Cardiac caths, GI scopes, hypoglycemia, and a full floor oh my!

I am currently training in the intermediate care unit (IMCU) which I am realizing is like the revolving door for the entire hospital.The IMCU acts as the step down unit from ICU (down the hall from us). It receives semi critical patients from the ER (GI bleeds, minor-moderate sepsis, small bowel obstruction, COPD exacerbation,  etc). We also receive patients from the other floors whose condition has changed, usually coming to us from the cardio-pulmonary floor or the medical floor. (Med-surg is separated into medical or surgical in our hospital).

This was my 3rd week on the floor. I have 3 amazing preceptors, but it never fails that when I'm with who we will call Preceptor A that things get crazy. It's not her fault, it's the universe's. This week our IMCU and our ICU were packed full. Topped off. I had a full patient load (that's 3 in the IMCU), my preceptor even had her own patient, and the IMCU charge nurse had a patient or two. The doctors were cranky, the nurses were cranky, surprisingly the patients were in a good mood. I left at 2000 and was beat!

The really cool things that I did see and participate in this week:

• watched sheaths being pulled on a cardiac cath patients. A cardiac catheterization procedure is where a long, thin tube (called a catheter) is inserted into a major blood vessel- usually the femoral artery.While this catheter is in the blood vessels there is imaging going on at the same time where the doctor can see and do diagnostic tests, such as looking for blockages in arteries or plaque build up. After the procedure the patients come to the IMCU, where there is still a sheath left in the blood vessel, but the catheter is out. After an hour we pull the sheath and hold pressure on the site for 20 minutes (minimum).  This is frightening/thrilling!
• attended an esophagogastroduodenoscopy (EGD). This is the camera that goes through the mouth, down the esophagus, through the stomach, and down to the duodenum (the top portion of the small intestine). On the screen it looks like a really complex video game with extra features like needles to give shots, the option to cauterize tissue, a balloon to mechanically dilate tight spaces, and a biopsy clamp.
• had my first episode of severe hypoglycemia with a blood glucose of 44 and initiated the severe hypoglycemia protocol. It was amazing how fast D50 works.
• discharged patients to home
• transferred patients to different units
• admitted patients from outside hospitals

My overall impressions of the last few weeks is that somehow the stress I associated with clinical in nursing school has subsided. Although it's been crazy busy, I don't have that anxiety knot that used to sit in my stomach. The switch has been flipped in many ways from nursing student to RN. I realize I have a lot to learn, but it's nice to feel calm and know that I can use my resources when I don't have the answers.

Yuletide poetry

As we contemplate the new year ahead, I sometimes find poetry does a much better job at summarizing the intangible. Here is a good one for contemplation. I first heard this poem this May when it was read at our nurse pinning ceremony. Simple and to the point. I hope you enjoy it too.

Life

Life is an opportunity, benefit from it.

Life is beauty, admire it.

Life is bliss, taste it.

Life is a dream, realize it.

Life is a challenge, meet it.

Life is a duty, complete it.

Life is a game, play it.

Life is costly, care for it.

Life is wealth, keep it.

Life is love, enjoy it.

Life is mystery, know it.

Life is a promise, fulfill it.

Life is sorrow, overcome it.

Life is a song, sing it.

Life is a struggle, accept it.

Life is tragedy, confront it.

Life is an adventure, dare it.

Life is luck, make it.

Life is too precious, do not destroy it.

Life is life, fight for it.

written by Mother Teresa

Pink and purple stethoscopes, senior nurse preceptors, and prepping for Xmas

The wonderful thing about training as a new nurse over the holidays is that your preceptors must be experienced nurses. Therefore, since you have experienced nurses, they get the holidays off because of their seniority. And that means you get the holidays to yourself- at least this year! (All bets are off for 2013).

Last night my hubby and I finished our gift wrapping while munching on smoked oysters and crackers. We each had our own tin of oysters so there would be no bickering this year! For our nieces we included a pink and a purple stethoscope in their present. They also happen to be getting a costume box full of princess costumes from their grandparents! They were my first stethoscopes that got me through nursing school, only to be replaced about a month ago with my fancy pants new Littman Cardiology III for the IMCU/ICU.  I must admit it feels like I've gone from riding a trusty tricycle to riding zippy new road bike with this change!

I didn't know what I wanted to be when I grew up and nursing is the passion that I never knew I had. I'm so thankful I've found this profession that challenges me in cerebral, emotional, and profound way. My nieces, who knows what they will grow up to be, but they are already so aware of the things they could be when the time comes! In the few times we have played together since I've moved here we have played pretend: policeman, teacher, nurse, artist, and  nursing student (they keenly observe their amazing mother in nursing school right now). I hope these stethoscopes bring them some joy as they continue to pretend and imagine and someday realize their possibilities. It probably doesn't hurt that the stethoscopes are also in the girls' favorite colors and should match their princess dresses too ;)

Here is to creativity, imagination, and playfulness!

Humor: You know you're a critical care nurse when...

Okay, yesterday's post was heavy. This morning I scoured the internet for some critical care nurse humor to lighten things up:

20 reasons you know you're a critical care nurse:

1. You dread the new resident rotation.
2. You’re used to not using the bathroom in a 12-hour shift.
3. You tell the resident and/or doctor what orders to write.
4. You eat in between hanging blood and plasma.
5. You’re there when the code 99 is over before the doctor gets to the room.
6. Your job is stressful and all you’re afraid of is the thought of cutting people’s hair.
7. You go in to work for your shift and you’re not overwhelmed—it is what it is. 
8. When you can't stand your patient not to look tidy and calm in the bed with all their lines neatly organized.
9. When you get angry that a patient doesn't have a central line.
10. When you understand the saying "There are many things worse than death."
11. When you put the code cart next to certain patient's rooms to ward off evil spirits. 
12. When your patient's room looks cleaner than your own bedroom.
13. When outside of work, you answer your cellphone with, "ICU this is ____"
14. You are superstitious about the words "Code" & "Quiet" being said aloud at work.
15. You believe in happenings of 3.
16. When the amount of devices in your room requires you to recruit a posse for traveling.
17. What you consider humor is considered deranged by others.
18. Your ECG leads come off, giving the illusion of asystole. When your co-workers get to the room, you wink and say, "gotcha!"
19. You alphabetize your drips
20. You have seriously considered giving yourself an IV coffee bolus before

I have done a few of these already in the last week! For example I got a swallow eval ordered on a patient that aspiration seemed a likely risk. When the doctor arrived I let him know that it was a good thing he ordered the swallow eval because the patient needed a diet change to prevent aspiration. He was thankful I didn't bother him with the phone call and went ahead and used some critical thinking skills.

And my patients' rooms always look tidier than my house...;)


Sources:
ScrubMag
AllNurses

The privilege of ritual in death

Note: in the spirit of HIPAA, lets be clear. I am not using patient identifiers.

This week started out on a cheerless note. I was getting report at 0700 from the night nurse for a patient new to me. This patient's cardiac telemetry monitor went wonky (after my ECG course I will be able to better describe this) and a patient's significant other ran out of the room to tell us something was wrong. Within moments several nurses including my preceptor and I were in the room and we were sending staff away because this patient had a DNR (do not resuscitate) order as their cardiac monitor went into asystole (aka 'flat lining').

I had not had this patient at all. All I knew about them was from report. When I walked in the room though and saw my patient's significant other and adult child processing what they had just witnessed my heart ached for them. I saw how hope disintegrates into grief in a matter of moments as they held on to someone whom they had loved dearly. 

Some nurses talk about doing battle against the Angel of Death and keeping score. I understand the anthropomorphism of a natural phenomenon. When I think of Death, I think of the story book death, the grim reaper in a cloak with bony hands coming to collect souls and take them to the next chapter. When you have a successful code it's hard not to be a little proud in thinking that you cheated Death and his bony hands are leaving the hospital room empty.

Regardless of this mental image I have, I'm not spiritual or religious. I don't believe in an after life. I try to live like each day is my last because as far as I know this is the only life we have and we better make it count. Nonetheless, I do think there are sacred moments when we participate in rituals that bring meaning to those involved. After the family left my preceptor and I went in to prepare the body.

This ritual was new to me. We were kind, we were gentle, we maintained dignity. We disconnected lines, we washed, we tucked in. There was an order to this ritual. This sacred duty has not changed much, apart for adapting to our current technologies, through the evolution of our species from hunter gather to present day web surfer. Our species has always cared for those who pass. Like a midwife bringing a child into the world, I felt  like my preceptor and I were preparing this vessel for the next journey, just the reverse one where dust will return to dust. 

Honestly, this process was not discussed enough through nursing school. This sacred charge of caring for the grieving and caring for the deceased is another part of being a nurse that keeps us humble as we are privileged to take care of our patients in their most vulnerable ways, even when they leave us.

Life is precious and momentary. Savor it. 

Feet on the floor

I finally had patients this week and worked on the floor!!!

The high lights from work were:

-hanging blood for the first time (as a student we watched this process, but could not participate)
-going to a cardiac catheter lab to see the placement of a Swan Ganz cardiac catheter
-starting an IV
-learning new equipment
-learning new computer charting system
-finally getting my own login and password so I didn't have to bother my preceptor every time I needed to access medication or do my charting!!!

Other fun things:

-attended 'Stroke Fair' - a mandatory class for all RNs in the hospital all about strokes because our hospital is trying to be certified as a stroke center. It was very informative.
-everyone is incredibly nice on my unit!!! I think this is the most valuable portion of my job - being surrounded by warm, supportive, funny people is therapeutic and I definitely feel welcomed and that this in an environment where I will succeed.
-the doctors that have a reputation for being mean to new nurses were told to be nice to me. This was very appreciated because some of them are curmudgeons.

The drive:
-I get to see snow in the morning (don't worry my studs are on my tires). It's gone by the time I drive home at night.
-I drove through fog as thick as butter on Thursday night and almost drove by the hospital entirely it was so foggy!

All in all it was a very good week. I think as a new nurse often your own worse critic is yourself. It's hard to be in an environment where everyone appears to be so put together. My nurse educator has a self deprecating sense of humor. It's been really appreciated when I find myself muddling, through an ECG strip for example. She is excellent at telling me what I am doing well first and then telling me what we can work on next. She is also insistent when I make a mistake to let it go once I've figured out what I'll do differently next time. No stewing allowed! I'm thankful though that my education was so rigorous. It's given me a confidence that although I certainly have a ton to learn, that I have a good foundation to build upon.

That's all I got on a Saturday morning. Now I'm off to play with my nieces!

Friday night misadventures in pajamas and barefeet

I did not work today, in fact I am considering this my last weekend for a long time to come (maybe even until I retire) and I planned on relishing it. My in-laws were out of town until tomorrow, so it was going to be a quiet night in.

Today I ran some errands, made up some holiday gifts, went to the gym, faxed papers for the real estate agent, and ended my day with a subliminal bath complete in a jetted tub.

In my pajamas I curled up on the couch with a stack of comic books - the Far Side and Calvin and Hobbes. Life was excellent. The dingoes asked to be let out so I let them out and then headed to the garage to grab a beer to accompany my comics.

Mango and Marley the cats were out there and made a dash for the door between the house and the garage. I instantly closed it to keep the girls out of the house. Then of course, like the cogs in a machine painfully becoming unstuck, I realized in horror that I had locked myself out of the house entirely. In pajamas. Barefoot. Without a cell phone. And it's 35 degrees F outside. %$#@!

So, I did the first logical thing that would avoid embarrassment

Option 1: I grabbed the ladder and went out the back yard in the dark where the dogs were and attempted to set up the ladder beneath my bedroom window. One of my windows was open today and I thought perhaps I could access it on the second floor. On my way to the window of course I stepped in dog poop. Great. I'm in pajamas, barefoot, and now I smell terrible.

My ladder was definitely long enough though to reach the window! The ground, however, was dangerously uneven. I seriously considered climbing it regardless of the risk. It did seem worth it to perhaps have the cops called on me for breaking and entering. Then I thought , 'Wouldn't it be ironic if I end up as a patient in the ICU where I'm supposed to start work on Monday?' Thankfully that sobering line of sanity shook me up enough to make me explore my other options.

Option 2: spend the night in the garage. This seemed like the completely logical option in comparison to being embarrassed of course. So I washed my feet and began hunting for blankets or anything that could keep me warm inside the garage. I think at this point my feet were numb, too. I found pink insulation, 2 cats that were not interested in cuddling, and a toddler's trampoline. Oh, and I found a painter's jacket. I did put that on because being in my pajamas and all, well, cold weather and female anatomy are just not decent in these situations! Let me tell you, I'm so thankful I had pajama pants and top on (as opposed to a nightgown only) or else I would have never considered option 3. I would just have opted for hypothermia instead.

Option 3: After my fruitless hunt I had to face the inescapable, humiliating fact that I was going to have to find someone to help me. I vetoed the neighbors on either side of the house because their lights were off. Plus, I couldn't ask to use their phone since in today's era of cell phones the phone number recall portion of my brain has atrophied and the only other family member in town happened to be out of town too. My best bet was walking to mayor's house because at least he had my family's phone numbers in his cell phone.

Walking barefoot on the streets (mind you there are very few side walks here) with the threat of goatheads (see previous post Botany Lesson #2) was rattling. I had considered wearing the ski boots that I had seen in the garage, however, I thought that might make people less likely to help me since I might look like a bit of a lunatic in ski boots, pajamas, a painters jacket, and my wet hair looking like a dandelion.

Somehow I did not get a single goathead lodged in my tender soles. I rang the door bell and simply said, 'I locked myself out!' and attempted to look like a lost little puppy. It worked ;). The mayor and his wife were thankfully having a beer when I arrived and invited me, served me a couple beers, shared great conversation, drove me home, and unlocked the door!

What a night. Now I can get back to my comic books.

Week 1: Hospital Orientation (aka Death by PowerPoint)

The moment you have all been waiting for! A work related post and less pattering about small town Southern Idaho.

Well here you have it!

I woke up at 5:00am and got ready to go to work on Mon/Tues/Wed. Since it's general orientation this week I prepped my business casual clothes and headed to the hospital.

Cons of orientation:

• Sitting for 8 hours. Although we did get breaks this was still torture. It was like being in nursing school again! I have a chiropractor appointment to correct that this week.

• People who read off their PowerPoint slides. Yawn!

• We went to the Simulation room to see the mechanical lifts the hospital uses. This was in all reality great, but the initial 3 minutes felt akin to an anxiety attack because I associate Simulation rooms with passing or failing out of nursing school. How unnerving!!!

• My charting program was created before the mouse was invented. Being of the 'point and click' generation this is really foreign to me. I'll get a hang of it eventually, but it feels archaic to me and I look incredibly dumb trying to click on un-clickable items while glaring at the screen.

Pros of orientation:

• I have a name tag that does not say "STUDENT"
• Someone explained the Idaho Nurse Practice Act. Unlike OR and WA, Idaho's Nurse Practice Act is incredibly vague. I was so relieved that the presenter acknowledged the vagueness of the act and clarified what is expected of RNs within the hospital and what we have to do to protect our license.
• I met some of my coworkers from the IMCU/ICU unit. One of my preceptors even started as a new nurse in ICU. It was a relief to know that it's normal to cry every day for the first year (yes, that still stays in the pros column - it's good to know what's the norm).
• Respiratory therapy does everything with tracheotomies and tracheostomy tubes. I don't like trach tubes - I have found the phlegm is one thing I cannot deal with well without turning several shades of purple while trying to maintain a nice smile for my patient. (Non medical people: a hole into the trachea, under the Adam's apple, is called a tracheotomy. The tracheostomy tube is the tube that goes into the hole to keep it open. This procedure and tube provides an airway for people who cannot breathe otherwise.)
• Windows! After having seen some hospitals and long term care facilities lacking natural light, I am a believer that natural light is good for patience and staff. Even cooler is the fact that patients control their own window shades. With the click of a button from the patient bed the curtains go up or down.

• Even Florence Nightengale agrees with me, "I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all at the least expense of vital power to the patient."

I'm guessing the next blog entry will be full of unadulterated terror as I probably will come to realize what I have happily/ignorantly signed my self up for as a new nurse. These words come to mind: hysteria, panic, consternation, and distress! 

In the mean time I'm enjoying my last weekend for a very long time. I hope that a year from now I can reread all this and can laugh at myself and reflect on how far I've come.

The truth behind pharmacology

This summarizes why knowing your medications is so important. It is so you can try to avoid this sort of cycle at all costs - both financial and physical- to your patients!!!

This poster was prominently displayed at the clinic I went to last week for my sinusitis and I thought it was really great in that it could foster conversations between patients and health care providers about what needs must be addressed and what preferences can be addressed.

Buhl Light Parade & Chocolate Mousse

Last night was my father-in-law's birthday dinner. In the style of a European meal we spent the day preparing an 8 course meal. We had 10 people for dinner with whom to share all the  delicious food and drink.

One of the greatest surprises (for me at least) was that the Buhl Light Parade went by our house. Right before the fish course everyone ran outside with their wine glasses to see the floats and clapped and cheered as trucks, 4 wheelers, and trailers, transformed by a plethora of Xmas lights into glowing floats, crept by . It was so small town Idaho.

The middle school band jazzed up the night with 'We wish you a Merry Christmas' while the procession was carefully monitored and guided by the 2 functioning city police cars in town. We sipped our wine and appreciated the scene with the other neighbors outside.

Below is our menu for such a delightful night.

Aperitif et hors d’oeuvres

Champagne and an appetizer of olives, mixed nuts, smoked salmon, and breadsticks

Entrée

A light potato soup

Le Poisson

Sautéed tilapia amandine served with cold asparagus and vinaigrette

Palate Cleanser

Lemon sorbet

Le Plat Principal

New York cut beef with Bordelaise sauce served with petite potatoes

Salade

Tossed greens and vinaigrette

Le Fromage

Assortment of cheeses

Le Dessert avec café

Mousse au chocolat with decaf coffee

2 week marker & top 10 list

So far we have been here for 2 weeks exactly. In an effort to adapt I am creating a top 10 list of what I have enjoyed so far while living in southern Idaho. These are in no particular order.

1. Being dry on dingo walks
Although I am turning into a raisin, I must admit I really enjoy not having to change my clothes every time I take the dingoes for a walk. This in turn has reduced the amount of laundry I have to do (for those of you who know me, you know the malice I harbor against doing laundry). And lastly, I am getting my daily dose of Vitamin D with these blue skies instead of drinking gallons of fish oil. Oh, and I get to wear a 'really cool' neon green vest over my clothes because there are few street lights here and even fewer porch lights. Therefore, I now glow in the dark for safety reasons.

2. Lack of traffic
When I first moved to PDX I was terrified of driving in the city. Thanks to my first job I quickly learned the ins and outs of the thriving metropolis. Now my soon to be commute to work is through cow pastures and farm fields. I am a lot nicer human being without the traffic. Goodbye road rage!

3. Cloverleaf Creamery & Seed to Store
In leaving PDX I thought I would never have any good food ever again. Although that has turned out to be mostly true in the case of restaurants (thankfully my in-laws are amazing cooks), I have found 2 places within walking distance from my house that have fresh local eggs, butter, milk, cheese, & ice cream(the creamery) and fresh local bread, local coffee, and local fruit (seed to store). I think the best part is that they know my name. Not even New Seasons or Whole Foods can do that in their big impersonal organic corporate way.

4. Hot springs
The closest hot spring in PDX was 1 1/2 hours away. In fact, I never even visited since the drive was such an inconvenience to get there and you would probably fall asleep on the drive home! I am so excited to spend cold winter nights soaking in the mineral waters that are a 20 minute drive away. In fact that's my plan at the end of my three 12 hour shifts is to go straight to Miracle Hot Springs.

5. Family
It was so great to spend Thanksgiving with family. My nieces are growing up so fast and despite coming down with the preschool plague it was a hoot to draw cartoons for them and play pretend nursing school (their mom is in nursing school - hence it was their suggestion, not mine!). Cooking with my in-laws in the evenings and introducing Michael's aunt to the Walking Dead has been a blast!

6. my hospital
I'm going to gush - it's brand, spanking new! I did clinical rotations in a lot of amazing hospitals in PDX, but even those look a little 'old' compared to this one. I can't believe how beautiful it is and I'm so thankful for giant windows that let the light in!

7. Cold
It's crazy because I so cherished not being cold in the PacNW. However, there is something charming (or it's the ice seeping into my brain) about seeing your breath on a dog walk and the ritual of bundling up to do battle against Jack Frost each day. I get to wear my long johns and my scarves and all my hats. It also makes me really appreciate the days that are 'warm.'

8. Walking almost everywhere
Interestingly enough, I think I walk here more than I ever did before. Maybe it's because I can walk to to gym or my hubby's office now, but since I've moved here I have been clocking 7 miles a day on the pedometer. Usually I struggled just to manage to hit 5 miles a day. I'm not entirely sure how that has happened, but it's pretty lovely to have all my conveniences - except work - are within walking distance.

9. A Husband with an office outside of house
My honey has been working from home since 2008. He is incredibly disciplined and a hard worker. However, here he gets to have his work office outside the house. This means he walks to work in the morning, walks home at lunch time, walks back to work after lunch, and walks home when work is done. Having a true barrier between home and work has made such a difference. It's so nice to know that he can't go into the other room to answer a work email on a Saturday. Yahoo! Also, it means there is a slight chance that the Star Wars posters might move out of the house too. I think they would be a great addition to his office space.

10. Stars
The Milky Way doesn't get much better than this! Or this week's glowing full moon for that matter. All the constellations are crystal clear and the planets too. Each evening walk is an adventure in astronomy.