ECG: course work and art work

Today I completed my ECG online course and exams through the American Association of Critical Care Nurses (AACN)! I was of course very excited to get a question to identify the image asystole (aka "flat lining"). It's always a sure fire way to boost your confidence in the middle of the test to know that you definitely got one question right ;) For the record: I did actually pass both tests - the foundations and the applications test.

Yes!!! I got this one right :)

Overall, telemetry, essentially the science/art of reading monitored ECG strips, I am quickly realizing is a life time of learning and processing. Although I have several of the basic rhythms down I am always amused when I bring a puzzling strip to an experienced nurse and what I was hoping was going to be a quick answer really turns into a 20 minute conversation of what it might be and why it might be happening. When in doubt 'sinus arrythmia' is the catch all phrase used to describe those bizarre rhythms that don't quite fit into a category. Nonetheless, it is a pretty loathed phrase especially in an ICU environment with very particular/picky nurses!

To sign off today, I am posting some ECG inspired tattoos (there are more than I ever realized).

"L'amour fou"

faith

ecg with a heart

ecg and arabic?

"follow your bliss"

First shift on "availability"

I worked last night, slept wonderfully today, walked the dingoes, made me some dinner and then the hospital staffing office called to tell me I was being placed on "availability" scheduling. I explained that I was in fact scheduled tonight and they said, "nope, not anymore. If we need you, we'll call you and you'll get availability pay." Well that's a new one.

So my cell phone is attached to me and the nearer 1900 is the more guilty I'm feeling for not being at the hospital! I'm terrified at 1915 my charge nurse will call to demand where I am and I'll swear up and down that I was just doing what the hospital staffing office told me to do!

Sleep: a new found hobby and obsession

Last week I worked Tuesday night and had mandatory Wednesday morning education. I took the liberty of grabbing some blankets out of the blanket warmer at 0730 Wednesday morning and finding myself a fold out bed in a patient room in the unused medical behavioral unit that is on the IMCU/ICU floor. I snoozed deeply for one hour and then stumbled back out to grab some breakfast and coffee just before  class. The cook downstairs took pity on me because she made me extra eggs and bacon and kindly suggested I take the BIG cup for my coffee. I definitely got some weird, followed by concerned, looks from my coworkers upon still seeing me on the floor at 0900. I would like to point out I am not the first nurse to sleep in the med behavioral unit and I'm already booking my stay for a few weeks from now when I'll have a repeat of this ridiculous schedule!
The days that I don't sleep enough I end up playing catch up. When I did get to bed on Wednesday I was running on adrenaline I think because my body was compensating and didn't know what else to do! I slept for 3 hours, went to a basketball game with some family members, and then came home and was promptly in bed by 2200 and slept for 12 hours straight. Nothing was going to convince me to get out of bed otherwise.
Being on this night time schedule makes me so much more responsible when it comes to tracking my hours of slumber in an OCD sort of way ;)

Sparkling red Danskos

I broke this pair in on the floor Tuesday night. They remind me of cherries in the summer time!

All about: PCIs and CEAs

I worked Tuesday night and had class Wednesday morning this week. What an experiment in sleep deprivation and an ode to the powers of caffeine! I had a busy beginning of shift with an immediate transfer of a patient upstairs (a real character and one of those you are always sad to transfer off your floor). My other 2 patients were a carotid endarectomy (CEA) surgery patient and a percutaneous coronary intervention (PCI) patient. So, today I'm going to elaborate on those 2 procedures!

The patients that have CEAs usually have this procedure because they have a high risk of stroke from stenosis (narrowing) of their carotid artery. They may even have had transient ischemic attacks (TIA) which is like a tiny stroke that has self corrected. The CEA patients, when they come from a certain doctor, have the most specific notes I have yet to see. It is very clear about how often neuro checks will be completed (every 15 minutes for 3 hours, every 30 minutes for 3 hours, every 1 hour for 6 hours is usually standard), when to initiate certain drugs if they have certain high or low blood pressure levels, what time to discontinue the antiplatelet IV drugs they are on post surgery, and what time their urinary catheter will come out, even if it's 0300 and the patient is sleeping. Here is a really great video on what occurs during a CEA surgery. In our hospital we use bovine pericardium (the exterior envelope of a cow's heart) to provide a patch.

PCI is very common on our floor. Patients go the the cardiac cath lab, have this procedure where they may or may not have an intervention, like a stent placed. They return to our unit where we check their labs and once their ACT (activated clotting time) is below a certain number we remove the sheath from the femoral artery. Removing a sheath is literally like holding someone's life in your hands. The bandage over the sheath is removed. The suture holding in the sheath is clipped. The arterial pulse is palpated. You attach a syringe to the sheath and withdraw about 5ml of blood. I keep my left hand on the artery just about the sheath entry point, have patient exhale, and then remove the sheath, promptly stacking my right hand on top of my left hand. If everything goes well, you sit there for 20 minutes holding pressure on the site and it coagulates just fine. You clean it and put a transparent bandage over it. Then you patient gets to lie on their back for 4 hours extremely bored so as to make sure the puncture site has plenty of time to start healing. The things that could go wrong with a sheath pull and require you to holler for help:

1. your patient has a vaso-vagal maneuver where their heart rate drops to less than 40 beats per minute and an emergency medication has to be pushed to speed up their heart rate
2. your patient doesn't stop bleeding. You keep holding pressure, you get more people in the room, and you grab a femoral stop device and call the MD
3. the patient has really high blood pressure that's 'fighting' you. In this case some morphine is a great idea because it decreases blood pressure and reduces your patient's discomfort of you pushing on them.

Now here is a great video all about PCI

Forever homesick it seems

The days that I don't work or don't have some diversion (like the past 2 weekends with my honey) I wake up deeply depressed, blue, and angry and missing my Portland home dearly. I have spent my time since November here trying to be cheery when I'm not at work for the sake of everyone else. It's exhausting keeping up that facade and by the end of the day I'm spent. I miss my community. Prior to Portland I never really felt a sense of belonging anywhere and to give that up has created an overwhelming sense of loss.

These are some of the multitude of things I miss right now and today I'm being indulgent and just letting myself be sad instead of trying to continually fight it.

• a sense of belonging; that was unique to Portland and I've never experienced that anywhere else
• knowing all my neighbors
• Charlie Watts, the neighborhood rabbit and his owner who perpetually chased him up and down the street with a fish net
• farmer's markets that I could walk to
• my butcher that made the best bacon and best ribs
• tea houses with bubble tea
• French bakeries with delicious pastries
• the MAX and the street car
• comedy clubs
• aerial performances
• biking to downtown
• Lebanese food
• neighborhoods that were walkable with character - Alberta, Mississippi, Sellwood
• not getting glared at by drivers when crossing the street when there is a green pedestrian sign
• never having to drive more than 15 minutes to get anywhere
• Ruby Jewel ice cream sandwiches
• perfect sidewalks to walk on everywhere I went on foot
• the culture - the fact that I coexisted with people radically different then me was sooo nice and they didn't think I was going (literally) to hell just because we had different opinions. We could discuss our radically different views and still get along over a great beer
• the weather - I miss the rain and the sunshine and the perfect temperature year round.
• tubing on the Clackamas river in August with my buddies and Pabst
• the art and science museums
• Star Trek and Shakespeare in the park
• Andean food
• Mount Hood, Mount St. Helens, Mount Adams 
• Sauvie's Island for it's berries in the spring and summer and corn mazes in the fall. The beaches are swell too!
• Hood River and White Salmon
• sea kayaking
• the coast - Lincoln City, Cannon Beach, Manzanita
• good beer - Cascade Barrel House, the Blitz, McMennamin's, Fire on the Mountain, Breakside brewery, etc
• talking to people - something about Portland makes everyone really nice and I always could chat people up in bars, on buses, in coffee shops
• festivals - beer festivals, renaissance fairs, pirate festival, hemp fest, chocolate festival, etc.
• good organic/fair trade/ bird friendly/ farmer kind coffee - Stumptown, Risottos, etc
• the constant obsession with zombies and watching the Walking Dead live at the theaters
• fire pits in the spring and autumn in the back yards of my favorite people
• the best library system - online books for almost anything
• hiking, even if it meant torturing my significant other
• tattoos of every shape and color each with a great story if you are willing to ask and listen
• gardens of every shape and size and how almost every house had artichokes growing outside!
• watching roller derby
• the Willamette river and all it's bridges

there are hundreds more things to add, but that's enough for now

The Goldilocks' shift and 2 pairs of Danskos (eeek!)

Friday night was awesome. My biggest complaint on night shift has been that it has been too slow. I realize that I sound a bit like Goldilocks- day shift was too crazy busy and night shifts have tended to be too boringly slow. Friday night was my Goldilocks night where everything was just right.

I had 3 patients. I transferred one upstairs, admitted one from the ER, and worked side by side with my favorite doctor who was admittedly looking a lot like a zombie from lack of sleep. My coworkers were a set of ladies I had not worked very much with yet and discovered that together we made a formidable team in the IMCU helping one another out all night. It was great to feel both supported and to know that I was helping my coworkers out equally.

By the time I looked at the clock it was already 0430 and I rushed to finish interpreting cardiac strips, download vital signs, finish noting orders, and be in time for my 0600 meds. By the time I finished giving report and clocked out at 0730 I was running on adrenaline that even after my drive home I was feeling great. The sunshine, that has previously missing from my life for the last 3 months (I didn't see it on day shift either), was glowing in a blue blue sky. We had pumpkin waffles at my in-law's for breakfast and then my darling suggested we drive to Boise for the day to spend our Xmas gift cards.

Much to my delight I got 2 pairs of Danskos - one orange with leaf prints and one dark cherry red (both sparkling). Interestingly enough I found them at two different farming stores. Shopping for Danskos in the middle of cowboy boots is pretty entertaining, but makes sense in the fact that they are all made of leather and last forever. My orange ones were from a little store, Flynn's Saddle Shop of Boise (gift certificate location #1 and they carry the shoes at much lower cost than anywhere else). The staff was super sweet and got me all the size 38s they had available in their small selection. Since Danskos are hand stitched even though the sizes are the same, the fit is not always equal. So after much deliberation I found my 'Cinderella slipper.' Since none of the other 38s fit quite right it was then onto D&B supply to use gift card #2 where I found the dark cherry red pair that remind me of the Wizard of Oz. Although I'll keep my black Danskos on hand, it's nice to feel like I have outgrown them for work!

We ended the delightful day of shopping (don't worry- my hubby got to do his very own shoe shopping with his REI gift card for hiking boots) with dinner with hubby's brother and sister in law and our nieces and drove back under the stars. It was so great to spend time with family, get out of the house, see some sunshine, and then sleep a well deserved 12 hours when I got home.

Challenges of a new nurse: your immune system gets a thorough beating

My already weak immune system has succumbed to some noxious bug travelling around the nurses at work. I felt the beginning of a tickle on Monday and then by 0300 today I was stuffed and Niagara falls was coming out my nose. AT THE SAME TIME. So much for trying to breathe and look decent. Oh, and my fingers are going to fall off from all the cleaning and washing they endured last night.

I kept it together long enough to get home at the end of shift. Technically I had an education class today, but my nurse manager mercifully sent me home.

Some Theraflu and hundreds of trees later I'm aching and unhappy. I was supposed to work at 0100 tomorrow (as in one hour after midnight tonight), but I called in sick. The next day or so will be spent sleeping and drinking broth to recover.

All good karmic, healing thoughts will be greatly appreciated.

Prepping for tonight

Tonight I'm flying solo!

I am following one nurse's schedule (my mentor) who is my 'life line' when I need to ask questions, but chances are she will be charging or in ICU so really not that available. Which is a good thing. My "mentorship" lasts a month, but I'm determined to be as independent as within reason and to not let my butterflies get the better of me (my biggest struggle is second guessing myself, which is not the same as asking for a second opinion - patient safety always comes first).

One of my preceptors called me out for saying "I think X...." too much instead of just saying "X is happening." I have been very aware of my use of language since that reprimand in order to portray confidence when I speak - both for my patients sake as well as for avoiding being verbally abused by some of our not so nice MDs. I also happen to be one of those people that apologizes with "I'm sorry" all the time so this exercise has been challenging, but necessary. It feels like I'm faking confidence at the moment, but I suppose the saying is 'fake it until you make it.'

Someday I'll hope to be terrifyingly confident (really it's quite a sight) as the nurses in the ICU that I deeply admire and hope to be as competent as in say...50 years? :)

Today (before I take my afternoon nap) I am cramming in some more of my online ECG class. For non medical people here is a very good, short definition of what ECG is (from: Wiki: Electrocardiography).

Electrocardiography (ECG or EKG from German: Elektrokardiogramm) is a transthoracic (across the thorax or chest) interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the surface of the skin and recorded by a device external to the body.The recording produced by this noninvasive procedure is termed an electrocardiogram (also ECG or EKG).

An ECG is used to measure the rate and regularity of heartbeats, as well as the size and position of the chambers, the presence of any damage to the heart, and the effects of drugs or devices used to regulate the heart, such as a pacemaker.

I really am enjoying all the education that I am receiving. Each day of ECG classes gives me something new to apply at work. Our unit has large screen monitors scattered throughout the halls with all the unit's patient ECG strips on the screen in real time. So, even if my patients' hearts are normal there is usually something going on that I can practice my ECG 'reading' skills on during the night. 

Back to the books and then time for some napping. 

Also, I included a dingo picture for today because they were being silly.

Mondays are better when they are shared.

Out on a Saturday night: Catholic Crab Feed!

I have a weekend off! 

Last night my honey and some family friends went to the all you can eat Catholic Church Crab Feed. The wind and snow were howling all day and I'm fairly sure the entire town of Buhl was in attendance. Rows upon rows of tables were wedged with people elbow to elbow patiently waiting for the glimmering silver bowls of crab legs to be delivered to their section. The atmosphere was jovial as the beer flowed liberally, the crab legs kept coming, and everyone diligently worked with their crab eating utensils brought from home specifically for this event. 

Our small group of people contained quite a bit of competition as we took turns showing off the biggest pieces of crab meat obtained with a plethora of utensils. There were at least 2 Leatherman multitools,  one set of pliers, big scissors, and the more traditional silver crab cracking devices in our section. It would have been entertaining to see what other devices were spread throughout the tables.

Another observation I made through the evening was how this has been one of the only settings where I saw a mixing of the Hispanic population and the white population for pleasure. Obviously, these two groups work side by side, especially in an agricultural community. However, I only see them mix socially at rodeos and now Catholic church events. It's interesting to hear the rhetoric in this area that is often anti-immigration, but to see the reality that this immigrant population is vital and necessary to drive the local economy.

Overall, it was a lovely and delicious Saturday night full of laughter and some indulgence. There isn't a day that goes by that I don't pine for PDX (except when I'm at work and I'm immersed in my element), but going to these events makes this adventure in the desert a little less isolating.

Night Shift Narrative

This was my interior monologue in my head last night:

2000: "Sweet I have all my assessments done and my first round of cardiac strips saved and interpreted. Plus my patients and their families are lovely. Boo yah!"

2200: "A family on the unit bought us pizza. One slice is heavenly! Time to get folks tucked in"

2300: "Just got an admit. Easy one at that. Why are they coming to my unit???"

0000: "Must do 2nd assessment and 2nd round of cardiac strips. Some IV antibiotics to hang. Geeze, my eyelids are twitching"

0100: "me so hungry...time for my salad. Gross... too much work to walk down stairs to get something else"

0200: "Just one cup of coffee. Please"

0215: "Omg. Adrenaline rush. That just happened. Time to fix it"

0230: "What the heck! Just gave an awesome SBAR to the hospitalist and I'm pretty sure they didn't even listen to the words coming out of my mouth. I'll follow the new orders, but I'm calling back in an hour because they WON'T work"

0300: "Here we go...."

0330: "Hi. It's me again. That thing you suggested didn't work. Now what? Sweet, thank you."

0400: "Finally....Now I'm awake enough for 3rd assessment and strips. I'll wait for lab to go draw blood and slide in right after them once the patients are awake"

0430: "Hee ha ha - my coworkers and I are hilarious at this time of the morning. We should be comedians!"

0500: "Omg, my eyelids are the weight of bricks"

0600: "Lab results are in, time to get all my electrolytes signed and acted on. A few phone calls to pharmacy should fix my potassiums...So on top of it!"

0700: "So happy to give report!!! Day nurse that arrives 5 minutes early I LOVE you. Plus you had 2 of these patients yesterday - fastest report ever!"

0730: "Time for the window frost scraping party in the parking lot with all the night nurses! And I can't even remember what was so funny at 0430. Probably something dumb."

0830: "In bed. All I can hear are IV pumps and cardiac monitor alarms ringing in my ears....yawn"