent the uterine endometrium.
Ella’s abortion followed this precise operation. No complications. No pain. She was groggy from the medicine, but after recovering from the procedure, she left the hospital and was driven home by her sister. In the recovery room, she smiled at me, ate crackers, and talked easily with the nurses and other patients. Again, I found myself surprised by the ease in which she and everyone around her had adapted to the events I had just witnessed. This included myself. I did keep my surprise quiet for fear of being branded a heretic. I suppose if I had I been injected with a fentanyl cocktail, I could have watched a train wreck while singing “Frère Jacques”, but I hadn’t, and nor did I have the years of experience that could allow me to fully gain professional distance and objectify the patient while sinking into a rhythm of automaticity.
I had a strong emotional reaction. What I had observed was this: one minute there was an observable human figure on the ultrasound and the next there was not. In the interim I observed blood being suctioned from Ella’s uterus and into glass jar that had a cheesecloth filter for catching solid tissue. At one point, the electric vacuum became clogged and the doctor had to withdraw the cannula from Ella. A scant amount of blood dripped from Ella’s vagina to the blue drape beneath her. Clearly, there was tissue obstructing the beveled end of the cannula. The doctor brought it to a bowl and tapped the cannula twice on the bowl’s edge. A clump of tissue loosened and fell; the doctor returned to the procedure and all eyes were back on Ella except for mine. My gaze remained fixed on the bowl where saw a small, dismembered arm with a hand. I counted five fingers and noticed the arm was bent at the elbow.
I strained to hide a flash of grimace. My eyes watered for a second and would have betrayed me had I not looked with feigned interest at the vacuum. Ella had her eyes closed anyway. Nobody in the room was looking at me. My nostrils flared and I thirstily inhaled air. All I could think was, “Get it together Nat…we’ll work this out later,” which I repeated at least seventeen times. My eyes returned to the arm and I noted veins below translucent skin. It was the left arm. I thought I could see the head of the humerus. It was approximately 5 cm long.
The facts were comforting to me. I looked around and noted instruments and where we were in the procedure. And with that, I moved from being emotion-filled to diagnostic-filled, which I found as alarming as first seeing the arm. The sting of what I had just seen was still with me, but was sublimated into fascination by examining the anatomy of the fetal remnants. My head was in two places at once.
Upon leaving the operating room, the emotional pull returned, forcing me to bend my mind around what I had just seen. This was heavy, heavy stuff but there was no time to think; there was another procedure to perform. I was on Madison’s schedule now. The rest of the abortions were for fetuses 8 weeks or less, which somehow seemed more acceptable to me. I couldn’t see the fetus as well, and they weren’t as developed as the 14 weeker, so it wasn’t as hard to watch. There were no more tissue obstructions either.
In between patients, Madison and some of the other nurses expressed their disbelief that some of their patients actually wanted to take the fetal remnants home with them for a funeral. Madison was clearly frustrated, “I mean, I can see wanting to have a funeral if it is a medically necessary abortion and you wanted the child to begin with, but for an elective abortion? I just don’t get it. And besides, most of our girls are on Medicaid…so you’re telling me you can’t afford an abortion, but you can afford a funeral?”
“Maybe they’re trying to show somebody,” I said, surprising myself. I had turned a corner and tried to picture the life of the person who had been on the operating table outside of the procedure. “Maybe they’re trying to let someone know that this is what they had to go through.”
“True,” Madison said, “there’s a million reasons to get an abortion, and we only see part of it. I guess the bottom line is that everyone should have access to it, regardless of their reason or means so they can be safe—it’s going to happen no matter what. I know we sound callous, but don’t think for a second that we don’t love what we do. It’s important. Women need to be bale to safely choose this procedure.”
Clearly, the day one decides to have an abortion shouldn’t be a happy day in anyone’s life. But for Luther, it clearly was. Although all the nurses had discouraged Susan from having her partner in the room while the procedure was taking place, she was adamant about having him there. “I didn’t get pregnant by myself,” she insisted. At with this, everyone acquiesced, and he was fetched from the waiting room. It was late in the day and this was the next to last procedure. When Luther came into the operating room, Susan was already laying back on the table. Her face had changed as soon as he entered the room: passionate to impassive in two seconds flat.
When I first saw Luther, all I could think was that he was a grubby little boy. Mannish in stature and size, I suppose, but his body language put him at 17 tops. His sweats were crusted up with dirty liquid stains and a distinct odor followed him into the room. I recognized the smell immediately—that of a dirty, neglected home. I had been in hundreds during my days as a social worker and group home counselor, and most of them smelled the same: stale cigarette smoke, dirt, must, and sweat all combined to create one of the most pungent smells in my memory.
Luther was taking off his hat as he entered, which I offered to take from him. He handed it to me and was signaled to sit down next to Susan. When he spoke, his words were saccharine, “It’s gonna be alright baby, baby—you’ll see. All these people are gonna take real good care of you.”
It sounded like bullshit to me. His words were hollow and unconvincing like those of a bad actor. Luther looked around at the staff after each sentence, as if looking for approval, and spent very little time looking at Susan. As the procedure progressed and the staff would offer encouraging words, he would mimic them like a myna bird, “It’s going alright baby, baby…just breathe baby, baby.” And although he said all the right things, I couldn’t help but think he was quietly celebrating because I could see him smile. A new feeling overwhelmed me during Susan’s procedure: that she was brave.
Perhaps Luther was relieved to not be a father at such a young age. God knows I was relieved to hear that an old girlfriend’s pregnancy test came back negative when a much younger Nat went through a pregnancy scare at age 18. So perhaps he was happy, but Susan was clearly not, and I think she wanted him to see that. Later, Madison told me she noticed the same thing, “I hate it when they perform like that.”
While Susan was in recovery, I realized that I had not given Luther back his hat. I went to find Luther in an otherwise empty waiting room and before I even got to the door, I noticed a new smell: the small room reeked of marijuana. Nobody had been smoking in the room, otherwise there would have been smoke, but somebody had clearly smoked recently and brought the smell in with them. When I looked at Luther, his eyes were bloodshot. I held up the hat, and said, “I have your hat.” Luther stood up, breathed heavily, and then sat back down, clearly overwhelmed. I tossed him the hat and said, “Good luck. Take care of Susan.” His head darted back to the television without another word. Stoned was no way to start out as a father.
Now I was relieved that Susan had the abortion. She knew she was doing what was best for her, Luther, and her unborn child. Having seen the situations that unwanted children can be born into, and the havoc that being brought up in a poor, neglectful, and/or abuse-ridden home can do to a child, I am certain that some people are better off not having been born. It hurts me to say it, but I think it’s true.
The gross reality of the abortion procedure leaves a lot for me to reconcile. Am I justifying a form of murder? Perhaps, but when exactly does life begin? Is it with the first mitotic cell division or the first heart beat? Is it the first lucid thought? A lot of unknowns. And what would happen if the child were to be born? Have I grown so self-absorbed to think that humans are so important that every single hint at a life should be preserved when there are millions of already born humans that don’t even get their basic needs met? More unknowns, though I’m inclined to answer yes to that last question.
I suppose it doesn’t really matter how I answer any question, because the reasons that a woman has to get an abortion are her own, and determining their “validity” is as difficult to ascertain as determining when life begins. The reality of the situation is that the procedure will continue to take place, whether legal or not, and to provide women with safe options is of the utmost importance.
My head was still spinning when I got on the bus to go home. It still is.
Friday, December 7, 2007
Stanford Life Flight
Phenomenal. Today I did a "fly-along" with the folks at Stanford Life-Flight. I got to go on three flights. The first was to a public relations event where we showed off for the some folks in Santa Cruz county. The second flight was to a hospital in the central valley to do a transfer and the third was to do a "scene" landing for a traffic accident. We were not able to land at the traffic accident because of its remote location, it was dark, and the fog prevented any and all visibility. Seriously fun.
All I can say is that this experience was riveting. I find the whole nursing thing pretty overwhelming on land--imagine trying to put an I.V. in a trauma patient while enclosed in the tiny passenger quarters of a helicopter! Amazing. One day I might get there, but for the time being I think I need to get things right while not wearing a flight suit.
Some may think this is a strange way to spend winter vacation, but like I've said before, I'm all in. Here are some pics of the day:
http://homepage.mac.com/gnattychad/PhotoAlbum26.html
All I can say is that this experience was riveting. I find the whole nursing thing pretty overwhelming on land--imagine trying to put an I.V. in a trauma patient while enclosed in the tiny passenger quarters of a helicopter! Amazing. One day I might get there, but for the time being I think I need to get things right while not wearing a flight suit.
Some may think this is a strange way to spend winter vacation, but like I've said before, I'm all in. Here are some pics of the day:
http://homepage.mac.com/gnattychad/PhotoAlbum26.html
Wednesday, November 7, 2007
"Only-oxycodone-will-make-my-muscles-strong-again"
REFLECTING ON: Maintaining objectivity even in the face of a med-seeking patient...
It had already been a long day before Grace and I had entered a Community Care Home in the East Bay. My feet were dragging as we passed the neglected lawn and entered the assisted living facility for adults. Folks here at the “home” have both mental and physical disabilities. We were there to see Polly, whom Grace, my preceptor, told me was a hard case. We got much more than that.
The front waiting room was a mix of 1970s décor that I’ve mostly seen in shitty dive bars, funeral homes, and my grandma’s living room. The walls were olive-green velour and the furniture was of the finest cracked vinyl. Doilies adorned the coffee table and ceramic Halloween decorations sat on top of those. Halloween had passed a week ago, but the heavy layer of dust let me know the decorations had been there longer than that. The front desk sat unmanned, so we peered down the nexus of hallways that sprouted off this bizarre portal. The halls were wide and dark and smelled strongly of cigarette smoke with a hint of emesis, emptied colostomy bags, and chicken curry. As I searched for signs of life, I only noticed shadowy corners and a cold breeze that did nothing to alleviate the pungent smell of “group home” living.
Grace and I called out and were answered with muffled, unintelligible shouting. For some reason, we took that as our cue to walk further down the hall. A man in a wheel chair with one leg suddenly rounded the corner. He wore old hospital pants and booties, a stained white v-neck t-shirt, and a brimmed beanie. Around his neck he wore a money sign medallion emblazoned with plastic gems. Never looking up, he moved quickly passed us while sneering at everyone and no-one.
As we worked our way from the a slowly disappearing exit sign, we found a second desk with a short, stout, worn and once-pretty Filipina woman passing out meds from behind it. She wore no identification, had deep, dark circles under her eyes and was only identifiable as a staff member because she donned Dickies scrubs and was behind the counter instead of in front of it. Without identifying herself, Grace asked if we could see Polly. The worn woman looked down at our badges, sniffed, and then shouted something in Tagalog down an empty corridor. A short man, whom I later found out was named Ben, scurried around the corner, gestured for us to follow him, and then disappeared again. We walked briskly toward the spot that he had disappeared at, only to find him at the end of another hallway, pointing towards an open doorway. He disappeared again. I felt like I was following the white rabbit down the hole. It was only at this point that I realized the hallways were lined with doors, which were painted the same color as the walls. Ben had moved so quickly I never saw his face.
As we entered the tiny, double-occupancy room, a trembling mass of a human lay awkwardly in its bed. She lie with her neck pinched so that her head deviated at a near perpendicular angle from her body—as if she lacked the will to move from a clearly uncomfortable position. This was Polly. I smelled pee and stale smoke and hoped that my nose would habituate soon. A mop of unkempt hair that I vaguely recognized as a grown-out bowl-cut hid her glazed over half-mast eyes. I watched a flash of recognition cross her gaze and Polly launched her into her performance almost immediately. “I-am-in-so-much-pain. I-am-shaking-all-the-time. Oh, Grace, what-am-I-going-to-do?”
Her staccato words came out like a 4th grader reading aloud round-robin style from a history book. This was clearly a script. She never deviated from this style. I kept looking for an unpredictable inflection in her tone or something that would give actual meaning/life to her words, but found nothing but all-too-recognizable med-seeking behavior. As the act played out, with Grace responded by making monotone, half-hearted assurances that everything would be okay, I half predicted the back of her hand to fall to her forehead like a damsel in distress. Then, as if I willed it, she did exactly that, “Oh why-oh-why won’t-the-doctor-give-me-oxycodone?” Her hand fell against her brow. “Only-oxycodone-will-make-my-muscles-strong-again-and-I-will-be-able-to-walk-again. Oh, oh. What-will-I-do?”
I looked away to hide one of those smiles that just can’t be hid, inhaled deeply, and attempted regain my composure before I took her vitals. In order to get her blood pressure, I had to unwrap her from the four sweatshirts she was wearing, which was a near impossible task given her unwillingness to sit up. I finally settled on taking her radial BP on her forearm. 140/80. She cried out when I mentioned this number but stopped when I told her that 140/80 was my normal BP. Not horrible, but not great. Temperature was 36.5 C, HR 85, and RR 20. Unremarkable really, outside her slightly lower temp, which I attributed to her lack of movement and the many open windows. Her physical exam yielded still more unremarkable information except for her right lower leg being edematous (+2 pitting), which I attributed to her recent knee surgery. The site of the surgery was reddish, but seemed to be healing well. When I felt around the site of the wound, she launched into a new script, “Oh, please oh please do not touch me like that. AHHHHHHHHHHH! So much pain. So much pain. I was attacked last week by a man that lives here. He’s crazy. He ran into me on purpose with his wheel chair. He’s got one leg. I don’t know why he did that. He’s so mean. I think they are going to evict him. Oh. Please. Let me escape this place.”
Her last sentence actually sounded convincing. I was ready to leave too. My ears burned, which they do sometimes when I’ve about had enough of just about anything. By herself, Polly was manageable, but I had already seen too much that day. Luckily, Grace dismissed us, “We’re going to go see what is going on with your meds and we’ll be right back.”
The hallway smelled better than the room, but I quickly realized that I didn’t want to be there either. As we approached the med desk, I felt like a re-enactment of Michael Jackson’s Thriller video was taking place. People were moving everywhere in random directions with various parts of their bodies hanging while other parts twitched. All of them wore blank expressions and were moaning or drooling. One woman in a wheel chair with a lazy eye and a half paralyzed face was shouting, “I want my god damn mail. It’s a fucking federal crime to withhold my mail. Give me my meds and give me my mail. You fucking crooks.” The one legged man in the wheel chair egged her on, and then turned quickly to face me, flashing a sly smile.
I found it easy to dismiss both the wheel-chair-lady and Polly’s complaints because they were crazy, looked funny, and were incredibly manipulative. Any legitimate concern that they might have was so hidden beneath the layers of lies and psychosis, I felt less than obligated to advocate for them. I was concerned and surprised by how easily I switched into that mode. Judgment. Hmmmmm. “Better get a handle on that, Nat.”
Grace had worked her way through the zombie melee and was talking to the worn woman. As I sat down at the med desk, Grace handed me a list of the meds and asked me to cross-reference them with what they had behind the counter. My mind switched out of judgment mode and phased back to my very green clinical skills. I was trying to remember everything to check: medication name, dosage, time, expiration date, prescription date, mode of administration…what else? I was sure I would miss something with the groans in the background. Fucking hell. The woman in the wheel chair was now ramming her chair into the counter. I moved down a seat and went to work.
I wasn’t a minute into the list when I noticed something that wasn’t on my list: the vicodin were huge and there were only two of them at the bottom of the pill bottle. When I opened up the bottle and held it to my eye, I saw that there were two 800 mg Ibuprofen tabs at the bottom. Then I went to my green skills list: prescribed on10/23 with 90 pills, 1-2 pills PO q 6 hrs, PRN. What was that? 8 pills max/day? 8 x 14 days passed=112 pills. 112pills-90perscribed pills=22 pills that couldn’t have been given because they didn’t exist. 22missing pills/8pills a day=almost 3 days of missing pain meds, assuming that she had consistently getting the maximum dose at the regular six hour interval. There was not way this place was consistent. Couldn’t happen. Too god damn crazy to be regular.
I smelled bullshit because narcotics were involved. I switched back into judgment mode and was happy to observe that I didn’t just apply my bullshit detector to the patient. Was I being too hasty to judge? No I had done the math right. There’s now way this place was regular in its dispersal of the meds. No fucking way. I was, am still pretty sure someone was pocketing the hydrocodone and switching it with an over-the-counter pain med. Jesus. Okay, maybe Polly was med-seeking, but she also had a legitimate concern. Now I felt bad. My judgment almost allowed me to ignore the facts. God I love facts and diagnosis based on them.
I looked to Grace and nodded toward the bottle as I handed it to her. Grace is hip to the fact that I’m a skeptic and like unspoken communication. She looked in the pill bottle and frowned. Then she spoke, “Good catch, Nat.”
When we brought the information to the worn woman’s attention, her English suddenly got worse and she had a harder time understanding us. She also couldn’t produce the PRN record, saying that it was locked up in the boss’ office and that the boss wasn’t around. Now the bullshit smelled stronger than the piss and cigarettes. I looked around and caught more Thriller video. Then I looked at the worn woman’s tired eyes and felt a tinge of sympathy. Shit. I would want some narcotics too if I worked here everyday. I smiled at her and said, “You’ve got a hard job. I used to do this too and it’s tough.” She smiled back as she hung up the phone with her boss. Then she lead us out of the facility, closing and locking the door behind us.
It had already been a long day before Grace and I had entered a Community Care Home in the East Bay. My feet were dragging as we passed the neglected lawn and entered the assisted living facility for adults. Folks here at the “home” have both mental and physical disabilities. We were there to see Polly, whom Grace, my preceptor, told me was a hard case. We got much more than that.
The front waiting room was a mix of 1970s décor that I’ve mostly seen in shitty dive bars, funeral homes, and my grandma’s living room. The walls were olive-green velour and the furniture was of the finest cracked vinyl. Doilies adorned the coffee table and ceramic Halloween decorations sat on top of those. Halloween had passed a week ago, but the heavy layer of dust let me know the decorations had been there longer than that. The front desk sat unmanned, so we peered down the nexus of hallways that sprouted off this bizarre portal. The halls were wide and dark and smelled strongly of cigarette smoke with a hint of emesis, emptied colostomy bags, and chicken curry. As I searched for signs of life, I only noticed shadowy corners and a cold breeze that did nothing to alleviate the pungent smell of “group home” living.
Grace and I called out and were answered with muffled, unintelligible shouting. For some reason, we took that as our cue to walk further down the hall. A man in a wheel chair with one leg suddenly rounded the corner. He wore old hospital pants and booties, a stained white v-neck t-shirt, and a brimmed beanie. Around his neck he wore a money sign medallion emblazoned with plastic gems. Never looking up, he moved quickly passed us while sneering at everyone and no-one.
As we worked our way from the a slowly disappearing exit sign, we found a second desk with a short, stout, worn and once-pretty Filipina woman passing out meds from behind it. She wore no identification, had deep, dark circles under her eyes and was only identifiable as a staff member because she donned Dickies scrubs and was behind the counter instead of in front of it. Without identifying herself, Grace asked if we could see Polly. The worn woman looked down at our badges, sniffed, and then shouted something in Tagalog down an empty corridor. A short man, whom I later found out was named Ben, scurried around the corner, gestured for us to follow him, and then disappeared again. We walked briskly toward the spot that he had disappeared at, only to find him at the end of another hallway, pointing towards an open doorway. He disappeared again. I felt like I was following the white rabbit down the hole. It was only at this point that I realized the hallways were lined with doors, which were painted the same color as the walls. Ben had moved so quickly I never saw his face.
As we entered the tiny, double-occupancy room, a trembling mass of a human lay awkwardly in its bed. She lie with her neck pinched so that her head deviated at a near perpendicular angle from her body—as if she lacked the will to move from a clearly uncomfortable position. This was Polly. I smelled pee and stale smoke and hoped that my nose would habituate soon. A mop of unkempt hair that I vaguely recognized as a grown-out bowl-cut hid her glazed over half-mast eyes. I watched a flash of recognition cross her gaze and Polly launched her into her performance almost immediately. “I-am-in-so-much-pain. I-am-shaking-all-the-time. Oh, Grace, what-am-I-going-to-do?”
Her staccato words came out like a 4th grader reading aloud round-robin style from a history book. This was clearly a script. She never deviated from this style. I kept looking for an unpredictable inflection in her tone or something that would give actual meaning/life to her words, but found nothing but all-too-recognizable med-seeking behavior. As the act played out, with Grace responded by making monotone, half-hearted assurances that everything would be okay, I half predicted the back of her hand to fall to her forehead like a damsel in distress. Then, as if I willed it, she did exactly that, “Oh why-oh-why won’t-the-doctor-give-me-oxycodone?” Her hand fell against her brow. “Only-oxycodone-will-make-my-muscles-strong-again-and-I-will-be-able-to-walk-again. Oh, oh. What-will-I-do?”
I looked away to hide one of those smiles that just can’t be hid, inhaled deeply, and attempted regain my composure before I took her vitals. In order to get her blood pressure, I had to unwrap her from the four sweatshirts she was wearing, which was a near impossible task given her unwillingness to sit up. I finally settled on taking her radial BP on her forearm. 140/80. She cried out when I mentioned this number but stopped when I told her that 140/80 was my normal BP. Not horrible, but not great. Temperature was 36.5 C, HR 85, and RR 20. Unremarkable really, outside her slightly lower temp, which I attributed to her lack of movement and the many open windows. Her physical exam yielded still more unremarkable information except for her right lower leg being edematous (+2 pitting), which I attributed to her recent knee surgery. The site of the surgery was reddish, but seemed to be healing well. When I felt around the site of the wound, she launched into a new script, “Oh, please oh please do not touch me like that. AHHHHHHHHHHH! So much pain. So much pain. I was attacked last week by a man that lives here. He’s crazy. He ran into me on purpose with his wheel chair. He’s got one leg. I don’t know why he did that. He’s so mean. I think they are going to evict him. Oh. Please. Let me escape this place.”
Her last sentence actually sounded convincing. I was ready to leave too. My ears burned, which they do sometimes when I’ve about had enough of just about anything. By herself, Polly was manageable, but I had already seen too much that day. Luckily, Grace dismissed us, “We’re going to go see what is going on with your meds and we’ll be right back.”
The hallway smelled better than the room, but I quickly realized that I didn’t want to be there either. As we approached the med desk, I felt like a re-enactment of Michael Jackson’s Thriller video was taking place. People were moving everywhere in random directions with various parts of their bodies hanging while other parts twitched. All of them wore blank expressions and were moaning or drooling. One woman in a wheel chair with a lazy eye and a half paralyzed face was shouting, “I want my god damn mail. It’s a fucking federal crime to withhold my mail. Give me my meds and give me my mail. You fucking crooks.” The one legged man in the wheel chair egged her on, and then turned quickly to face me, flashing a sly smile.
I found it easy to dismiss both the wheel-chair-lady and Polly’s complaints because they were crazy, looked funny, and were incredibly manipulative. Any legitimate concern that they might have was so hidden beneath the layers of lies and psychosis, I felt less than obligated to advocate for them. I was concerned and surprised by how easily I switched into that mode. Judgment. Hmmmmm. “Better get a handle on that, Nat.”
Grace had worked her way through the zombie melee and was talking to the worn woman. As I sat down at the med desk, Grace handed me a list of the meds and asked me to cross-reference them with what they had behind the counter. My mind switched out of judgment mode and phased back to my very green clinical skills. I was trying to remember everything to check: medication name, dosage, time, expiration date, prescription date, mode of administration…what else? I was sure I would miss something with the groans in the background. Fucking hell. The woman in the wheel chair was now ramming her chair into the counter. I moved down a seat and went to work.
I wasn’t a minute into the list when I noticed something that wasn’t on my list: the vicodin were huge and there were only two of them at the bottom of the pill bottle. When I opened up the bottle and held it to my eye, I saw that there were two 800 mg Ibuprofen tabs at the bottom. Then I went to my green skills list: prescribed on10/23 with 90 pills, 1-2 pills PO q 6 hrs, PRN. What was that? 8 pills max/day? 8 x 14 days passed=112 pills. 112pills-90perscribed pills=22 pills that couldn’t have been given because they didn’t exist. 22missing pills/8pills a day=almost 3 days of missing pain meds, assuming that she had consistently getting the maximum dose at the regular six hour interval. There was not way this place was consistent. Couldn’t happen. Too god damn crazy to be regular.
I smelled bullshit because narcotics were involved. I switched back into judgment mode and was happy to observe that I didn’t just apply my bullshit detector to the patient. Was I being too hasty to judge? No I had done the math right. There’s now way this place was regular in its dispersal of the meds. No fucking way. I was, am still pretty sure someone was pocketing the hydrocodone and switching it with an over-the-counter pain med. Jesus. Okay, maybe Polly was med-seeking, but she also had a legitimate concern. Now I felt bad. My judgment almost allowed me to ignore the facts. God I love facts and diagnosis based on them.
I looked to Grace and nodded toward the bottle as I handed it to her. Grace is hip to the fact that I’m a skeptic and like unspoken communication. She looked in the pill bottle and frowned. Then she spoke, “Good catch, Nat.”
When we brought the information to the worn woman’s attention, her English suddenly got worse and she had a harder time understanding us. She also couldn’t produce the PRN record, saying that it was locked up in the boss’ office and that the boss wasn’t around. Now the bullshit smelled stronger than the piss and cigarettes. I looked around and caught more Thriller video. Then I looked at the worn woman’s tired eyes and felt a tinge of sympathy. Shit. I would want some narcotics too if I worked here everyday. I smiled at her and said, “You’ve got a hard job. I used to do this too and it’s tough.” She smiled back as she hung up the phone with her boss. Then she lead us out of the facility, closing and locking the door behind us.
Tuesday, October 23, 2007
Pride, prejudice, and nursing
REFLECTING ON: Personal prejudices and confronting them while providing home care to patients during my community health rotation.
So I think it’s pretty clear that I have a strong prejudice towards rich folks. I judge them and am convinced that their money is what contributes to their swollen egos and entitlement. I have had enough negative experiences with them that I also hold the belief that their lack of humility within the healthcare setting is what allows them to make unnecessary demands and strike fear into the hearts of all healthcare providers because of their access to attorneys. They ask for help yet threaten lawsuits, which in my opinion, is the factor in hospitals and most institutional settings being unable to provide the necessary resources to all parts of their patient population.
Then I met Susan and all my prejudices fell by the wayside. She’s 94, has a metastasized abdominal tumor that, because of its advanced progression, could only be debulked rather than removed. Even after the debulking surgery, her GI system struggled to work through her colostomy. Sometimes her stool was green, sometimes light brown. Today it was orange, though she referred to it as “a tawny mustard”. Susan was so yellow as she lay against her white sheets, we now think the cancer has spread to her liver. I later learned that Susan used to have the healthy habit of running marathons. Her heart sounds confirmed that story: regular and strong like a Swiss watch.
Her husband, though well intentioned, was having a difficult time switching roles from high-powered banker to home-care provider—he recently had a run in with the washing machine where he put in too much detergent and flooded the laundry room. Even if he could provide competent care, Susan had an enormous amount of pride and wouldn’t let him switch her ostomy bag. Though she had tried at first to switch the bag by herself, the fact that she had relented to let us provide care indicated to me that she knew her time was close. She wouldn’t talk about that directly, though, and refused to be seen by hospice. Understandably, Susan wanted to continue to see the nurse that she had become comfortable with. Now, in her twilight, she had so little control and was being threatened with having to see a whole new batch of people. How’s that for humility?
In Susan’s perfect Pacific Heights mansion with a perfect view of the Bay, we changed her colostomy bag, switched her fentanyl patch, and drew blood for labs to confirm in our suspicions regarding her liver.
The perfect view doesn’t matter much when you’re in pain.
So I think it’s pretty clear that I have a strong prejudice towards rich folks. I judge them and am convinced that their money is what contributes to their swollen egos and entitlement. I have had enough negative experiences with them that I also hold the belief that their lack of humility within the healthcare setting is what allows them to make unnecessary demands and strike fear into the hearts of all healthcare providers because of their access to attorneys. They ask for help yet threaten lawsuits, which in my opinion, is the factor in hospitals and most institutional settings being unable to provide the necessary resources to all parts of their patient population.
Then I met Susan and all my prejudices fell by the wayside. She’s 94, has a metastasized abdominal tumor that, because of its advanced progression, could only be debulked rather than removed. Even after the debulking surgery, her GI system struggled to work through her colostomy. Sometimes her stool was green, sometimes light brown. Today it was orange, though she referred to it as “a tawny mustard”. Susan was so yellow as she lay against her white sheets, we now think the cancer has spread to her liver. I later learned that Susan used to have the healthy habit of running marathons. Her heart sounds confirmed that story: regular and strong like a Swiss watch.
Her husband, though well intentioned, was having a difficult time switching roles from high-powered banker to home-care provider—he recently had a run in with the washing machine where he put in too much detergent and flooded the laundry room. Even if he could provide competent care, Susan had an enormous amount of pride and wouldn’t let him switch her ostomy bag. Though she had tried at first to switch the bag by herself, the fact that she had relented to let us provide care indicated to me that she knew her time was close. She wouldn’t talk about that directly, though, and refused to be seen by hospice. Understandably, Susan wanted to continue to see the nurse that she had become comfortable with. Now, in her twilight, she had so little control and was being threatened with having to see a whole new batch of people. How’s that for humility?
In Susan’s perfect Pacific Heights mansion with a perfect view of the Bay, we changed her colostomy bag, switched her fentanyl patch, and drew blood for labs to confirm in our suspicions regarding her liver.
The perfect view doesn’t matter much when you’re in pain.
Monday, March 12, 2007
UCSF!
A flood of things to write about. The most of important of which is that I got into UCSF!! I really can’t believe it. I almost think that I’m not worthy. There’s something there that I need to think about, but it’s too late to get too deep tonight. I had to read the letter three times and then over the phone to my Mom to believe it. Wow. Life is going to change significantly.
Friday, September 1, 2006
UCSF Personal Statement
REFLECTING ON: I guess the entrance people read this and thought it was good enough...gives you and idea of what I did before UCSF...
Shortly after graduating from Berkeley, I found myself standing in front of thirty-five street-wise sixth graders in a dilapidated classroom in Newark, New Jersey. I was drawing a diagram of the irrigation systems of ancient Mesopotamia. My back was to the class and I heard someone cracking jokes about my drawing. It was Esperanza. After making several home visits to determine why Esperanza never did her homework, I discovered that her father was a crack addict and that her mother was a prostitute. Despite her distressing living situation, Esperanza still smiled at me and quipped that I was a better teacher than an artist. Then she stopped smiling, looked me dead in the eye and said, “Mr. Chadwick, I don’t mean to be rude, but what the f--- do I need to know this for?” The class collectively gasped and I had an epiphany: not only did few of these kids care about ancient Mesopotamia, but this knowledge could not help them at all with their most pressing problems. It was in this moment, in the heart of Newark, that I dedicated my life to helping people who had the greatest and most immediate needs.
Esperanza's question has had a profound effect on my professional career. Since that time, I have only held occupations in which I could help underserved youth with their most urgent needs. Upon returning to the Bay Area, I filled the role of surrogate parent to twelve severely emotionally disturbed (SED) boys as a group home counselor at St. Vincent’s School for Boys. During twenty-four-hour shifts, I learned to navigate the ebb and flow of their volatile natures while teaching them basic life skills. Next, I continued my work at Treasure Island Job Corps where I forged partnerships with local businesses and unions in order to place inner-city youth in construction and childcare jobs. Most recently, I returned to the classroom at Timothy Murphy School in order to teach academic subjects to the St. Vincent’s population. Though it was not uncommon for me to dodge a thrown chair in the middle of a lesson, my student’s extraordinary stories of survival and obvious need inspired me to show them how learning could enrich their day-to-day lives.
Whether I was working with a “student” or a “client”, I came to realize that the most appealing part of my work has been helping each person to gain the tools they need to survive their personal crises. I have chosen to pursue a career in nursing because it is a natural extension of my desire and talent for helping people through extraordinarily stressful circumstances. Nursing offers me the unique opportunity to integrate my crisis management experience with a precise set of science-based assessment and intervention skills that will have a significant impact on the health of an individual. Taking Chemistry, Physiology, and Anatomy has only confirmed my sincere interest in understanding the human body and has further inspired me to learn the methods to heal it. In order to help the people that are most critically in need, I intend on becoming a Critical Care Clinical Nurse Specialist in an Emergency Department. Through direct patient care, I believe that nurses are the critical link between a patient’s needs and the road to recovery. I am excited to combine the skills I have acquired as an educator and social worker with those that I will learn in order to become an outstanding nurse.
To gain a better understanding of Critical Care Nursing, I have been volunteering weekly in the Emergency Department of an East Bay hospital. Knowing that all experience is what one makes of it, I have observed, investigated, and absorbed as much as possible. Mostly though, I clean as many beds and stock as many supplies as quickly as I can so as to let the nurses and doctors do their work. And they do work. Hard. I once asked a veteran nurse named Maureen why she had become a nurse. Immediately “Moe” sized me up for what I was: a little green. She said that although she did her job because she enjoyed helping people, “it ain’t all superman stuff where you’re bringing someone back from the brink of death. Sometimes you’re just wiping butts.” At first I was puzzled by Moe’s blunt response. Then I realized that she was testing me. Moe was trying to tell me that there are many parts of caring for and healing a person and some of those duties are far from glamorous.
Although indeed “it ain’t all superman stuff,” each interaction with a patient or their family is a unique opportunity for assessment and intervention, no matter where that assessment might take you. I have watched in awe as RNs skillfully and thoughtfully navigate the countless different situations that bombard the Emergency Department. I have observed RNs assist in resetting dislocated shoulders, rapidly assess heart attacks and administer nitroglycerin, restrain violent drunks, soothe a woman that had to identify her deceased sister, irrigate the wound of a man that was hit directly between the eyes with a hockey puck, calm an erratic 17 year-old that had ingested psychedelic mushrooms, do a blood transfusion on a woman with a hemoglobin level of three and a scabies infestation, and perform countless other duties that boggle my mind. Even more impressive than the breadth of technical knowledge the RNs applied in each case was the obvious compassion they showed each patient.
I want this job. I want to know how to do what they do.
I am resolute in my decision to become an Emergency Room nurse. Emergency nursing enthralls me because I can fundamentally help people to heal, and in turn, pursue the things that give their life meaning. It would be an honor and a privilege to undertake my nursing education at UCSF.
Shortly after graduating from Berkeley, I found myself standing in front of thirty-five street-wise sixth graders in a dilapidated classroom in Newark, New Jersey. I was drawing a diagram of the irrigation systems of ancient Mesopotamia. My back was to the class and I heard someone cracking jokes about my drawing. It was Esperanza. After making several home visits to determine why Esperanza never did her homework, I discovered that her father was a crack addict and that her mother was a prostitute. Despite her distressing living situation, Esperanza still smiled at me and quipped that I was a better teacher than an artist. Then she stopped smiling, looked me dead in the eye and said, “Mr. Chadwick, I don’t mean to be rude, but what the f--- do I need to know this for?” The class collectively gasped and I had an epiphany: not only did few of these kids care about ancient Mesopotamia, but this knowledge could not help them at all with their most pressing problems. It was in this moment, in the heart of Newark, that I dedicated my life to helping people who had the greatest and most immediate needs.
Esperanza's question has had a profound effect on my professional career. Since that time, I have only held occupations in which I could help underserved youth with their most urgent needs. Upon returning to the Bay Area, I filled the role of surrogate parent to twelve severely emotionally disturbed (SED) boys as a group home counselor at St. Vincent’s School for Boys. During twenty-four-hour shifts, I learned to navigate the ebb and flow of their volatile natures while teaching them basic life skills. Next, I continued my work at Treasure Island Job Corps where I forged partnerships with local businesses and unions in order to place inner-city youth in construction and childcare jobs. Most recently, I returned to the classroom at Timothy Murphy School in order to teach academic subjects to the St. Vincent’s population. Though it was not uncommon for me to dodge a thrown chair in the middle of a lesson, my student’s extraordinary stories of survival and obvious need inspired me to show them how learning could enrich their day-to-day lives.
Whether I was working with a “student” or a “client”, I came to realize that the most appealing part of my work has been helping each person to gain the tools they need to survive their personal crises. I have chosen to pursue a career in nursing because it is a natural extension of my desire and talent for helping people through extraordinarily stressful circumstances. Nursing offers me the unique opportunity to integrate my crisis management experience with a precise set of science-based assessment and intervention skills that will have a significant impact on the health of an individual. Taking Chemistry, Physiology, and Anatomy has only confirmed my sincere interest in understanding the human body and has further inspired me to learn the methods to heal it. In order to help the people that are most critically in need, I intend on becoming a Critical Care Clinical Nurse Specialist in an Emergency Department. Through direct patient care, I believe that nurses are the critical link between a patient’s needs and the road to recovery. I am excited to combine the skills I have acquired as an educator and social worker with those that I will learn in order to become an outstanding nurse.
To gain a better understanding of Critical Care Nursing, I have been volunteering weekly in the Emergency Department of an East Bay hospital. Knowing that all experience is what one makes of it, I have observed, investigated, and absorbed as much as possible. Mostly though, I clean as many beds and stock as many supplies as quickly as I can so as to let the nurses and doctors do their work. And they do work. Hard. I once asked a veteran nurse named Maureen why she had become a nurse. Immediately “Moe” sized me up for what I was: a little green. She said that although she did her job because she enjoyed helping people, “it ain’t all superman stuff where you’re bringing someone back from the brink of death. Sometimes you’re just wiping butts.” At first I was puzzled by Moe’s blunt response. Then I realized that she was testing me. Moe was trying to tell me that there are many parts of caring for and healing a person and some of those duties are far from glamorous.
Although indeed “it ain’t all superman stuff,” each interaction with a patient or their family is a unique opportunity for assessment and intervention, no matter where that assessment might take you. I have watched in awe as RNs skillfully and thoughtfully navigate the countless different situations that bombard the Emergency Department. I have observed RNs assist in resetting dislocated shoulders, rapidly assess heart attacks and administer nitroglycerin, restrain violent drunks, soothe a woman that had to identify her deceased sister, irrigate the wound of a man that was hit directly between the eyes with a hockey puck, calm an erratic 17 year-old that had ingested psychedelic mushrooms, do a blood transfusion on a woman with a hemoglobin level of three and a scabies infestation, and perform countless other duties that boggle my mind. Even more impressive than the breadth of technical knowledge the RNs applied in each case was the obvious compassion they showed each patient.
I want this job. I want to know how to do what they do.
I am resolute in my decision to become an Emergency Room nurse. Emergency nursing enthralls me because I can fundamentally help people to heal, and in turn, pursue the things that give their life meaning. It would be an honor and a privilege to undertake my nursing education at UCSF.
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