One year - it's a wrap!

As of this month I have been working as a nurse for a full year for the same hospital system. It has been an incredible journey that has been peppered with challenges and jubilation in varying degrees. Here are the major brush strokes that I have learned:

1. You will never stop encountering something new. I kept thinking "I can't wait until I hit my one year of nursing" like it was going to be a panacea and suddenly I was going to get rid of the anxiety that creeps up in my stomach when some new disease process or new piece of equipment walks in the door. What I have found is that I have had enough 'firsts' this year that when something strange appears in my patient or patient's room I know enough to take a deep breath and start figuring out what needs to be done next. This is what experienced nurses know to do instinctively - they can synthesize what they know and compare and seek out the differences they need to learn and account for to give patient specific care.
2. Teamwork is the solution to all challenges great and small. I am fortunate that I work with fantastic people. They are my sounding board when reasoning through treatment options. They are the arms that help me reposition my patients every 2 hours so prevent skin breakdown. They are the people I look forward to spending 12 hours with at a time even when it's a full moon and Friday the 13th and the ER is shipping us 5 patients all at the same time. 
3. There will always be a bully lurking somewhere. It might be a fellow nurse. It might be a doctor. It could be anyone really. But the sooner you learn how to deflect these personalities the better. This has been a hard lesson for me as I tend to be a people pleaser and desperately want to make everyone around me happy. I have learned to retool these skills into purposely killing every bully with kindness and becoming more direct in my communication. This technique works for me and I feel that I have become a more skillful communicator overall. My most triumphant moment was asking a team leader who was notorious for mocking people who asked for help by stating, "Are you going to make fun of me for not knowing this or are you going to  use your experience to help me become a better nurse by teaching me how to do this right?" Suddenly this particular person became incredibly helpful to me. I wish I had figured this out months earlier as I dreaded working with them.
4. Getting involved beyond the floor. A particular rewarding experience for me has been to join the Performance Improvement (PI) Committee. We work with our coworkers to generate the coming year's competencies (education required for our job). This means working with the nurse educator to find out what new piece of equipment is coming down the pipe line. For example, we chose to high light education on the Stabber of Death this year as one of the new neurosurgeons uses that particular piece of equipment regularly in his practice. And yes, it is actually called the Stabber of Death. It's used to place intraventricular drains at the bedside for patients with high intracranial pressures.
5. Learning to disconnect appropriately. The first year has been hard for me to disconnect from my work when I'm not there. Thankfully the number of work related dreams has started to decrease. Transitioning from school where there is always homework hovering on the edge of your thoughts to a job that is demanding in physical and emotional ways has taken some time to balance. I have found that seeking out new hobbies - cooking being most prominent recently- has been therapeutic and helpful. I am a better nurse when I don't think about it 24/7. That does not mean I don't take education outside of my work very seriously. It just means I am learning to manipulate the on/off switch much better so that I am 100% present when I'm with my family and friends.

And with that my friends,family, and followers- I'm closing up SageBrushRN. It's been a wonderful place to write and share my thoughts during this first year of nursing. Your comments have definitely been appreciated and should other new nurses stumble across this blog I hope they find it helpful as well. I'll leave the pages up, but don't plan on adding any more at this time.

~Have a dynamite holiday~

Leaning In, Leadership, Ladies!

I just read Sheryl Sandberg's book Lean In about women in leadership positions. She is a very good author, but an equally articulate speaker. I found this TED Talk a powerful reminder of how social change is both an individual and societal act. Enjoy!

Thinking outside the box: Fighting Fire with Fire- using HIV to fight Cancer.

How to start a movement

Adrenaline

I knew I had an admit coming since midnight, but they did not roll in the door until 0200. That sort of delay always makes me nervous because I know a train wreck is coming my way. I assisted (by myself!) the MD to place a central line and hovered nearby as RT placed an arterial line. I hung and titrated dipervan by myself. I had lots of nurses helping me and I delegated away and took advantage of every offer while maintaining control of the situation.

I pretty much felt like this guy.



I came home humming and then promptly passed out at 0900 in a fit of adrenaline let down. What a satisfying night :)

Flying solo

It happened almost without my notice. Titrating IV drugs, handling alarming vents, and even drawing labs via needle sticks are becoming second nature. I have a long way to go before becoming comfortable in this job - actually if I ever become comfortable it will be time to change jobs.

However, the alarms and tasks that had a way of getting my adrenaline pumping are become less stressful and now I seem to have more mental focus to do what I enjoy - think about my patient and consider their disease process and how I can improve their outcomes. These last 2 weeks I took care of the same patient and having the band width to think about their situation was really great versus feeling like I was giving all my energy to complete each task as it arose.

In January I will rotate back to days and I know it will take time to construct a rhythm there as well. Nonetheless, the chance to rotate back and forth every 8 weeks or so will be welcome as a chance to stretch my skills as well as get the chance to work with all the doctors and nurses that roam our halls. Additionally, I have now floated to the Meridian ICU (in the same hospital system, 20 minutes out) and to the surgical ICU (down the hall). Although I feel like Dorothy in the Land of Oz when I leave my home unit it's nice to have those first floats out of the way!

Happy autumn.

Back to nights: the space to think and teamwork

I had mixed feelings about returning to nights 2 weeks ago, however, as my preceptor, who has the exact voice of Quagmire from Family Guy stated, "you have time to critically think on night; days you just try to survive."

The first night I was able to successfully handle 2 sick ICU patients on my own which was the boost in confidence I had been seeking. I also participated in a code on another night where I did chest compressions for only the second time in my life. It was a well orchestrated dance that I felt like at least I knew my own moves instead of being in the way.

The end of orientation is 2 weeks away, but now a definite point on the horizon. Although I'm not looking forward to flying solo the teamwork is incredible and I'm thankful to be working with such nice competent people. 

This quotation fits well with tonight's mood and is one of my little brother's heroes:

"My work is all about adventure and teamwork in some of the most inhospitable jungles, mountains, and deserts on the planet. If you aren't able to look after yourself and each other, then people die" 

- Bear Grylls

Gratitude and Happiness: Say thank you today!

Quotation for a Friday

Why are American health care costs so high?

A free upgrade from bronchitis to atypical pneumonia and why Zoomcare is still awesome....

Today I have been working on mandatory education for work from my computer. My throat is still raw, I sound like I have been smoking for 40+ years, and my lungs are tired of cough-cough-coughing. The upside is my rib cage muscles will be buff and my abs are getting an extra workout.

Low and behold the nurse from Zoomcare called me to check up on how I was doing. First off I have never ever had this happen with primary care. Obviously they are concerned that their patients get better after they leave.  The nurse was concerned that my symptoms had not improved much since Sunday and said she would have the MD call me.

An hour later I chatted with the MD and explained that some of my symptoms had changed, but not improved per se. She said it sounded like I was dealing with atypical pneumonia, not bronchitis, and that she was calling in a prescription to my pharmacy right away for azithromycin. And that she will be calling me back on Friday to see how I am doing.

I am so pleased at the care I have received!

Zoomcare: An unwanted adventure in really great primary health care

I have been battling bronchitis x10 days. I officially lost my voice at the beginning of my three days of work this week. It made for a frustrating 3 days of work since I talk ALL the time. I fortunately was able to not cough during those 12 hour shifts due to antitussives and decongestant meds and continued to wash my hands incessantly but I barely slept last night as it all caught up to me and I turned into a phlegm monster.

I popped online Sunday morning around 0445 to figure out just where I could go on a Sunday to have an MD confirm the fact that I have an infection and whether it was viral or bacterial. My hospital does have employee health and an urgent care clinic. Both are closed on Sundays. Not helpful!

I happened to notice a few weeks ago a Zoomcare in downtown Boise. I booked an appointment online from my cell phone in bed . It's a one time flat fee for service. No hassle or haggling with insurance. And I'm not going to ER for something minor and clogging up the system meant for traumas, severed limbs, and septic shock.

Overall, the experience was incredibly satisfying and the service was superb and I am serious when I say every town in America should have an urgent care clinic like Zoomcare. I walked in for my appointment at 11:00am and I saw the PA at 11:05am. No waiting. Although I was totally disappointed that my bronchitis is viral (meaning that I will be miserable for another 2-3 weeks) they were helpful in giving me an albuterol inhaler to help with the shortness of breath I have been experiencing. So now I'm on the road to recovery and can breath again.

Environmental behavior : walking & biking

"Walking is man's best medicine."

~Hippocrates 

I might add "bicycling" to that quotation too! According to my Noom app for my phone in the last 7 days I have walked 26 miles and biked 15 miles. This doesn't even take into account the thousands of steps I take during a 12 hour shift at work. 

These last few moves have reminded me how often human behavior is shaped by the built environment. In our previous location I was in my car at least once a day to do anything. Additionally,the idea of walking the dingoes was a chore fraught with stress as dogs would come out of their yards to attack my pups; walking on the street rather than sidewalk was a somewhat safer option but still unpleasant when dodging vehicles.

Our new neighborhood has nice sidewalks that encourage activity and neighborhood community. Like our Portland home, we have met the neighbors and know their names! Parking in downtown here takes just as long as a bike ride to down town and one is definitely better for your blood pressure than the other. Additionally, bikes are fairly common here and cars know to watch for cyclists. I maybe drive 1-2 times per week for errands that require a vehicle - like groceries for the week.

In our ongoing national critique of obesity the human environment is often missing from the discussion. Food deserts breed fast food and unhealthy food options when grocery stores are lacking. Unsafe, unpleasant streets breed more driving rather than walking or biking. It's not surprising our population struggles with its waistline when we spend more time behind the wheel. 

The last 7 months of living rural were terrible for my health and now I'm slowly chipping away at the 30 pounds that I gained there from not enough exercise (despite dogs walks) and the amount of time I spent driving to get anywhere (even if it was to go hiking or walking my 5-7 miles a shift). It was a self study in how environment shapes behavior and it was humbling.

Although in the ICU I do a lot less teaching than I did in the IMCU, this is a consideration that I keep in the back of my mind - where do my patients live? Just like air pollutants or water pollutants can poison the human body the built environment constructed without regard to human body can cause an equal amount of damage. 

There is not an easy or quick solution to these - sidewalks are not poured over night and bike lanes are expensive to build, but the conversations are definitely the beginning.

eICU: A really neat resource!

This is a link to a really great article about the eICU (electronic intensive care unit) at my hospital. It explains how this resource works and how great it is to have extra hands on deck when managing a critical patient with rapidly changing conditions. I have worked with the eICU nurses a couple times in the last 2 weeks and have come to really appreciate how they have a 'bird's eye view' of vital sign trends and labs.

Dr.Pate's Prescription for Change: St. Luke's eICU

So far so good...

This week marks my third week of orientation. It has been a very challenging but enjoyable process. I have encountered very complicated patients and worked diligently to heal and comfort side by side with my preceptors.

A few things that have been of interest in the last 3 weeks:

• Although I am in a medical ICU we are apparently referred to as the CCU (coronary care unit). Why this is no one seems to know. And our surgical ICU is referred to as just the ICU.
• I worked with my first balloon pump. Although I will not have a balloon pump patient for probably 2-3 years (they require specialized training)this was a very interesting experience. We literally did not leave the bedside for 12 hours at a time because it is such a delicate and dangerous piece of equipment.
• I worked with a  Swan Ganz catheter, though not a common piece of equipment anymore, it is still seen in critical care occasionally. This is also a delicate and potentially dangerous piece of equipment, but one that I could be working with in the future. I took my first PAWP (that stands for pulmonary artery wedge pressure), where a balloon on the Swan Ganz cathether is inflated inside the pulmonary artery (the artery with deoxygenated blood that travels from the heart to the lungs to pick up oxygen) to capture the approximate pressure inside the L atrium of the heart. This was a terrifying/thrilling moment in my life crystallized by the fact that I had an audience that included not just my preceptor but a handful of nurses from the unit that wanted to come see a Swan Ganz cath.
• We are the only nurses that get floated outside of the hospital. Apparently if the Meridian St. Luke's is short staffed we can be sent over to help. This is quite different from floating to another unit in the SAME hospital and unfortunately requires a car.
• I completed my second telemetry course. This time it was partially online with the American Heart Association and partially done with a real human being. It was excellent, but also provided a sense of accomplishment because I had real life examples to base my questions on. I also realized that all those squiggly lines have become somewhat second nature to me and the class did not feel overwhelming like the first time.
• I started the ECCO (electronic critical care online) program through the American Association of Critical Care Nurse (AACN). This has been a challenging and rigorous course, but completely applicable to my work. I feel like I am in nursing school again, but at least I get a paycheck with it and a lot less tears ;)
• We are officially moved into our new home! I'm a mile from the hospital, 2 blocks from hiking trails, and 1 mile from downtown. On Saturday I went paddle boarding on the river with a coworker from the SICU and her husband and we finished the day at Boise Fry Company (the yummiest fries I have ever eaten). It felt like a "typical Portland day" and I slept the best sleep I've had in half a year. It was awesome.

Off to unpack some more boxes...

Top 10 favorite things of week one in the MICU

10. The hospital food is edible.

9. The IV pumps are the same as my previous hospital so when they go into a frenzy of beeping I now know how to fix them!

8.I will not develop carpal tunnel because we do paper charting ...and Epic, the electronic charting system, is going to roll out in X number of years.

7. My unit it known for "having all the comedians"

6. The ICU is unlocked - this means families can come and go as they please making the patients and nurses much happier!

5. Nurses get to self schedule!

4. There is soft serve ice cream in the cafeteria for when you have one of the those days.

3. When you admit a patient to the unit there are so many people helping you have to start kicking them out. Seriously!

2. My preceptors are amazing, knowledgeable, supportive, and nice. The staff nurses are inclusive, kind, and have a great sense of humor...and Wednesday nights are waffle nights!

#1. The hospital provides scrubs!!! My laundry basket is both cleaner and lighter!

Into the hot water....tomorrow

"A woman is like a tea bag-you can't tell how strong she is until you put her in hot water."

-Eleanor Roosevelt

Here is to thinking good thoughts about tomorrow - 

my first day in the medical ICU!

View of Table Rock in Boise, ID from my hospital

Orientation: check

First week of general hospital and general nurse orientation is done! The first 2 days consisted of death by PowerPoint - pretty typical of hospital orientations so it seems.

The last 3 days of the week consisted of only nurses-everything from new grads to seasoned veterans. Half of our days were spent doing critical thinking exercises - such as viewing video clips and prioritizing patient care. The second half we reviewed and were checked off in a simulation lab for IV starts, feeding pump manipulations, sterile wound dressing changes, patient controlled analgesia pumps, IV pump management, and restraints. It was actually really nice to know what was expected of us as well as receive pointers from the nurse educators. The nicest thing about a transfer internally though is that the majority of the equipment is the same - I won't have to trouble shoot a new kind of IV pump beeping at me in the middle of the night - it will be the same old one that drives me crazy ;)

Last, but not least, is all the online education modules we have to do as RNs reviewing everything from lab draws, to hanging blood, to managing delirium in the ICU. Again there is some redundancy but it's nice to have access to some newer modules that I had not seen in my previous hospital.

My favorite part of this week was walking through the halls of the hospital when I was in search of a cup of coffee. Large hospitals are like organisms to me and I like to pretend that I am like a little cell roaming the corridors doing my one little job, but that together we are what keeps this giant running 24/7 all year long. All though there is illness inside the walls of the hospital it is also a vibrant, humming place where there is always something going on and there are always people present and busying themselves around the clock running on caffeine, adrenaline, and hope. There is something to that energy that just makes me buzz along and keeps me going for 12 hour shifts.

Monday is learning the charting system, and then Tuesday I'm back on the floor!

Games: for your health

This video by Jane McGonigal is fantastic. It talks about the value of playing as adults, but also about this woman's struggle with illness and how creative play gave her a tool to help her help herself through the healing process of a traumatic brain injury.

I found her discussion on post traumatic growth to be insightful because some people do persevere and recover from a traumatic event and those people are thought to be 'lucky' or 'resilient.' Rather this shows that they are simply using a different set of tools. The nice thing is tools can be shared, like McGonigal talks about here.

here is a link to here to her website as well: https://www.superbetter.com/

Gratitude

"Let us be grateful to the people who make us happy; they are the charming gardeners who make our souls blossom"

-Marcel Proust

Relocation: Boise!

It's officially started: Tomorrow is the start of general orientation at my new hospital (same hospital organization, but new city and bigger hospital). I am soooo incredibly excited and I have big dragon sized butterflies in my stomach all at the same time!

I have my note book ready, my business casual outfit set out for 2 days of boring hospital admin stuff, and then scrubs for 3 days of nurse orientation with simulation! After that who knows what my schedule will bring. Hopefully I'll be moved into our new house by the end of the month too!

A little information about Boise itself for those who are unfamiliar with the area:

• Population: roughly 210,000....the largest city between Portland, Oregon and Salt Lake City, Utah
• Climate: semi-arid climate with 4 distinct seasons....today's weather: high of 94F and low of 64F. 
• Pronunciation: Boy-see....the locals will slap you for saying Boy-zee
• Activities: Boise Downtown (BoDo), Idaho Shakespeare festival (outdoor ampitheater that has plays all summer long), the Boise River for floating/kayaking/rafting, the Boise Foothills for hiking/biking (considered the "foothills of the Rocky Mountains," and Bogus Basin for skiing/snow shoeing

My mantra for nursing

"Cure sometimes, treat often, comfort always."

~Hippocrates

I have to return to this quote on a regular basis to find my footing, to regain my common ground. This is where Hippocrates' quote must be turned inwards as well. It's not just a prescription for how we care for others, but how we must care for ourselves in order to excel at our profession.

I had another miserable, no good, awful, question my existence as a nurse sort of night. In the course of seven months, I consider 2 episodes like that to be a pretty good track record. 

However, when all hell does break loose, it frustrating the lingering effects it has upon your psyche. I have had four nights off and go back tomorrow night. I even avoided a four hour immediate pay shift (easy money and easy work!) when they were short staffed earlier this week because I absolutely couldn't bring myself to step back in the hospital that soon. I'm cringing at returning tomorrow night even.

I have replayed that 12 hour shift over and over and over and over.....it doesn't matter if I'm cooking, packing, cleaning, walking the dingoes, trying to fall asleep in this horrendous heat, or rehashing it with a coworker. I imagine this is mildly what PTSD is like. Poor souls.

It's going to take awhile to lay that night to rest, as well as feel satisfied that if I encounter a similar situation that I will be able to use what I learned from that night to make it better. 

In the meantime, I'm trying to be gentle with myself and know that reflection is the key to resilience.

Achy breaky back

  

After 6 wonderful years of living relatively pain free from chronic aching back pain (as long as I'm not sitting down) something happened to my precious spine. I am blaming it on the day shift hours I picked up this week!!!

I woke up Tuesday morning with 8/10 pain- burning, sharp pain- radiating from my lumbar spine outward in all directions. Sitting, standing, lying down, sneezing all brought new sharp sensations of tortuous pain I had no idea even existed. Putting on pants was like being put through a version of a Spanish Inquisition interrogation - I would have admitted to anything to have had the pain just stop. Thank goodness for slip on shoes at least, I may of never left the house otherwise.

I called the chiropractor and waited with clenched teeth, yoga stretches, an electric heating pad, and a bottle of Aleve for my Wednesday appointment. The appointment went well, apparently my L5 vertebrae was out of place and since muscles can be slow to respond to change I've got another 2-3 days of hurt ahead.

So, here I am now, Thursday morning, down to 4-5/10 pain post adjustment with a new back brace, more Aleve, and a rice pack heating pad just wondering how the next 3 nights of work are going to go...

9 more nights to go...

This week I was caught off guard when the staffing office called and asked me to work part of a day- not a night-shift. I caved and said yes to coming in since they had already exhausted the day shift roster and were in need for help.

I worked from 1500-2000 essentially and suddenly remembered why I have come to dislike day shift. Even though there are tons more people on the floor they are all as frantically busy as you and unable to help you if you need help, as well as vice versa. I can't even be helpful to my coworkers because I'm running around like a loon. 

After a 4 hour shift I was SO incredibly tired. It was quite stunning and when I got home all my ambitions for packing more boxes evaporated as I turned into a slug and melted into a chair.

I am slowly wrapping my head around 5am mornings again as my first 3 months on orientation will be on days at the MICU. In the mean time, I have 3 weeks and 9 nights to go at the IMCU and many more boxes to pack!

Announcement: Ch-ch-ch-changes!

Dear friends and family,

June is already upon us and some more changes with it! The summer heat, rattlesnakes, and tired dogs are in full swing here in the Magic Valley.

Recently my husband got a promotion indicating that he is going to be travelling more often. With this information and the fact that his company was dismayed at how far away Twin Falls is from a large airport it was decided we would be relocating to Boise!

Initially we were discussing the idea of moving to Boise and to have me commute the 2 hours to Twin Falls for work, but upon talking to my manager it actually turned out to be incredibly easy to transfer from Saint Luke’s Magic Valley to Saint Luke’s Boise (downtown). Furthermore, I will be moving from the intermediate care unit (IMCU) to a medical intensive care unit (MICU) where I will be brought on as a new nurse in a formal new nurse residency and given lots of support and education to flourish in the more critical/stressful environment. 

Although I will definitely miss my IMCU because of all the wonderful skills I built there and the BEST coworkers a new grad nurse could ever ask for – we are really excited to be moving to a place that meets our wants and needs in a community.

Additionally, this week we had an offer accepted on an adorable bungalow in downtown Boise. The location is perfect – both my husband and I will be able to bicycle or walk to work (my honey, having got a taste for having an office outside the house, will be finding a downtown office space), there is a park 2 blocks from our house, and the farmer’s market is within minutes by bicycle. 

We have been struggling since leaving our wonderful community in Portland and it seemed that Boise would offer a balance for us in terms of family, community, “bikability/walkability” all the while being both affordable and best for our careers in a way that may not have been possible in Portland (e.g. my husband can have an office outside the house due to affordability, I can be in an ICU with less than 2 years experience!!!).

To our dearest Portland friends – we still miss you dearly and we love you SO much. We missed every week without game night. We are so excited to be 2 hours closer driving and when we come back to visit we will be so much more fun to hang out with now because we will be more settled in our lives here in Idaho. Now you all have to come out and visit because we have our own set of breweries to show off and new biking trails, rivers, and ski hills to explore! ;)

To our families – thank you for bearing through the multitude of plans we kept trying to make and through our mourning period over the past 6 months. You made the hard days a little better and we love you for sticking by us in our worst moods. We are so happy to share our new home with you and even happier that we will be good company once more instead of your whiny children.

Again, thank you all for your love and support and we look forward to seeing you in Boise! I will continue my blogging adventures as my nursing career continue to unfold.

A rattling tail of a story

On my hiking adventure this week I was in the lead of our small hiking group with Roxie on her leash and following me and my coworker a few paces behind. The path at the time was gravel and we were down in a small ravine with a mix of wildflowers and sagebrush on the left (the uphill side of us) and lush grasses and choke cherry trees to the right (the downhill side of us) next to a creek. 

Beautiful, wildflowery day

My coworker and I were talking as we hiked, mostly about how the hike was going since we had completely misread the map and were somehow on mile 6 of what was supposed to be a 3.5 mile hike. My left foot was coming down next to a sage brush bush and out of the corner of my eye I saw the ground below it move and then I heard the infamous warning rattle like a "tsh-tsh-tsh-tsh-tsh." 

My body and it's primal fight-or-flight instinct reacted eons before my mind was able to catch up and process what was going on. Instead of putting my left foot down on what was a coil of a snake's body, I pushed off my right foot and leaped in an Olympic style fashion probably a good 4 feet ahead all the while dragging Roxie with me.

I hollered for my coworker to stop and from the sagebrush bush we heard the rattle again and a rattlesnake's head pop out from below the bush to peer at us. I generally have no problems with snakes, but this was my first encounter with a poisonous one. Thankfully the snake and I had mutually scared the pants off each other that Monday afternoon and both reacted by running/slithering in opposite directions. The snake looked at us for probably about a minute deciding which way to go, and then turned up hill while shaking it's rattler at us as it headed up the hill. I am so incredibly thankful I did not get bitten!

Not my photo---but about the right size

Things that I learned from this heart thumping experience:

1. Always pay attention to where your feet are
2. I will never hike alone and whoever is with me better have a medical degree of some sort
3. I have no clue how to treat a rattlesnake bite in the field-so now I've looked it up

The do's and don'ts of treating a rattlesnake bite according to Backpacker Magazine:

• DON'T
• slice the bite mark to try to suck out venom: you are creating a wound site for infection
• suction the area: you aren't going to get any venom out anyway since the it has already started pumping through your system since your heart rate accelerated from the situation
• apply a tourniquet: it will concentrate the venom in one area and accelerate cell death in that one place. It's actually better to let it get diluted through your system.
• apply an ice pack (who is carrying one of these while back packing anyway?): the cold will slow the circulation to the area (much like a tourniquet) and concentrate the cell damage
• DO
• Get medical attention as soon as possible
• An antivenom will be needed to treat the patient. 
• Interesting fact: rattlesnake antivenom is made from the serum globulins from horses that are immunized against many different species of snakes
• Remove tight fitting clothes/jewelry: this in preparation for swelling
• Clean the bite area: with soap and water or an antiseptic from a first aid kit
• Carry the victim (or yourself) out slowly: Ditch the backpack, you don't need to make your body work any harder
• If you have a pen: mark the swelling area every 15 minutes. This helps doctors guess the amount of venom in the bite
• Interesting fact: about 20% of bites don't have venom injected by poisonous snakes and are considered "dry" bites

South Hills: Wildflowers and sore legs

Yesterday, Roxie the dingo, a coworker also a nurse, and I went for what we thought was going to be a 3.5 mile hike and ended up being a 9 mile hike in the South Hills. The weather couldn't have been more perfect - all the wildflowers from purple lupines to Indian paintbrush were blooming and Rock Creek was bubbling away.

Today, Roxie and I are both limping around the house. Here are some photos from the day!

Lupine

Roxie checking out the flora

Viewshed

Beaver ponds

Valley

Aspens so close to the desert

The entirety of one of the valleys we hiked

Body language: a good lesson for new nurses and old nurses alike

In an earlier post I had mentioned the power of body language to influence our behavior and feelings. We have known for a long time that forcing our selves to smile makes us sound nicer on the telephone and can cheer us up. As a dog owner, I learned the equivalent of this with my dogs that you can hold their tail up when they are scared and that this cheers them up too. Our moods are incredibly responsive to our body's actions. It is counter intuitive in many ways, but biology often drives behavior.

I stumbled across this TED video and it made me think about how hard it is to teach communication to new nurses. I felt that I learned next to nothing in my nursing communication course except for how to prepare an SBAR (that will be for another post). I don't think the communication and confidence "thing" clicked until I started my job and realized I had other people's well being in my hands. I emulated my coworkers and quickly learned what did and didn't work.

There is very little, apart from life experiences, that can prepare you for the occasional dose of crazy patients, aggressive doctors, or bullying coworker nurses. I thought this video was a great reminder to how to not read only others, but to read ourselves in the great game of communication. Enjoy!

Whopper of lesson: withholding judgement

There are a lot of medical conditions that one does not have control over - genetics, environment, and life just happen. People live their lives as best they can and they get saddled with some disease process   that pose obstacles and challenges that we can't even wrap our heads around.

Then there are days when you want to holler some sort of Hippocratic quotation at your patients that seem to have gotten themselves into their predicament, such as these:

1. "Let food be thy medicine and medicine be thy food."
2. "Everything in excess is opposed to nature."
3. "Walking is man's best medicine."

The thing is though humans have a million foibles and it's actually surprising we don't make ourselves sicker or injure ourselves more often.... I am compassionate to the type 2 diabetics and the smokers - I love chocolate and coffee - who am I to point a finger on these addictions? 

These poor folks suffer enough without an additional serving of judgement. My job is to care for them and give them the best tools possible to help themselves. We all do the best we can and we are all in this together with our individual burdens to carry. If we can help each other, all the better.

As a new nurse I had this idealistic view that I would never be judgmental towards my patients. However, the idealistic view got a big whopping dose of reality recently. A handful of times now I have been the nurse for trauma patients that have been intoxicated and driving. It is harder than I imagined to to find a compassionate spot for these individuals when you know the passengers were perhaps life-flighted out of the area and that the patient you are caring for is the perpetrator of the accident and the least injured out of the bunch. 

My nursing assessment and skills are equal amongst all my patients, but these patients have challenged me to remain kind and warm without shutting them out for their behavior that landed them in a hospital bed. These experiences made me think back to some of my classmates that had done a nursing clinical in the prison system in Portland. They told me they made a point not to read deeply into their patients' charts until the end of the rotation, because they knew they could not reserve judgement otherwise if they knew the crimes their patients had committed. 

And so I have endeavored to immerse myself into the medical side of these patients and do my best to forget the trauma that brought them to my unit. I also plaster a smile onto my face because I know scientific research tells us that our body language tells our body what to feel, so by the end of my shift I have moved from a place of judgement to a place of kindness. 

Again, it's been a whopper of a lesson and probably one that will be relearned many, many more times.

Vineyard Lake Hike

Spring time has finally arrived to the Magic Valley and the weather is warming up. Greenery here is ephemeral and lasts for just a short time between the end of winter's bitter cold and the beginning of summer's infernal burn. Therefore, this month has been a chance to explore the area by foot a bit more. Today a  fellow nurse, who has become a friend and mentor, took Roxie and I to Vineyard Lake before the day got too hot. 

The lake is fed by a natural spring coming out of the ground and there are little rock fish and minnows that cavort in the waters. Apparently it is also a popular cliff diving area, although that seems like a dangerous idea with all the lava rock littering the landscape. 

~~~Enjoy~~~

Looking from one bank to the other

The spring comes out of this little canyon to feed the lake

Vineyard Lake from afar

spring feeding the lake

basalt everywhere

Equipment malfunction and the "calm" panic voice

This week I had the most bizarre thing happen with my IV pump. I was running heparin via IV - an anticoagulant medication used to treat clots or potential clots in patients at risk for pulmonary embolisms or strokes among other things. Often heparin is a once or twice a day injection, but this patient needed it IV due to their circumstances. 

At about 0500 I heard the IV beep telling me there was "air in the line." However frightening that sounds, it's really rare there is actually air in the line. The IV pumps are incredibly sensitive and even eensy-teenie-weenie bubbles that cannot cause harm to the patient will set it off- generally to the annoyance of everyone within a 5 mile radius. I went to look at it and jiggle the line that exits the bottom of the pump and noticed that it was wet!!!

I have now adopted my "everything is okay, I deal with type of stuff every single day" voice when in fact I have most likely never ever seen what I am witnessing actually happen EVER. I have to admit I'm not really sure where that tone of voice came from, because prior to being a nurse that tone never existed for me. I have never been a confident person, but wearing the scrubs seems to give me an alternate ego of Nurse Reese who will take care of you no matter what. I cannot even imitate myself in that voice when I'm out of scrubs!

Anyway, I calmly explained to the patient that I was going to clamp her IV and check the tubing. I unlocked the pump to visualize the tubing inside - again something I do actually do all the time. Instead, when I unlocked the pump the IV tubing fell into 2 pieces - it looked like it had been sliced in half with a pair of scissors! I thankfully reacted fast enough to grab the bag of heparin and turn it upside down before I had created too big of a heparin puddle on the floor. 

I grabbed all new tubing, primed the line, and set the patient back up on the medication and then asked a more experienced nurse to look at my severed tubing. The nurse said, "Huh, I've seen children chew through their IV lines, but I have never, ever seen that happen." Awesome.

In the midst of this I had called lab for a stat PTT draw (the lab that tells us how well the heparin is working - the goal is to be within a therapeutic range), called the pharmacist to tell them what the problem was and that I would notify them as soon as I had the lab results for further orders, and talked to the doctor who happened to wander in during the middle of all this for report. My fear was that the patient had not been receiving enough medication and therefore was at risk for a repeat medical incident. However, all is well that ends well because in fact her PTT was a little too high -even with the leaking tubing- and pharmacy had me turn off the medication all together.

I don't think it was until 0730 that my heart rate came back down to normal. However, no one else was the wiser ;)

Pulmonary embolism & deep vein thrombosis

In recent weeks I've had new encounters with pulmonary embolisms (PEs). So, this post is to explore the origin of this condition and what it looks like.

First off, deep vein thrombosis (DVT) refers to clots that form in the veins of the legs. DVTs are often the cause of the pulmonary embolisms. Normally, the blood in the veins is pumped back to the heart by the leg muscles that 'milk' the veins through contraction. However, clot formation occurs when a person is on bed rest or is inactive (like mentioned above - long car trips or long hours at a desk). In the hospital a lot of attention is paid to preventing DVTs; patients that are in the hospital post surgery or are on bed rest for more than 24 hours are automatically given heparin, an anticoagulant, that prevents clotting.

These clots when they do happen can break off from where they have built up within the leg veins. The clots then travel to the heart and get pumped out to the lungs - getting lodged and causing a pulmonary embolism.

Again, pictures are worth much more than my words so here is a quick video that illustrates the phenomena of DVTs and PEs:

It's also worth noting, this can occur in any age group. In March 2011, the athlete Serena Williams had a foot surgery in New York and then traveled to Los Angeles, where shortly afterward she had to be rushed to the hospital for a PE (Serena William Hospitalized for Pulmonary Embolism). 

So remember to get up and move around to keep your legs and lungs lively!

Bedside manners matter

Today was my turn to be the patient. I went to a routine OB/GYN appointment only to be horrified at how unkind the doctor I had was. I really shouldn't be surprised, I see doctors misbehave all the time. However, since I was the patient, I really took it personally this time. I left the appointment nearly in tears at how cruel this MD was. And in clinics you don't even have a nurse to back you up!

Everything I said was interrupted and worse was that my doctor argued with me. There is a difference between educating a patient and dismissing a patient. Unfortunately I got the latter treatment because my doctor couldn't keep their mouth shut long enough to listen to my actual concerns and to find out why I had these concerns.

After a long drive home and a nap it really just reminded me how thankful I am that I get to be in my patient's rooms when the MD comes in. Often I do the emotional clean up post doctor visit such as when they deliver frightening news that a patient has to have a critical surgery or a patient will have to have dialysis for the rest of their life. My patient's often end up in tears too and it's unfortunate it has to be this way.

There is no doubt that MDs are the harbinger of bad news in most cases, but there are those who succeed in their communication. They grab a chair and sit eye to eye with a patient. They are comfortable around emotion and tears. And they shut up and listen. These are the doctors that succeed in bridging the gap between medicine and humanity. These are the doctors that patient trust.

Now I just need to find myself one of those....

A blissful week - I'll take it!

"Gifts have ribbons, not strings" ~Vanna Bonta

This week was gift-like. I am doing my first 3 on/1off/3 on run of work days. I don't know if it's the seasonal change, but my first 3 nights thus far have been delightful patients. On my third night I had one patient all night and reveled in doing a lot of teaching and putting together an informational packet in Spanish for them to better understand their new condition.

Meanwhile, my coworker and I were spying on the ER waiting room (we can see the waiting room from our patient rooms) and it was packed. We savored the quiet we were enjoying, but also anticipating getting slammed with admits. Somehow, not one patient came to the IMCU - and we did a dance for joy to be skipped over this week.

Now onto the next set of 3 days!

Nights like the Exorcist

The last few weeks have been fast paced with lots of cardiac patients and renal patients, and a handful of some crazy patients that require the whole nine yards of 1:1 sitters, restraints (had my first experience with leather restraints recently), and anti psychotic meds that really sometimes don't seem to do anything initially. To top it off somehow these wild patients always end up in the same room number and now I shudder at group report when I get that room number!

I had a 2 night stretch recently with the a patient where the 1st night sounded like scenes of the Exorcist movie were emanating from within the room and by the second night the medications had caught up to my patient and calmed them down beautifully. By the end of that week I was exhausted - mentally, emotionally, psychologically. It's traumatizing to use restraints for everyone involved. I feel like it took several weeks to recover from that patient particularly.

At the end of the 12 hour shift I really struggle to clear my mind enough from an experience like that so I can sleep and do it all over again that night. I maintain my compassion with these patients, however, it's sometimes hard to do when ducking flying limbs or more recently had a patient grab my stethoscope that was hanging around my neck and being called every name under the sun. My heart breaks for these people - what a frightening experience - and yet it is simply exhausting. That's why days off are necessary for this job - so I can recharge my batteries and my compassion and remain a good, caring nurse.

Water and spring time in the desert

waterfall from a canyon's edge

baby pygmy goat at organic farm

sturgeon swimming away at the Clear Lakes trout farm

snake river meandering

Perrine Bridge over the Snake River Canyon

"In the spring I have counted one hundred and thirty-six different kinds of weather inside of four and twenty hours. " 

~Mark Twain

Kidneys: the water treatment plant of your body

It seems some things come in waves. A few weeks ago every time I got an admit it was a GI bleed, in the last 2 weeks it's been kidney/renal problems. 

For some reason I find kidneys to be mysterious organs - maybe it's because it seems like they are hiding back behind the rest of the organs like they have a secret? Or the fact that you have 2 of them, but can live with 1? Anyway, I thought it was a great opportunity to review the basics. 

First, this short 45 second video is a great big overview of the kidney (plus the English accent is funny- especially the word for capillaries):

All right, so we know the kidneys produce urine. But that's not the only thing you kidneys do!

Here are some of the other very important and necessary functions of kidneys:

Excretion of waste:

Kidneys remove waste produced by your body's metabolism. Major waste products would be urea (that makes up uric acid) and nitrogenous wastes. To much of either of these waste products does intense damage to the body and brain. Often times in renal failure people will present with altered mental statuses because of the build up of waste products that starts to affect their level of consciousness or even personality.

Acid/base balance:

Our body tries to maintain a neutral pH. Carbon dioxide (CO2) and hydrogen ions (H-) are both acidic substance in our bodies. Bicarbonate (HCO3) is a basic substance in our bodies. Our lungs regulate the CO2 through breathing. Our kidneys can regulate HCO3 by not filtering it out of the blood and into the urine. The kidneys can also regulate acid by filtering out H- from our blood and into the urine.

Fluid volume regulation:

The entire goal of the human body is to reach homeostasis. With everything. Really, your body is like Goldilocks, it doesn't want things too hot or too cold, too acidic or too basic, too full or too empty. Fluid volume is another one of these markers. 

The body- more specifically the hypothalamus in the brain-  is constantly monitoring your fluid volume and telling the kidneys through hormones messages - "okay - we are too full, take more fluid off " or "we haven't had a drink of water all day - get rid of waste, but hang on to the water!!!"

Blood pressure:

This is related to fluid volume, but also to your body's needs. If you go for a run, your blood pressure is going to go up because your heart is pumping and your muscles are demanding more oxygen and want to get rid of waste. Blood pressure at the kidney level has to do with the retention of sodium. When we need our blood pressure to increase, the kidneys get a signal to retain sodium, because water follows salt. When you keep your sodium, you keep your fluids and your blood pressure increases. 

In cases where someone has high blood pressure because they are unhealthy or sick, one medication that is often prescribed is a diuretic. These medications often cause the kidneys to release the sodium into the urine. Again- water follows salt - the salt leaves, so does the extra fluid, and voila - your high blood pressure patient's blood pressure decreases and they have to urinate fairly frequently.

Production of red blood cells:

So far we have talked about hormonal messages traveling to the kidneys to activate a response. However, kidneys are responsible for releasing their own messenger called  erythropoietin. When the kidneys sense they are not getting adequate perfusion (meaning their own red blood cell/oxygen supply is not sufficient) this hormone is released and sent to the bone marrow to stimulate the production of more red blood cells. In patients with renal damage, they tend to be anemic because this function is damaged and the bone marrow never gets the message to make more red blood cells.

Now go drink some water and appreciate everything your 2 kidneys do!

Sage brush sunrise

I live a blessed life where I see both sunrises and sunsets every day that I work because I am awake for both. My last night at work this week was crazy busy and I came off my 12 hour shift with a big dose of adrenaline, so on my drive home I stopped and snapped some photos along the way.

sunrise in the side view

sunshine in color, review mirror

sage brush sunrise


"Keep your face always towards the sunshine- and shadows will fall behind you"
-Walt Whitman