Two years in the ICU

A little background: I have spent the last 2 years working in a medical ICU working with a wide array of patients and their diagnoses from detoxing, diabetic ketoacidosis, congestive heart failure exacerbation, GI bleeds, terminal cancer, sepsis, respiratory failure, and even a couple of West Nile virus cases. I have learned so much about the human body and the journeys it is capable of surviving, but I have also learned so much about myself. I needed a place to write my thoughts and so I have returned to SageBrushRN to explore those ideas.

ICUs are able to combat and correct a lot of things. I am most proud of my moments when I've had a chance to feel like I made a real difference. I've had patients come back in a say thank you for getting them through a pneumonia, a heart attack, a freak infection that came out of no where, and various other maladies. 

However, what I was not prepared for in ICU was the torture care of terminal patients. When I say "torture care" I mean cares that are done to a patient that is very clearly not going to survive but we are still doing everything possible like we still have a chance to cure. 

I have cared for people for weeks with tubes coming out of every orifice that are unable to communicate but still grimace with every position change every 2 hours. I have lost a little of my soul to these patients that will spend the last hours of their precious lives being poked and prodded under fluorescent lights in the ICU. I have wept when we have coded the same person time after time because the family has no idea the violence of a code and would rather subject their love one to another Code Blue rather than hold their hand and savor what time is left. 

I have recently read Atul Gawande's book Being Mortal and it gave voice to all these feelings I have been grappling with over the last 24 months. Our medical culture is inept at dealing with mortality and we rather flail helplessly against certain death in an attempt to make ourselves, not our patients feel better. 

Gawande sites a study about palliative care where patients with Stage IV lung cancer  were randomly assigned to receive either usual oncology care or usual oncology care plus palliative care specialist care. The following is astounding,

"...those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experience less suffering at the end of their lives - and lived 25 percent longer (his emphasis, not mine). In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality (Gawande, Being Mortal, 2014)"

I got into ICU to save lives, but the longer I am there I realize the majority of what I do is prolong suffering of both patients and their families. I got into nursing to serve others, to relieve their suffering, to make the world a better place. I do not fear death, I fear suffering as a patient's last memory of this world. 

When I've worked with families and doctors wise enough to recognize and accept the end of life I have been honored to be death's midwife and remove the trappings of ICU and provide relief from pain and suffering to let someone pass. When I can remove the lines and let a mother hold her child one last time, or a spouse snuggle in for one last hug that is the comfort my patients deserve - to feel love and security from those who matter most to them.

It is with relief that I am now leaving CCU. It was an honor to work with such brilliant nurses and to be part of a such an efficient team. However, I have found that my nursing practice and my nursing soul need a change and will find that change in the new journey of PACU nursing...

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~

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.

Quotation for a Friday

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!

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.

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.

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....

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.

Denial is a big river

Denial is a big river that meanders and has no real direction. Some people cross this river in a speed boat. Others are on tubes that get caught in the eddies spinning around and around. It is one of the many stages of grief, but one of the hardest to watch in my opinion.

Sometimes patients are not going to get better and the discussion to change care from aggressive treatment to comfort care is a difficult one to have to begin with. It's even more challenging when family members of a patient cannot acknowledge the end is inevitable and the nurse or doctor's message falls on deaf ears. This leaves a patient in a "no man's land" where we continue treatment and delay hospice.

I also personally think this is forcing the patient to have quantity over quality when it comes to last days of their life. I think it should be the inverse - quality over quantity. If my terminal patients could all go home on hospice and enjoy their families and be at home to die peacefully and comfortably with their cat on their bed, death would be a much gentler experience in our culture.

Acceptance is not something that can be forced, but taking care of a patient that is suffering and not going to get better is an emotional burden that I did not expect. I've spoken to other nurses on my unit and all of them have stories of feeling like they were torturing their patient while waiting for a family member to finally make the decision to change to comfort care. Some even told me of asking for switching patients because they could no longer handle the emotional toll of going in for another shift.

Having had my own experience with this now in my own job I sought comfort in knowing this has happened to other nurses that have come before me. The commonality of this experience, however, is a huge cause of chagrin. It has made me a bigger advocate for advanced directives/living wills as well as encouraging families to have these difficult discussions BEFORE anyone ends up in the hospital. No family member wants to feel responsible for "pulling the plug" or "giving up" - this is why these unfortunate situations happen.

In Idaho the state website offers a wealth of information on Living Wills including:

1. Living Wills and Idaho's Natural Death Act
2. Frequently Asked Questions about living wills
3. A helpful form to fill out to share with your family, etc

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

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.

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.

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!

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

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

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

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

Here is to creativity, imagination, and playfulness!

The privilege of ritual in death

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

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

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

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

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

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

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

Life is precious and momentary. Savor it. 

Feet on the floor

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

The high lights from work were:

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

Other fun things:

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

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

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

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

Week 1: Hospital Orientation (aka Death by PowerPoint)

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

Well here you have it!

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

Cons of orientation:

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

• People who read off their PowerPoint slides. Yawn!

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

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

Pros of orientation:

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

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

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

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

2 week marker & top 10 list

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

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

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

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

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

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

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

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

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

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

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