Butterflies the size of dragons: 1 week until orientation ends

In class yesterday it was brought to my attention that my orientation ends on February 8th. I am desperately clinging to the scrub ties because I don't want it to end. Even though I rarely utilize my preceptors at this point, I am very much against the idea of no longer having them at my beck and call.

My nurse educator just laughed at me when I looked at her with the signature 'panicked new nurse' eyes and she confidently stated that in fact I would be just fine without anyone hovering within hollering range.

I'm glad she is convinced and I'm thankful UP prepared me for this. But I would be lying if I said if the butterflies in the my stomach are the size of actual butterflies. They are more like the size of dragons that are terrified of fire.

I'm back on nights this Friday/Saturday/Monday. I'm going to savor it!

First night, flipping, and feline thievery?

My first night shift was Sunday night. I slept in as late as possible....made it to 0800. Walked and brunched with my honey and then around noon took some melatonin and curled up to nap. Around 1430 my husband was in the midst of a home improvement project when a neighbor knocked on the door.

He was thinking perhaps it was a neighbor welcoming us to the neighborhood. In PDX within 2 days of moving into the city of 1 million our neighbors from all sides of our house had welcomed us into the neighborhood and wished us a Merry Christmas. We have been here for a week and a half in a town of 4,000 and it's been radio silence on both sides.

He opened the door and the neighbor inquired if we had stolen her cat. My husband pointed out that there was a cat sitting in the front yard, but that it was there of its own volition. Although she acknowledged that yes the cat in the yard was hers, she did warn that the neighbors on the other side of the house had stolen her cat for several months and that when the cat goes missing she calls the cops to make sure the other neighbors haven't stolen it. My husband reiterated that we have dogs and that her cat was still sitting in the front yard. She went away and left us puzzled about being supposed 'cat burglars' for a cat that wonders the neighborhood freely.

After roughly a 4 hours of intermittent napping I dined and headed into work for the MOST boring shift since I started. Although it was a full moon and we had several sun downers in the IMCU, it was a relatively quite night apart from calming some frayed nerves. I did get the chance to acquaint myself well with my patients' charts and their medical history which was really interesting. However, at 0200, which is about the time I want to curl up under a desk and snooze, I grabbed a cup of coffee and walked a few laps of our unit. Everything went well and when I walked out the door at 0730 it felt surreal to be leaving my unit on time!  I had to wait for my vehicle to thaw for 10 minutes, but then was treated to a drive home with the full moon and the rising sun.

A dingo/husband walk was in order and then I headed to bed until noon. I had to drag myself out from my bed since I return to day classes for the next 2 days. Waking up at noon was akin to torture and I really felt like a 3 year old ready to throw a tantrum when I woke up. My circadian rhythms are going to be confused for the next few months as I will be continuously flipping between nights and days due to my day classes. I did force myself this afternoon to make a hair appointment and a dentist appointment (I successfully chipped a tooth while eating dinner last night and I look like a dandelion with a mullet). I also created the image below to hang on my door.

I have not yet passed verdict on this whole night shift experience since I was told that last night was an exceptionally slow night. I'll be working again Friday night, so we will see how this night owl thing goes... In the meantime, I will beware of wayward cats.

Triple A, AAA, Abdominal Aortic Aneurysm

Known by many short hand names- AAA, triple A- an abdominal aortic aneurysm is a very serious medical complication. In the last few weeks I've seen a handful of them along with the 2 primary methods of fixing them- open or endovascular method. This video was really helpful for visualizing what the medical problem is and the two procedures.

Last week on days!

This is my last week on days before I trade in my early morning drives to work for early morning drive to home. I'm not very excited about becoming a night owl, but it's the position I was hired for so I am trying to keep my chin up about it.

Unfortunately, I also start my weekly day classes on Wednesdays from 0900-1300. I've already had to request 3 Wednesday night shifts off in the next month because whoever is doing the scheduling keeps trying to double book me and I think it's quite unfair to work 4 hours, maybe get 2-3 hours of sleep, and come back at 1900 for a 12 hour shift. So far, those changes have been made and greatly appreciated on my part (and my patients')

On the positive side though, I did have my first class yesterday and I really enjoyed returning to a learning environment. At heart I am nerdy and cerebral and really enjoy delving into the nitty gritty details of pathophysiology. We focused primarily on the respiratory system yesterday and one of the MDs came into give a presentation on sepsis. It has been interesting comparing and contrasting my experiences as a student nurse in teaching hospitals to that of being an RN in a community hospital. The latter is about 10 years behind current, best evidence based practice (EBP). This MD is young and new to the area and is open to following EBP and was very encouraging to us to call him when we saw particular problems arising in our sepsis patients. This physician was also acutely aware that some of the senior physicians are stuck in their ways and may need to be pushed to take the appropriate measures. It was great to have that acknowledged.

Our duplex is pretty much unpacked and organized. My honey and I have had so much joy cooking together again. Breakfast consisted of fresh eggs, avocado, peppers, and local salsa. It was delicious. I ran errands yesterday and splurged on a new paleo/gluten free cookbook that I am looking forward to cooking with. The best part is the book comes with a 30 day meal plan AND shopping lists for each week. It is so handy and the meals look mouth watering!

Here is to my last week of daylight :)

Frozen pipes and chest compressions

I woke up for my Monday shift at 0530 and made my usual bee line for the shower. I was looking forward to a shower, followed by breakfast and coffee, and then hopping on the road for my commute. I knew I would be on the floor with the nurse educator as my preceptor that day. For some reason whenever I work with her we have a really smooth day and nothing ever goes wrong and I end the day with a little boost in confidence that I might actually do okay once I fly solo.

I turned the shower faucets on and nothing happened. I turned the sink faucets on. Nothing happened. I quickly realized that the pipes were frozen and that the possibility of taking a shower was zero. I couldn’t even wash my face that morning. I tried to tame my hair with a flat iron. My temper flared a little as I stomped around the house getting ready. At least I still got my coffee (I had filled the water reservoir the night before!) and put on tons of deodorant and hoped for the best.

At 0715, right as I finished writing notes from report, a code was called. The charge nurse, the nurse educator, and I raced the stairs to get to the appropriate floor. Everyone was in the room and of course we elbowed our way in as well. I rotated in and out of chest compressions (my very first on a human being!) with a respiratory therapy student and participated in the discussion of what was going on. I quickly realized into my second round of chest compressions that a shower would have accomplished nothing that morning. I was drenched in sweat from CPR and adrenaline. The whole room smelled like perspiration of people in a stressful situation who were thinking/acting their way through it.

Once we thought we had the patient semi stabilized we moved to transport them to ICU. There were 9 of us in the elevator plus the patient in bed and we lost the pulse. One nurse climbed on the bed for chest compressions and I grabbed the foot of the bed and sprinted down the hall with it like a mad/super woman. On a daily, normal basis hospital beds and I rarely get along. They beep at me and I try my best not to lose my temper and kick them.

That morning though I hauled 2 people in one bed with 2 nurses and 1 doctor running behind my bed with a monitor and IV pole like I was carrying nothing more than a hospital chart. It was a scene off the movie screen. I can’t remember the last time I’ve had adrenaline pumping like that, but what I remember most of Monday morning is how my focus honed in on the situation. All the background noise and activity faded away.

I had trained for this and didn’t realize that perhaps all that learning and ACLS classes had sunk in on some level that could only come to fruition in the midst of action. All of us were in harmony, like a scene in a musical where everyone happens to know the choreography of the dance and jumps in, except I had never rehearsed this with any of these people that were on the code team. It was beautiful in a macabre way as we ran down the hall to the music of the code.

I know that I have so much more to learn, but Monday morning there was a flicker of understanding that I know more than I think I know and sometimes it’s okay to trust oneself in that.

I love my job and my calling of nurse.

No anonymity nursing in small town Idaho

Having returned to my husband's childhood home town has been interesting in the sense that most of my patients are from the area and several know of the family I married into. This is completely disconcerting, in a give me stage fright sort of way.

In PDX I think the city was large enough that most nurses had a sense of anonymity. The nurse was a facet of a patient's life only so long as they were in the hospital and only occasionally would the patient  and nurses lives cross again outside of the hospital.

I miss that anonymity, but when my patients ask about my lineage (which is customary apparently because I have not had a day yet where I haven't had to explain where I am from, if and who I'm married to, and why I don't have children yet!) they seem to find comfort in the connection however distant it may be. I find this an interesting situation and one that I am still growing used to each week.

Homesickness & potassium problems

I have been busy and inattentive to my blog recently! Winter weather has been depressing me and a trip home to PDX on my last few days off was good for the soul. I have been homesick for the rain, greenery, microbreweries, tea and coffee shops, but most of all my dear beloved friends. This interlude in my life without them has been difficult. Over the weekend I did not get to see everyone I wanted to, but I soaked up the presence of those I did to tie me over for the drought ahead.

Work is still going well. Last week was pretty great because the cardiac cath lab nurse called me in to see something new. She is swell and calls all the gals 'sister' and when she's working she keeps me in mind. This is one of the very real benefits of being in a small hospital. Anyway, I got to witness a cardioversion where a patient was in atrial flutter and was shocked back into normal sinus rhythm. It was much less violent then the shock delivered to a patient with a heart attack and thankfully the patient won't remember the experience thanks to drugs like Versed. 

Yesterday I worked and it was the most infernal day on the floor since I've started. We have been busy up to this point, no doubt, but this was a busy day where the cogs of the machine were not working properly and parts were spinning out. 

Our problem point was  IV potassium that was needed for a patient that no matter how much oral potassium they were given could not maintain the appropriate reference range. The day consisted of a torturous array of phone calls and faxing/refaxing the morning orders all day long to pharmacy. Around 1700 as our patient was being prepped for a trip to a procedure, the pharmacist came to our floor to tell us why he wasn't sending us our medication. When they finally listened to the reasoning of why so much potassium was needed they complied and had the pharmacy tube us the IV potassium just in time for the doctor doing the procedure to pick it up. 

It was an incredibly frustrating day of trying to do our job despite the numerous obstacles that came up. I am hoping this doesn't occur again any time soon. On the plus side though, I arrived to work today and they told me I was not scheduled, so I'm taking it as good karma and time to recuperate from yesterday and regroup for tomorrow and Thursday.

Medical poetry from my drive home

On my drive home tonight from the hospital I heard this on NPR. Made me smile that there is such thing as medical poetry.

Myth Dispelled
by Adam Possner

The flu vaccine cannot
give you the flu, I tell him.
It's dead virus, there's
nothing alive about it.
It can't make you sick.
That's a myth.
But if we bury it in
the grassy knoll
of your shoulder,
an inch under the stratum
corneum, as sanctioned by
your signature
in a white-coated ceremony
presided over by
my medical assistant
and then mark the grave
with a temporary
non-stick headstone,
the trivalent spirit
of that vaccine
has a 70 to 90 percent
chance of warding off
the Evil One,
and that's the God's
honest truth.

Citation :
"Myth Dispelled" by Adam Possner, MD /JAMA. December 5,2012 Vol. 308 (21):2178. "

Coronary Circulation: Useful Clip

Our unit receives several patients from the cardiac cath lab. This week I figured I should familiarize myself with the coronary arteries in order to better understand where blockages are precisely when I get report on these types of patients.

I found a great YouTube video and ended up drawing along since I memorize best whatever I write out by hand. Enjoy.

I also found this useful picture to further clarify the matter.

Week 4: One month of nursing!!!

Yesterday I completed my one month of being on the floor. Yesterday was also the first day I sort of felt organized and that was even with an unexpected emergency in one of my rooms.

The most interesting thing I encountered this week though was sitting in on a care conference. Care conferences are a multidisciplinary meeting between staff and usually a patient's family. It is an opportunity for families to ask questions and the various disciplines to come together to discuss a plan of treatment for a particular diagnose. It's interesting because you get different specialties talking to one another and collaborating. It's truly an example of how it's better to have more minds working together than one. Doctors were explaining the risks and benefits associated with tPA (a clot busting medication used in strokes). It was really informing as they explained the statistics behind the medication.One of the doctors drew out 18 circles to represent a patient population.

• Without tPA 33% (or 6 out of the 18 circles) would recover on their own, while the remaining 67%  (13 circles) would not recover previous neuromotor status. 
• With tpa 44% (or 8 out of the 18 circles) recover, 6% (or 1 out of the 18 circles) have internal bleeding and risk death, and the remaining 50%  (the last 9 circles) would not recover previous neuromotor status. 

It was a really great tool and I scoured the internet looking for a similar image to put into my blog, but alas no luck!...Down below was my attempt to re-create what I saw drawn. Keep in mind this could be inaccurate since it's being drawn from memory. 

This week I think the most comforting thing happened at lunch when I sat with an experienced nurse. I had befriended her earlier in the day when she realized she had no pen light and just received a stroke patient. I gave her mine to borrow for the shift (don't worry, Tessa, I got it back!). The nurse told me that it was normal to feel completely disorganized in the IMCU regardless of how many years experience one had. That was so incredibly appreciated because most days no matter how efficient I am at the end of the day I feel like I've been running around putting out fires and charging into the next challenge without feeling like I ever get ahead.

However, this constant challenging pace is also what draws me to nursing. It's incredibly exciting to think that for the rest of my nursing career I will have days that I feel overwhelmed or challenged and that I won't know the answer. It keeps each day new and engaging without a fear of ever getting bored!

Bubble study for echocardiograms

I forgot to mention that I got to see an bubble study done this week. This YouTube video that I found shows the visualization done with the echocardiogram during the bubble study. This can be done at the bed side. You can see the infusion of bubbles appearing in one chamber and heading into the next one (since I don't know how to read an echocardiogram, I won't even take a gander as to which chambers of the heart this YouTube video is showing us).

The reason most bubble studies are done are to find a hole in the heart (such as an atrial septal defect). In atrial septal defect, the bubbles enter the R atrium and leak over into the the L atrium revealing the presence of a hole. (For those who are not medically trained: blood is supposed to go from the R atrium> R ventricle>lungs>L atrium>L ventricle> rest of body>R atrium and the process begins again.) There are lots of people wandering the world with holes in their hearts that they and their doctors are completely unaware of. Often these holes aren't discovered until someone is much older and a hole is then discovered. The reason a hole would be a concern though is that it creates turbulence and turbulence can lead to clots and clots can lead to strokes.

I think I mentioned earlier that my hospital is wanting to be certified as a stroke center, so this study is apparently becoming more prevalent whenever we have a cardiac patients. We already examine their hearts for everything else, so a bubble study is a quick way to provide some extra information and act on it if stroke prevention is needed.

As for the nurse's role in a bubble study, it's pretty simple. The patient needs to have a patent IV and the nurse needs to have 1 syringe with 9ml of NS (normal saline), 1 empty syringe, and a 3 way valve. One valve is attached to the patient's IV and each syringe is attached the remaining two valves. The valve to the patient is closed and the nurses flushes the 9ml of NS back and forth between the syringes making it froth full of little bubbles. Then when the echocardiogram tech is ready, the valve to the patient is opened and the bubbles are flushed into the patient. Instantly the bubbles appear on the image, like in the YouTube video above. It's one of those tests that is instantly gratifying as you know the results right away!

Happy New 2013: car payments and moving!

Yesterday was spent test driving cars. My honey and I have happily lived with only 1 car for the last 5 years. However, since we no longer both work in the same town that was bicycle friendly (like we did in Moscow, Idaho) and we no longer have access to public transportation (like we did in Portland, Oregon), we have come to face the harsh reality of considering a new car purchase. Since I get the commuter car to go the hospital in the next town over this leaves my hubby without a vehicle. This is an issue on weekends especially where he would rather go skiing at Bogus or Brundage while I'm working my 12 hours shifts.

It was snowing and twenty degrees all day yesterday, which meant it the most excellent day to test out the small SUVs that we have in mind. What was even better was that each car salesman was happy to point us in the direction of an especially icy road to show off how great their vehicles handled the snow and ice even without studs on! Having never gone car shopping, this was actually pretty fun! Thanks to consumer reports we narrowed our search down to 6 vehicles to take out for a spin yesterday. This gave us plenty to think about in the coming month as we figure out finances for a new car payment. Ugh!

Meanwhile, we have decided to stay in Buhl. This means we will be moving into a nearby duplex soon once all the repairs are done. I have been so thankful to live with my in-laws, however, I know I become an absolute monster when I switch to night shifts as I demand absolute silence when I sleep during the day. I flip at the end of this month (yessss- no more 5am alarms to get up!) and hoping that we can have our new place arranged and homey by then.

As for today - it's a day to play and enjoy the winter time as we reflect on the year behind us and the year starting.

P.S. For your enjoyment here is a photo of Brisbane enjoying his winter holiday in McCall. He's in a dingo snow hole here.