Tuesday, July 29, 2008

Lessons Learned: Week 5

Not a lot of time right now, but I was reflecting on last week's dichotomy of humor and despair. That's kind of what it's always like: an emotional roller coaster, and you've just got to stay stable.

We're learning what honor it is to be a nurse. I mean, really. That's part of week 6's lessons, but it seriously hit home for me in week five.

The most difficult thing, I learned, is not to watch someone die or even lay there and suffer.
The most difficult thing for me, I've discovered, is to watch the eyes of someone who loves that patient, and who has loved that patient for decades, as that patient is treated, tested, writhing in pain, out of it.
When you see the partner of a patient- and that partner is so alive, so intelligent, and so present, and then you look over at the patient helpless in bed, struggling to remember his name...
And then you see the way that partner looks at your patient, as the doctors and nurses place the ECG electrodes on that patient's body - you see that partner's eyes, and you look at their wedding rings, and you realize that the sweating, hyperventilating *person* in the hospital bed who can't even tell you his/her name at that moment because they're so out of it is *everything* to this person in the room, who stands in the corner, out of the way, strong, keeping it together, letting us do our work, stabilize, extend life another minute, hour, day.

I lost it for both of us. I had to leave the room and duck into the closet. Trauma has never bothered me, but that look in her eyes cut me right to the soul.
I fought tears, and lost.

A fellow MEPN (and good friend) asked me, "Did you see her eyes?"
"Yes. That's why I had to leave."
He nods. "I had to leave, too."

We just stood there, hugged each other for a bit, sighed, and went back to taking vitals.

Later that day, I found out that another patient had received a final cancer diagnosis, and that it was not only extremely early, the prognosis was very good, AND it was treatable. She hugged me and we jumped for joy together.

A nurse practitioner friend of mine told me that not a day goes by that she doesn't give bad news, good news, cries, laughs or hugs a patient. And she says if you can't feel, it's time to leave the profession.
I think I understand why.

Remember: there's a life in front of you. There's a person in that bed. We are so much more than the sum of our diagnoses.

Wednesday, July 23, 2008

Humor in the Process

Some topics make people really uncomfortable.
The very first clinical day, I mean the FIRST Tuesday of skills practice, one of our instructors did a mock interview and included these words: "Fist Fucking. Depending on where you work, you're going to have to ask questions about things like this, things that make you uncomfortable. Don't shy away. Is that clear?"
The class, half in shock and half in awe, nodded quietly.
Oh yeah. Crystal.

This week's topic wasn't about fisting, but it was about "nutrition and elimination."
I think people forget just how much they lose control of their body when they're really sick, or maybe they just ignore their daily functions, especially those that are a little more private.
But nurses? Nurses cut right to the chase. "Did you have a bowel movement today? If so, how big? What was the consistency? Color?"
A lot of people would run screaming from the very thought of having this conversation.
Nurses have to dive right in, and there's no pussyfooting around it.
We measure pee. We look at poop. We clean up poop.
And we insert catheters. Oooof.
If you've ever had a catheter, you know that you want someone who has some idea of what he or she is doing. It's not pleasant. But guess what? We are about to practice on our unassuming patients (under supervision, of course).
We are also now able to, ahem, administer enemas and do digital extraction.
If you don't know what that is, use your imagination.

There are some things that river guiding actually DID prep me for- there's a saying among guides, "All we ever talk about is boating, sex, and poop."
Oh yeah, and alcohol.
But seriously, having to discuss the groover, asking people on LONG multiday trips if they've used it (a HUGE issue, I assure you), has allowed me to be a little less afraid of this, um, new frontier.

The practice catheterization was hilarious. Imagine walking into a room with a bunch of fake "show-ers-not-growers" mounted on white plastic boards with fake bladders, all set out on a table, next to about 10 other vulva models mounted similarly... and that was Tuesday morning.
I've posted some photos just to let you all know that you, YES you, can be doing the same thing.
Nobody kept a straight face, but it was seriously rewarding when your Foley actually made it into the model bladder. Hope you can see what's up.

We also did NG/FT insertions (naso-gastric and feeding tube), which weren't too troublesome, although on a live person who might puke on you, I'd imagine it's a bit tougher.

This week, we're responsible for total patient care for three patients, including monitoring InO (Ins and Outs - anything that goes in, and anything that comes out).
Soon we'll focus to one, total care, including meds, IV, etc except for narcotics.

And it's only Week 5. Oh yeah, we're about halfway...

Sunday, July 20, 2008

Ambling along.

An early Sunday morning. You know you're in school when 8:00am feels like sleeping in.
The infamous parrots woke me up this morning. Yes, parrots. In San Francisco. Apparently they like to summer in the Parnassus/Cole Valley area, and this morning I discovered that they love apple trees.
That was actually a novel alarm clock.

In any case, we're done with our 4th week, and into the 5th. By the end of this week, we're halfway through the first quarter. It's pretty amazing to see how much we are learning. Tomorrow we have another pathophysiology test (yay) and we have some relatively difficult homework in Pharmacology where we have to investigate a toxicology report for Ms. Vickie Lynn Marshall.
Then there's the usual reading, heaps of it.

The patient care is awesome - Friday was by far the most interesting day I've had as far as variety of problems, and alertness/communicativeness of patients. I saw my first pressure ulcers, which the wound nurse confirmed as stage I and stage II. The nurse I was shadowing is AWESOME, lots of experience, moves fast, and is by far one of my favorites to learn from. We got that patient taken care of, dressed the wound properly, and started ambulating the patient. I can see why it's such a problem though- when you have thin skin, a recent MAJOR surgery, and someone in pain, it's hard to turn the patient every 2 hours. Somehow, though, we did get the patient moving, which also got the lungs to clear.

Someone called a code that I got to cancel. Incidentally, someone decided that the code team members should wear all black. Not kidding. How morbid is that? Hmm, the "death angels" or the "pirate-ninjas"? I guess the person in arrest isn't gonna know one way or another, but I thought the decision was pretty morbid.

Friday was also a day of A-Fib (wild to listen to), learning more meds, checking vitals, learning about HIV, catching an infiltrated IV - Me: "I think it looks swollen, and the patient says it stings." Nurse: "Well, Medicine can sting sometimes." Nurse looks at the arm, and says, "It looks okay."
5 minutes later, Nurse: "You were right, good eye, it was infiltrated. Here's how we deal with it."
I thought that was really cool of her- for one, any praise we get we thrive on- and of course I'm going to defer to the judgment of a 20+ year nurse. What really got me was that even though she's been a nurse for two decades, she listened to my observations and took the time to double-check things- she didn't have to, but she values anyone's observation, including a brand-new student. I really respect that, and I told her so, "thanks for listening to me." Her reply, "when you stop listening, you stop growing and learning. Everyone's input is valuable, and when it comes to patients, it's better to double check then to let it be. Remember that."
I nodded.

That's probably the best advice I've had so far.

I also shook a patient's hand good-bye - she thanked me for helping her out, which made me want to help her more. When I left, she was just about to undergo a very very painful procedure, and I wanted to be there to hold her hand for it, but time didn't allow.
The conversations I had with that patient were some of the most intriguing I've had, but I have to save that story for another time.

MEPN is a constant balance of emotion, work, schoolwork, and time for self. The latter gets lost, so I'm determined to do a bit of that today.

Friday, July 11, 2008

A Vignette.

I think today my emotions are catching up with me. I was completely devoid of any feeling until I decided to go work out, and while on the elliptical, after being up since 5am, a Genesis song came on- "Follow You, Follow Me."
The tears started coming. Just waves of tears, which kept coming until the woman on the machine next to me startled me by asking if my workout always counted backwards from 60 minutes. Startled, I choked out an answer, "Um, I don't know- I was off in la-la land. Sorry."

Thankfully the workout was almost done.
And when I got home, the tears started running down my face again.

Today was relatively easy, as far as patient care goes, at least I thought.

This vignette has been haunting me (stuff is changed so that I don't violate HIPAA):

The nurse I'm shadowing and I are in a patient's room. Yesterday we've determined that although he understands some English, when it comes to medical procedures and medicine in general, Spanish is the best language to communicate in. He's lived in the US quite some time, very kind, mild mannered, and he is very sick with an organ failure and transplant rejection. He's having problems- including a very high fever, and they don't know why, although it might be due to a bacterial colonization of his rejected organ.

A team of docs is rounding. One doctor approaches him, the others stand back, watching him like he's in a Holiday window scene. Nobody touches him, yet everyone's eyes are focused through an invisible divider. He sits at the edge of his hospital bed, mellow, calm, quiet - either too sick to care, or simply peaceful. I am curious about the physician's process, and I immediately realize how intimidating and how isolating this approach must make him feel. One doctor begins to give a history on him, the basics that healthcare providers are taught to do. Someone in the back pipes up, "Um, he speaks Spanish" (the day before a physician had just spoken English to him very slowly and loudly, as though he would instantly learn a new language if she could just increase the volume- if that we're true, I'd have Cantonese down pat by now). The doc starts over, begins to speak decent Spanish, interjecting English here and there when she doesn't know a word. I softly ask, "Entiende?" (Do you understand, sir?), to which he replies, "no," and I explain what they're saying, quietly. My heart aches.

All the while, the other doctors scribble busily. Their heads are close together, and they're bent over their charts in Gumby-like positions, looking up at each other. One of them is flipping through the chart madly, searching for test results. I'm reminded of the scene in "Alice In Wonderland" when the scribes in the Queen's court keep repeating "That's very important..."
".....`What do you know about this business?' the King said to

`Nothing,' said Alice.

`Nothing WHATEVER?' persisted the King.

`Nothing whatever,' said Alice.

`That's very important,' the King said, turning to the jury.
They were just beginning to write this down on their slates, when
the White Rabbit interrupted: `UNimportant, your Majesty means,
of course,' he said in a very respectful tone, but frowning and
making faces at him as he spoke.

`UNimportant, of course, I meant,' the King hastily said, and
went on to himself in an undertone, `important--unimportant--
unimportant--important--' as if he were trying which word
sounded best.

Some of the jury wrote it down `important,' and some
`unimportant.' Alice could see this, as she was near enough to
look over their slates; `but it doesn't matter a bit,' she
thought to herself....."

Has he had this test? Why not? Who missed that? Why has he had this problem for this long? What's going on? Why are the results not faxed? We need to order this test!
I ask him about the particular test. He states it's been done. More than once. He'll do it again he says, shrugging his shoulders. It's not a test I'd do again. Even the physician says, "Once is enough for anyone. And you've done it more than once." A glimmer of humanity and humor shows through, eases the tension.

More fervent scribbling, heads down, focused on the papers, no touching, no smiles, just serious business.
It's comical. It's tragic. I stifle a laugh, because I honestly cannot believe how dehumanizing this process is at this point. Deep breath.

Outcome: An antibiotic changes. The group leaves. A passing good-bye from one physician to the patient. They bustle out the door to review the next person's medical history, which I know will teach the new residents a lot, and make them very good at what they do.
My focus now is to get good at what I'll be doing.

His nurse and I exchange glances. We leave the room and don't even have to say what's on our minds. As we're walking down the hall, she breathes, "Sometimes, it's kind of a circus." My chest feels heavy suddenly, and I don't know why.

Don't get me wrong- the physicians are AWESOME. They are highly intelligent, respected, and amazing at what they do. They work extremely hard, and provide excellent care. But sometimes, it seems like the teaching process can be incredibly dehumanizing. I know that bedside manner is being taught more in medical school, but if nothing else, that experience today was a stark reminder of how distant medicine and science can be.
And how frightening- Imagine being so sick in a country where you spoke most of the language, but when it comes to medical procedures, things get difficult to understand. Part of me wonders how often we think of this fact. His nurse and I discuss this point of view extensively, and check on him more often. He's not feeling very good today, and we both know that.

Two hours later, this man has a fever of 103F, and his respirations are alarmingly high. Is it the fever? If so, what's causing the fever? Is he septic?

One of the doctors, a newer MD, very friendly, told me yesterday that many of the patients die of DIC. When I ask what that is, she explains, "Disseminated intravascular Coagulation. It's horrible. Basically, they go septic, clot internally and die. Not much we can do about it."

I can't stop thinking about it. I don't see this patient getting better, not in his condition, but I'm not the provider- I'm just a student.

He tries to eat lunch, but barely puts anything away.
When I leave, he's sleeping.

And now I'm at home, trying to study, and completely unnerved. Welcome to my first reality check.

It makes me even more determined to be the best nurse I can be, and subsequently, the best provider.
And the tears are still coming.

Thursday, July 10, 2008

At Night, the Mosquitos Come.

The past three nights I haven't been able to sleep well. The sliding door to the balcony is a MUST to leave open, since SF has been having a heat wave (not as bad as a few weeks ago), and otherwise the air just stagnates. Apparently, somewhere on the property I live, mosquitos are breeding.
There is absolutely nothing more obnoxious than waking up with one of them whining in your ear. I don't care if it's on the river, or an urban mosquito, I don't like them. In fact, the Dalai Lama has even admitted to killing a few himself.
I don't feel so bad about the few I squished last night.

Sleep is a precious commodity, mostly because we're absorbing so much or studying early to late. On Wednesday there's this wonderful feeling of the week being over with, but then the reality that one has to get up at 5am (it keeps getting later every morning I have to do this) and be on the floor, ready to go by about 6:40, if you're lucky, is a stark reminder that oh yeah, I'm fighting for my sleep time. Some of us have to be ready at 6, in Palo Alto (not me, not yet).

We're 1/3 done with our first quarter, and have one more "first test" on Monday. It's been a nonstop onslaught of homework, testing, learning, practicing. It's awesome, definitely, but intense. They're not kidding. I think that the more hands-on patient care one has had, the easier it is to do this program - just being comfortable touching a patient is a skill that one learns by having to do it, constantly. And that's what we're here to do. To learn how to interact with patients, Do No Harm, and hopefully, do some good here and there.
Little victories mean a lot.
It's that intense. We're just constantly DOING.
I really like this MEPN program. I mean REALLY like it. Nothing academically has spoken to me like this before, and it really is perfect.

Last week during clinicals I got to watch a liver biopsy on a 37 year old transplant patient. His cousin had given him part of his liver. His family was super cool, and I enjoyed talking to them; however the biopsy nearly made me faint. I can watch someone bleeding out all orofices, but show me a 6-8 inch long needle (I'm not kidding, and I was told that was the small one), and I'm not okay. It's why I'm not a surgeon.

Speaking of surgeons... they're incredibly busy, and there are a few residents and attendings who will say hi or good morning, but for the most part, I have a joke to share:

Do you know what the difference between God and a doctor is?
God knows he's not a Doctor.

I'll leave you with that. I have to get going for another day of clinicals. We're still observing mostly, and today we have to pick one patient and know their history, diagnosis, discharge prognosis and care plan. No meds yet.