Balance and Options

I’ve been a terrible blogger in these last few years, and my ability to write has suffered...so you’re going to have to bear with me here.  I will wax a little abstract and reflective here, as I try to find my voice again.  It won’t be the same voice, because as a nurse and a human being, I’ve had to change and evolve—some things are better, and some are a little worse (rusty, shall we say?).  Initially, when I first became a nurse, I wrote because the sheer amount of information coming at me was overwhelming.  In a matter of just two years, I had changed my career completely, and it was absolutely the right decision, but the gravity of each moment on the floor weighed on me.  To know something abstractly, at the academic level, is one thing, but to synthesize that knowledge and apply it to a dynamic situation, is quite another.  And so, I let my neurotic self run rampant, researching every fact and detail, arriving at work an hour early in order to learn about the potential challenges of that day.  You see, each decision, because of my lack of experience back then, felt like I was about to either kill someone or save someone—and to a large extent, I was right about that.  For example, even the simple act of giving lasix was a struggle.  If I gave it too fast, I was sure that I would cause ototoxicity (which I just learned, while confirming how to spell ototoxicity, can be potentiated by Aminoglycoside—still learning).  So that one supposedly simple task, along with the millions of other things that I had to do, felt like an eternity if I was to do them with any integrity at all.  12 hour shifts felt like 48 hour days on another planet with a much slower rotation.  The long days on that planet, however, didn’t mean a slowing down on the planet's surface...far from it.

Part of me misses those days because of how profoundly focused and curious I was.  I genuinely loved the job (still do), but the lions share of my dogged mental effort was born mainly out of not wanting to cause harm.  Not killing anyone is pretty much an absolute necessity in this line of work, and a profound motivator.  To compound matters, anyone who knows me just a little bit, knows that I am a little ADD.  When in a room, I’m pretty much absorbing everything that’s being said, the overall temperature of the room, as well as psychological and physical assessments of patients, nurses, doctors, nursing assistants, and even the janitor.  Taking in that much information, simultaneously, is exhausting.  So the 48 hour days felt like 96 hour days, because I was always “on”.

Fast forward 6 years, and here I am.  A somewhat “seasoned” nurse.  So, out of necessity for not wanting to kill myself, I had to adapt.  I couldn’t take all of those 96 hour feeling days.  I was more than a little obsessed.  Didn’t take breaks.  Didn’t take care of myself.  I essentially did all of the things that everyone tells you not to do.  All nurses, in their way, will put others in front of their own needs.  It’s a part of our strength, and a large part of our weakness.  It’s our “disease to please” as one RN put it.  I kind of love and hate that phrase.  It sits heavy in my mouth, like a bad word.  But like all bad words, it has its purpose, and are often more effective at expressing things than long-winded prose.  But I digress.

So where is my nursing now?  Mostly better, and a little worse.  I can’t quote you the exact pharmacological mechanism of every med in encyclopedic fashion like I once did…but I know what’s normal and can sniff out a spiraling patient versus a minor set back with the best of them.  I am comfortable with my patients, whereas before, I was running around so incredibly frantically that I didn't know how to actually sit down and listen.  At the beginning, I didn’t know how to recognize the subtleties of a patient’s presentation.  A mildly elevated temperature might go relatively unnoticed, whereas now, because I can synthesize that temperature with coldish extremities, mild leukocytosis, a normal blood pressure (but abnormally low for that particular patient) and know that they are in the initial stages of going septic. 

I hate to say it, but a lot of is instinct now.  I can sniff out the problem.  Whether it be the new resident that is more interested in appearing to care for his patients versus actually caring for them (because they’re new inexperienced and scared shitless—as they should be) or knowing that their is a problem with the overall skill set for a particular assignment.  I know I need to get more specific with these examples, and I will.  I just wanted to get to a jump off point.  A place where I’m a little more analytical and less instinctual.  Writing has always inspired that process in me:  the ability to listen to my own thoughts that are swirling by so fast that I often can't pay attention to any of them.  

So, I’ve pretty much swung from one side of the pendulum to the other.  Whereas before I had a lot of information and no experience, it almost feels like I’ve forgotten much of the book knowledge and gotten a little too comfortable in my ability to gauge a patient’s situation based on instinct.  Maybe this is the time where I find balance in my life—both personally and at work.  Wouldn’t that be nice?

Goal: Hiatus

Three years ago, I pretty much killed this blog through neglect.  It wasn't so much lack of interest as it was my attention being completely divided.  And the emphasis of my attention needed to be on my personal life.  So, here it goes.  In a word:  divorce.  As in I went through one.  Okay, maybe more than a word...

I never planned to divorce, which, until recently, completely flies in the face of how I attempted to conduct my life: lots of actuated and accomplished plans.  High-School-check.  College-check.  Find self-ehhh, kind of check.  Find wife-check, (then uncheck).  Have meaningful experiences-check.  Live happily ever after-check?  

Maybe what I should have made as my goal was say something like:  give oneself over to love, completely and utterly, and then keep on doing that until you learn everything that you've simultaneously always/never wanted to know about yourself and others.  Check on that.  Double check.  More checks to come.  The thing is, with my former wife, I held onto that love with a kung-fu death-grip for maybe slightly longer than I should have, but I really had no way of knowing that.  Like, I could tell you stories...and maybe I will one day, but for now I'll just wax introspective. Okay, maybe a couple of ambiguous details...

The divorce process itself wasn't ugly in that we didn't fight or haggle over money or property.  Truth be told, the paper part was relatively simple, even though it took me well over a month to have the emotional presence to read the damn papers.  As she was and still is an attorney, she facilitated the technical aspects of the divorce at little to no cost besides processing fees.  And although I was profoundly intimidated by the fact that she spoke "legalese" which definitely fueled my paranoia that somehow I was going to get screwed over, she didn't do anything untoward.  The fact is that by the time it came to get a divorce, we were both ready.  That was, if anything, the easy part.  The years leading up to the separation and divorce, however, were the emotional marathon.  Several years of emotional distance were followed by a year of couples counseling.  Ten months of separation.  Finding out who my friends were.  Crashing on couches.  Escapism...self-delusion...profound desire to go home but not feeling like I had one anymore.  Crying myself to sleep more nights than I care to remember.  The fact that I got up in the morning and made it to work was enough.  I really don't know how I did even that.  There's more, of course, but this is the abridged version as I am attempting to close the three year writing gap.  Well, I crossed the finish line.  And as is the case with most semi-introspective people who go through traumatic events, I feel like I'm a better, stronger person for it.  Would I wish it on anybody?  Nope.  Did I have to go through it?  Yup.  The following is an excerpt from an email I sent out once we had made the decision:

"Dear Friends and Family,

It is with a mixture of relief and sadness that we write to all of you
today.  We have both come to realize that it is best for both of us to
end our marriage.  This decision is mutual and amicable.  We have made every effort to try to preserve the marriage by seeking counseling over the passed year.  Through this process, we have come to realize that while we still love one another, we are not suited as husband and wife.  We do, however, have the utmost respect and admiration for one another and will continue our friendship" ... "We have both decided that this divorce will be friendly, dignified, and based on mutual understanding."

Ever the goal maker, I believe that we accomplished what we set out to do.  I just didn't know the goal it until later.

One of the things I learned through this whole process is that I have a tendency to continually put myself in the ringer, get completely twisted and rung out, and then go in for more.  Love does that to me sometimes.  So does ambition.  The movie Amores Perros (title of this film totally in sync with the tone of the next couple of paragraphs) comes to mind.  In particular the part when Susana says, "Si quieres hacer reír a Dios, cuéntale tus planes." (If you want to make God laugh, tell him your plans."

No I haven't fled the room, moving from "death grip on love" to "headlock on determinism", but I've realized that free will isn't the only thing out there for me.  Who one loves, how one loves, and even choosing to love is anything but simple.  Even if free will is out there, it percolates and filters through eons of human evolution, hella genetic code, billions of neurons, and the primordial ooze of relationshops long past.  

So, discovering all that very much flew in the face of my life's philosophy.  I held onto an idea, that with persistence, I could always make things happen the way in which I planned.  This is a good value, perhaps, if not more than a little flawed.  It's a good starting out philosophy...but it doesn't make for much in the way of character if I always get what I want...because whether I like it or not, it isn't all about me.  The reality is that there are a ga-jillion variables well out of my control and I have to make peace with that.  I suppose I could continue to battle.  But my hands are tired from my white-knuckling grip.  So in making this peace, I have divined a message through the eons of hella genetic code, ooze, and what not.  The distance and temporal component of the message makes determining who I should love kind of a mess.  But the message is clear:  I get a completely unknown number of years, give or take, to try to love.  Love is the mechanism through which I might bring something meaningful in myself and those around me.  And I should love completely, utterly, and deeply...  




...And yes I have a girlfriend and she's awesome.

Insomniac Ramblings

12:35am might not the best time to get restarting into my blog. Its two hours after my sleeping pill clearly didn't help me with just that, and I'm left , like Romeo, "so unsatisfied"--somewhere between lucid thought, the daze of the work day, psychadelic dreams, my personal studies and good old fashioned sleep. I sure would like to buy me some of that good sleep. For a quarter!

My wife is studying for the BAR coming up this week and vibrating on her own frequency of atomic collision while I continue on my pin-ballesqe jostle-tostle through and at the laughing hand of God. And it is laughing and it is God's hand my friends. This makes perfect sense to me, so I should probably stop. I have insight enough that this sounds like ramblings to someone else, but my expressive brain that shares some of the questionably bundled neurons stuffed to the back (the funny looking ones that occasionally squawk or fizzle) can't resist conducting a tangential tryst with such enticing impulses. Feel me? Pop....

Not a failure if it weren't such an effort. So I leave you with a prayer from the righteous words of Jerry Springer, "Until next time, take care of yourselves and each other". Schmuck.

My Little Brother

My little brother, Elliott, was born at eight and a half months with a clubfoot. That was an outstanding outcome given the complicated nature of the pregnancy. Under doctor’s orders, my Mom had been bed-bound for the last three months of her pregnancy after her amniotic sac prematurely broke, induced labor but then miraculously resealed itself. Bottom line: today Elliott is healthy and my hero. He's 22 now and going to nursing school.
Elliott’s actual birth followed the pregnancy’s theme of dramatic and unexpected events. Already on edge due to the previous complications, when my Mom’s water broke for the second time at 5:30 am on November 19, 1986, my Dad drove us to Kaiser Sacramento at over 100 miles per hour. I was nine years old. When we arrived, all the doors of the hospital were locked due to an ongoing nursing strike. We pounded on the doors for what seem like hours. My Dad had me run up and down the hospital looking for open doors. As I ran, I can distinctly remember watching nurses picketing while my Mom lie panicked on the sidewalk. I did not understand why they wouldn’t help us. I still don’t. My Mom suddenly screamed in panic because she knew Elliott was well on his way. This was her third child. My Dad, always heeding the call of an emergency, grabbed the locked steal and glass sliding door, and with the superhuman strength that you read about, unhinged the door and moved it to the side. An alarm went off that triggered the attention of an irritated, all too casual nurse to walk down an extremely long hallway and yell at us, “What the hell is your problem?” My Dad ignored her, carried my Mom passed her and to the nursing station of the birthing center, and got the help of a more interested staff member. Almost fully dialated, she went straight to the birthing room. While on the gurney, my Mom howled just like a wolf and could be heard throughout the hospital.
In the shuffle, I was left with the nurse we had first met. She put me in a little square room and said, “That your Mom?” I nodded, she snorted, told me to stay put, and closed the door. I REALLY didn’t like her. Following my Dad’s example, I ignored her and left the little square room and followed the still audible howls. In my mind, the hospital staff was suspect and I wanted to make sure my Mom was okay.
I followed my Mom’s howls through a labyrinth of hallways and doors. I found her. The birthing room had a large window and I had arrived just in time to see my Dad cutting Elliott’s umbilical cord. Elliott was born at 7:00 am. Another nurse came up to me and told me I wasn’t supposed to be there. I just looked up at her and pointed through the glass and said, “That’s my brother.”

UCSF MEPN interview

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.

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.

Chadwick, RN

Yup. I passed the NCLEX! I am happy. Really happy. I feel quite accomplished. I over studied, but that also saved me from feeling the anxiety of seeing something on the test that I'd never heard of. And now, 3 days of 12 hour shifts and 1 four-hour class each week sounds like a real vacation. My off time will be mine. No looming deadlines. No papers. No tests that will determine the course of my life. Just good old-fashioned work.

I've been working on the cardiothoracic floor for 4 weeks now. I'm all thumbs but I love it. The struggle is so much more tolerable when it's not in a book of theory and out in "the real". I can see that my efforts are directly benefiting the patients that I work with. It's awesome.

And for now, it's time to relax a bit.

Murals @ UCSF

Uploaded - Jul 16, 2008-8
Originally uploaded by nat_chadwick

I've recently purchased an iPhone and am having mad fun taking pictures and uploading them to my flickr account. I can even post them from the phone onto my blog. Wild. Technology is something. Anyway,they have these medical murals all around the UCSF campus. Some of them are really bizarre, especially when you get into detail. Click on the photo to see more iPhone photos and bizarre mural photos.

M.I.A.

So, sadly I haven't been writing much. I've been MIA from most of my life these daze. I miss writing, but I've been a little preoccupied with studying for the NCLEX and starting the new job. Unfortunately, I still haven't taken it because the date I originally wanted to take it was not available due to scheduling issues with my new job. I am so incredibly happy and feel so lucky to have gotten a job on the floor where I work. It happens to be the same floor where I did my Med-Surg rotation. I'm seeing new MEPNs all around me as I attempt to learn the ropes. I loved this last year, but I would not try to do it again. It was an intellectual-spiritual-physical-addyourown-ical challenge. I do hope they enjoyed it like I did. It was a hell of a year. At this point, I will be taking the NCLEX on the 30th. I cannot wait to have that monkey off my back. Wish me luck.

Psych Moments

So I've just recently started my psych rotation on a floor that specializes in patients with schizophrenia, bipolar disorder and shizoaffective disorder. I've been out of psych for long enough that I miss it. Random moments and exchanges with patients that you won't ever experience anywhere else happen on these floors. Here are a couple:

First day getting adjusted--I am suddenly distracted from a conversation with a biploar patient due to a loud noise. I ask the patient to repeat what she just said. She responds, "Look, I know I have a short attention span, but I'm bipolar. What's your excuse?"

Second day, talking to a patient with schizoaffective disorder. I attempt to assess his ability at abstract thinking by asking him to interpret the saying 'A rolling stone gathers no moss'. Our exchange:
Patient: Stones don't gather moths. Besides moths couldn't lift stones either.
Me: No, moss.
Patient: Oh, that changes everything. That rock is a loser. The moss is the winner.
Me: Why is that?
Patient: The rock couldn't gather any moss so the moss must have gathered all the stones!
[I still don't know how to interpret that one]

Third day, walking up to patient who is rolling their eyes in every direction, " I can't even see my eyes!"

Another patient, when asked if she was Catholic, said, "I'm on the cusp."

A HIV+, 60 year old man diagnosed with shizoaffective disorder that was coming down off a recent crack binge was asked about his goals, "I'm just trying to get a grip on what little years I got left."