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."

“There’s a boy in here”

This is me venturing out of my personal narratives and into an op-ed style...

While doing an observation at a pre-school for my Pediatric Nursing course, a four-year-old girl entered the classroom and, curious to identify the strangers in her classroom, asked her teacher, “Who are the new people?” Her teacher responded plainly by stating that we were nursing students. The little girl’s face quickly changed from an innocent and curious expression to being conflicted and confused. She took a long pause and then looked up at her teacher and said, “But there’s a boy in here.”

Indeed there is a boy in here—right smack-dab in the middle of many people’s privately held stereotype of what a nurse looks like. The little girl, of course, is certainly not without adult company. On more than one occasion I have been asked, “So you’re going to be a male nurse?” as if I was still in the process of choosing my sex as well as my profession.

Yes indeed! I’m a “murse”. Or, more accurately, a “mursing” student. And to be perfectly honest, I’m never offended by people’s surprise at a man becoming a nurse; not only do I revel in throwing people for a loop, I understand that some part of their stereotype is not without basis. According to the 2002 U.S. Department of Health and Human Services’ National Sample Survey of Registered Nurses, only 5.4 percent of RNs in the United States are men. Given the fact that registered nurses constitute the largest health care occupation, with 2.5 million jobs, the chances of interacting with a female nurse are pretty likely.

What does trouble me, however, is the all-too-frequent follow up question, “Why didn’t you go to medical school?” Given that 72.2 percent of physicians are male, I suppose I should probably expect this question, too. And yet, I am simultaneously fascinated and deeply concerned by how infrequently the flip side of this question, “Why didn’t you go to nursing school?” isn’t being asked of medical students. Clearly, nursing is not on equal footing with medicine.

I believe that the reason that this question isn’t asked points to a different, very misguided part of the nursing stereotype that is seldom discussed openly: that nursing is some sort of a lesser, sloppy-second alternative to medicine—particularly for a boy. I take serious issue with this aspect of the stereotype not only because is it categorically untrue, but also because this belief is extremely dangerous due to its roots in the long-standing power struggle between men and women. Historically, women have been professionally subjugated to men due to the inaccurate and sexist perception that men are smarter than women.

The reason that this hushed stereotype still exists is rooted in socially constructed and learned behavior. As exemplified by the four year-old at the pre-school, from a very young age we learn gender rules on a variety of subjects that range from toys and clothes to behavior and jobs. Consequently, I believe that the average Joe and Josephine on the street quietly subscribes to the idea that nursing, being female dominated, is also associated with the female personality attributes of caring and empathy while medicine, being male-dominated, is associated with the male personality attribute of scientific objectivity. Or, put more simply, RNs are sensitive girls and doctors are scientific boys. Furthermore, this translates to why Joe and Josephine view medical science, being more quantifiable than the ever-ambiguous emotion, as being equated with intelligence, while they view nursing as less intelligent.

It is absolutely time to smash these perceptions. Easy. Although it is true that nursing fosters a slightly more nurturing perspective than medicine, nursing is an incredibly dynamic field that includes nursing research on subjects not traditionally associated with nurses. For example, a colleague of mine, Monica R. McLemore, a Ph.D. Candidate and American Cancer Society Fellow at the University of California, San Francisco School of Nursing, recently described her research to me, “Simply put, I study the isoforms of CA125, which is a tumor marker of ovarian cancer. I also attempt to correlate these isoforms (using kilodalton size as a proxy for the true amino acid sequence, since I'm not THAT well funded) to serum concentration.” How about them apples?

As a man within a traditionally female-dominated profession, I am acutely aware of the fact that my presence in this profession is still perceived with some discomfort due to the fact that the socially constructed stereotypes of yesteryear still govern many people’s perception of the field. My message to you is this: let’s evolve people. It is absolutely time that we embrace a more enlightened perspective in order to truly understand the incredibly dynamic and diverse field of nursing.

I got a job!

I got the phone call today that I got a job on the cardiothoraic floor where I did my Med-Surg rotation. Wow! I feel so incredibly fortunate to have found a job so early in the year that is so in line with what I want to do. I accepted and then called my wife and then my parents. I will bask in the glory of this moment today, but tomorrow, I move on to the next thing to worry about...the NCLEX!

Nurses As Scientists

A classmate and colleague of mine, Elizabeth Goldstein, recently created and published a self-made podcast that explores the notion of "Nurses as Scientists". She is interested in demonstrating how nurses use science in our everyday actions, though it might not always appear so...take a listen.

How job interview anxiety and this program has caused me to talk to myself...

Reflecting on: Job search anxiety that manifested itself as apocalyptic self-doubt...

I am a little tired. Okay. A lot tired and want a break. My anxiety has been getting the best of me lately. I re-rehearse things that I certainly already know for tests, and for interviews. Thank god spring break is almost here. I have pushed myself and learned an amazing amount in one year. I have sufficiently squished and jammed my brain so full of knowledge that occasionally I don’t remember what’s going on around me. My brain aches like it does after a really hard test. All the time.

I’m complaining but am not going to change because this kind of ache is hugely beneficial to me. Knowledge allows me to better understand my patients and facilitate desired outcomes for them. From time to time, however, I need my rug pulled out from underneath me. I also need a little balance; a few purposeless conversations that aren’t always guided by overarching school goals might do me some good.

The long and the short of it is that I'm starting to talk to myself (loudly) in public. Most concerning...

Tomorrow I have a job/scholarship interview on the cardiovascular-thoracic floor at the hospital where I have been doing my clinical rotations. That is certainly freaking me out. No doubt. I made the plunge a year ago and was committed to an academic and profession. But this is the job. This isn’t school. This is the work! This is the work that I want to do. These patients—this is why I am in this program. Holy. Freaking. Cow.

The advanced practice degree, though meaningful and eventually useful, is not exactly my focus right now. Understanding the exactness of nursing procedure and working with patients is. Each patient is a lesson. There is no way of knowing what might happen in a day, except to monitor them and pay attention through assessments.

So I am committed to this work—as I am committed to working on this floor. Initially, I was concerned that working on a cardiac floor was not necessarily consistent with my career goals because it is not strictly a critical care environment such as the emergency department or ICU. When I really examine what I have learned this year and what I want to learn, I realize that working on this floor is perfect for me. My primary goal is to help patients that are critically ill and better understand them. While the ED certainly provides this opportunity, I do not believe that the patient care perspective that I will develop in the ED will be as complete as I need. Having volunteered in the ED for almost two years, I realize that nurses mostly get little snap-shots of different patients before stabilizing them and then discharging or admitting them.

While I feel that I am capable of doing these important tasks and still want to work in the ED, the cardiovascular-thoracic floor affords me the opportunity to cast my net a little wider, and better understand the history of the disease/illness that has brought the individual to the hospital. Thus, when eventually I decide to work in the ED, I will have insight into the exact "snap-shot" that I am seeing. Given the fact that heart disease kills more Americans than any other disease, the skills that I will learn on the cardiac floor are particularly relevant to emergency and intensive care nursing. Furthermore, the variety of patients and pathologies is particularly appealing to me, not to mention the fact there are codes almost weekly on this floor, thereby allowing me to be surrounded by and participate in critical care as well as acute and even preventative care.

God I hope I get this job.

Heart Attack and Angioplasty...

The heart is becoming my favorite nursing preoccupation. I could write pages about the pathophysiology of a heart attack (myocardial infarction/MI), or you could just watch this really good video. In a heart attack, the heart essentially essentially chokes itself to death.

To correct for the "choking", the coronary arteries must be widened, which can be done by placing a Stent, or artificial tube, in the coronary arteries to widen it. An excellent explanation:

Here is the actual video of someone's angiogram where they are injecting the dye in order to see various parts of this guy's vasculature.