Teaching.

That photo is off my boat on the Grand Canyon, which was a sweet trip.

Full circle. Two years after starting the MEPN program, I'm now lucky enough and crazy enough to help teach new MEPNs. I'm river guiding rarely, working as a nurse in the Emergency Department a LOT, and teaching to really fill my soul.

I never knew how much I'd love teaching.

I also never knew how frightened I'd be to re-enter the Master's portion of this program.

So, I had to leave my Level 1 Trauma Center job in order to teach, so now I work at a Level 2 Trauma Center, hopefully going to be splitting a dual appointment with the Emergency Department and perhaps the PICC/IV team. Days, thankfully. I work DAYS. Sweet.

Night shift made me insane.
But that's not what I'm here to blog about.

I wanted to talk about teaching. It's been challenging, for sure. I watch the new students get so excited about the smallest part of nursing they get to experience. I watch their faces light up when they help a patient make a small achievement for the day- and for me, that's the real reward. Sometimes they get so lost in details that I could scream (oh, the questions), but I know it's part of their learning process and I want them to ask, ask, ask.

Their passion is amazing.

So we were talking about inserting nasogastric tubes the other day, and one student asked me, "What if they bleed? Or what if you hurt the person while you're doing this procedure?"
To which I replied, "Well, sometimes you do hurt people - I mean, it's not comfortable. Do you harm them? No. But you do hurt them. You aren't always doing something nice - sometimes you're doing something that is really uncomfortable."

She stated, "Wow. You must kinda lose some of that connection, you know? I mean, ER nurses must learn how to not care."

I blinked. And said, "No, you never stop caring. If you stop caring, you leave nursing. You just learn to differentiate between what's actually harmful and what's necessary for healing. I've refused to do things before. People have the right to say no. And you get used to how procedures go. Not every procedure goes perfectly every time. You just do your best."

And I realized I meant that. I could have told her about my patient the other day whose heart stopped mid sentence and was a DNR, and how even though I was still taking care of patients that day, I stepped into the room with the family and cried for 15 minutes with them. And that I still think about her.
I could tell her that I walked into a room with an intubated patient, noticed her BP was sky-high and titrated up her sedation and spoke to her in soothing tones, and watched her heart rate and BP drop to a more normal zone. I could tell her that I never say anything bad about my patient even if they're sedated, because I assume they can hear me, and my place isn't to judge.
I could tell her that sometimes I judge anyway, and I have to shove my judgment aside. I'm human, and people do stupid things, for sure- but how many times have I done something dumb? Nobody deserves to get hurt.
I could tell her that every time I feel like I hurt someone I cringe inside.
I could tell her that I give 110% to people while I'm there, because, well, that's my job and I love what I do.
I could relate the time I had a guy who learned he was probably never going to walk again, and how I held his hand and my friend Jen held his other hand because he wasn't sure if his child was alive, and how we both stood there and cried with him for an hour, because we had the time to give and we could be there and he said, "Please, please don't let me be alone." And dammit, we weren't going to let him be alone that night.

I couldn't do this job if I didn't care.

No, really

Yeah, now it's really been a while. And why?
Because no matter what anyone tells you, it all comes down to the fact that night shift... TRULY SUCKS.
Yes, the camaraderie is amazing. Yes, you will learn more than you would on day shift. Yes, you have to troubleshoot for yourself, and doggone it, it's good for you when you talk to salty old nurses who can reminisce about how tough it was to have a night shift and be so stranded with few resources and new interns and new residents and oh my god we're gonna hurt these 8 patients I had to take care of in the snow uphill but....
it all comes down to:
Night shift sucks. Ass.
It creates good bonding, and to those who are naturally night people? Good on' ya. Please keep our world turning.
I remember being up before sunrise. Now I stay up until 11am sometimes. And it makes me feel weird.

But overall, it's good for me. Or so I keep telling myself. So, until the holidays are past, I am going to keep a positive attitude. I have my dream job. I am working in a level 1 UC trauma center that gives me tuition discount etc...
I see things that most people will never see (Rheumatic Fever? Really? Seriously?)
I see cutting edge treatment. I've run a gurney to the OR with a surgeon's hand in someone's heart, holding an Aorta together. I've seen dead people come back from a code. I've seen trauma unlike anything I could imagine. And I'm still here.

And my husband is by my side. So, that speaks for itself.

Assaulted or A-peppered? Happy Nurses' Week.

I mean seriously, come on.

There are nights (actually, I guess mornings) when I leave the ER and I wonder if people show up just to fuck with the nurses.

Since starting work as an ER nurse, I've been kicked, grabbed, clawed at (I understood that one, though- 90 year old on whom I was inserting a Foley catheter), spit on, yelled at, called every name and *then* some, pushed, and had someone very nearly injure my thumb. And that's just from the patients.
That's not including patient's families.
Let's not forget the MDs who sometimes lose their cool, because even though we're part of the healthcare team, we're still "just a nurse" to some of them.

I've seen tricks, from fake seizures, to "I'm suicidal" right before discharge of a homeless person (because they have to stay on an 8 hour hold after that until the Psych team evaluates them, so they have a bed to sleep in), to "I can't walk" - until that person wants to smoke outside, to "I have 10/10 abdominal pain... can I get a meal tray please?"

And yet, most of the time we just take it all in stride and brush off the mean comments, the yelling, the snide remarks, and know in our hearts that we do our best to care for people who really, really need it.

And sometimes, people say "thank you." You have no idea how much I appreciate those words.
And sometimes we fuck up, like all humans. Hopefully they're small f'ups.

Last night, I had a *patient with advanced cancer (*NB reader, I will reiterate, all patient stories are changed to comply with HIPAA). He was grouchy because he had been there a while, had no white blood cells to speak of, and we had been promising him a room for hours. And then, of course, I missed his portacath when trying to access it. I've never missed before. I was about halfway in and the Huber needle bent, which I've never experienced, which honestly, just sucked. And when you have an already grouchy patient, who has a real reason to be grouchy, who is actually very sick, and you're trying your damndest to do something good for them and you fail? Well, you feel very much like you suck. I had another nurse re-try and he was successful, and fortunately we got that person upstairs to a more comfortable bed, but yowza, if looks were lasers- I felt like he mustered his last bit of energy to shine some anger on me. I understood, but I had been doing a lot behind-the-scenes to help him out, regarding pain management, paging physicians, and getting the antibiotics and blood going that he needed to help make him feel better. It wasn't so much the missing the portacath, mind you - it's probably the knowledge of impending death, pain, feeling like hell (Hemoglobin and Hematocrit of 7.2 and 21.5, respectively, which SUCKS), and having everyone tell him "soon, you'll get a bed" for four hours... and then me missing the portacath.
And I felt awful. I had worked on his inpatient orders while taking care of three other very very sick people- my least acute patient had an open compound fracture (splinted in place) and was going to surgery in a few hours - and understandably had pain control issues, which I was also having to manage every 20 minutes - and trying to get a doctor to increase an order for dilaudid ("no NOT 0.4mg, we gave him 4mg today. Yes. What?? You want to start with 0.4? Did you see his arm? Okay. I can guarantee you're going to be paged all night. Can you increase it to 1mg q 2 hours?"). My other two were 1) psychological issues with COPD (who went home after her breathing improved greatly) and 2) someone with a BP of 225/115 with blurry vision. Yeah.
And just when it was all almost under control, we get someone who overdosed in to my section- not my patient, but when that happens, we all help out because it's a heavy, heavy workup.

We had an assault patient show up as well. It was 4am, and he was a bit difficult to deal with, and the doc was getting frustrated. The doc asked, "So what did he tell you about being assaulted? Do you think he really was?"
I deadpanned, "No, he was actually a-peppered."
At 4am, that was really funny, and decompressed some of the insanity of the night.

Later that night (or early morning), my mentally ill COPD patient came back to scream at us and tell us that we're all incompetent, and then ask if she could watch TV. She started holding her breath to show us how short of breath she was (yes, after screaming). It was an incredible act, and I just shook my head. She pointed at me and the doctor to say that we sent her to the "Clinic hospital" and we were incompetent. Um, yep, I gave her info on a free clinic where she could follow up for managing COPD and her behavioral issues at her request, and made sure she had directions and a bus token. Apparently, she was angry that they weren't open at 5am on Sunday morning. Sigh.
It was almost as good as the girl in triage who I watched shove her finger down her throat to vomit, and then tell us she had nausea and vomiting. Classic.
I had no energy to say anything. At 6am after working all night and taking care of everything under the sun, I just have no patience for that kind of bullshit.

So, my point being: Happy Nurses' Week.
Someone, a friend of mine who is almost an RN and just finishing nursing school, said she thought that we have "very little power and great responsibility."
I absolutely disagree.
I think with great power comes great responsibility.
I know with absolute certainty that I do my very best every day for my patients, even if I shake my head sometimes.
We have the power to make people feel very comfortable in times of great distress, and sometimes in times of great embarrassment.
We have full on Jedi-mind power to decompress a lot of situations.
We have the ability to mostly let things roll - water off a duck's back, my friends.
We have the trust of both patients and physicians. And of our colleagues.

And we deal with a lot of shit. Figuratively and literally.
So, point being, next time you see a nurse, make his or her day.
Just say, "Thank you."

Spring Cleaning

Those crowbars are on the floor of Will's grandpa's kitchen. We were pulling out drywall and I put the bars down and *gasp* there it was, love in the middle of us pulling down the walls. Kind of awesome.

Between working night shift and planning a wedding, writing has taken a back burner to life lately. Some fun things have happened: I found my digital camera, although it's not charged, so I can share more fun photos of cool things, like the most awesomest pen light EVAR in the shape of a killer whale that my friend Katie sent me as a thank you- and my little kiddo patients love it. *Happy Dance!*

Wedding plans are deep underway: venue, bridesmaids all picked and dresses purchased, DJ, Photographer, on to cake tasting. The worst part is the list of invitations. We have been *agonizing* over the invites. Anyone who's been a bride knows this pain.
Sheesh.

I've also been weeding out sources of stress. This past month, I've gone 50 days without any alcohol (I know, can you believe it?), which was a real eye-opener as far as stress relief goes. Many of us use alcohol to de-stress, and I've had to use other venues, such as walks, yoga, stretching, meditation, tea, art, and of course, shoe shopping. I've had more massages in the past month than I have in the past year. There's been some balance restored. Much needed.
I have also done some work examining (with help) people who have used me in the past or who I have allowed to cross my boundaries - this list includes folks from college to people I work with occasionally, to even patients, and recognizing how much I tolerate without speaking up has lead me to be a lot healthier- and now I let people know immediately if something bugs me. I still have to say in some cases, "If you can't say something nice..." is a good rule, but for the most part, I'm not rolling over on my back anymore.

The smell in the air and the wind and rain has been reminding me of river season. I had a moment, driving up the central valley, where I just flashed back to the first time I drove into a river canyon, and that familiar feeling of love and excitement comes back to me. I can't wait to put my paddle in the water.

That's all for now. Working to get a per diem job, taking another year out from UCSF so I can really have the experience to help me as an expert in the future, and doing work on maintaining and constructing good boundaries.

And I'm also saving up for shoes. Oh my god, shoes.

Vampire Hours.

It's been a while since I've posted, which is partly due to the holidays, and partly due to the fact that I've been on night shift for the past month.

I feel like a vampire.

A couple of things have been developing. For one, I'm actually on my own as an RN next week, which I'm simultaneously excited and terrified for- on one hand, I won't have someone looking at everything I do; on the other hand I won't have someone checking up to make sure I did things right.

The night crew is so amazing at helping each other out with things in the ER, so I have to say I have seriously enjoyed working with everyone all night. The camaraderie is beyond anything I've seen.

The sleep deprivation has been difficult, but I'm lucky enough to be able to sleep between the hours of 8a-4p. Wild. This schedule all stops next week when I work a more normal 1200-0030, or noon to midnight in regular time.

Other wild things: We've had Tornadoes here in SoCal, snow, rain, thunder. I love it.
Today I also had my first experience at Disneyland as a SoCal resident. All I have to say is that "Yo-ho, Yo-ho A Pirate's Life for me" never gets old.

Oh and wedding preparations. More to come with that.

Learning.

Every day I learn, I am humbled by how much more there is to know.
Here's a sample:

I've learned that fake seizures are indeed, obnoxious.

I've learned that asking a parent, "How are you doing?" when their child is sick and in your care goes a really long way.

I've learned that more people should speak Spanish in California.

I've learned not to trust other peoples' charting and to make my own assessment.

I've learned to try for the "tough stick."

I've learned that no matter your religion, there's a special place in hell for people who hit-and-run 80 year old grandma crossing the street to go to church.

I've learned to go to the doctor, even if he's a jerk, because the time you go to him and it's really a big deal, you earn more respect than you ever imagined.

I've learned to never let it go to your head.

I've learned that I will have days where I seriously screw up, and am grateful that nobody is hurt. (Knock on wood).

I've learned that I love what I do.

I've watched other people sit on their asses and not help out when push comes to shove, and I will never be like that.

I've learned that if you tell me the exact amount of pain medication you need, where to start your IV, and that you're allergic to all meds except ativan and dilaudid, then I consider you a GOMER (Get. Out. Of. My. ER.), and I never thought I'd ever feel that way towards anyone. And if you ask me for a meal tray and then tell me you're suicidal after I refuse because I'm waiting for your lab tests? Then you have incurred my wrath and I resent paying taxes for your visit. And I especially resent you if your ring the call light 40 times while I'm in a pediatric code next door.
See this youtube video, it is so illustrative of the crap I deal with: http://www.youtube.com/watch?v=_m64cy1MMPg&feature=related

I've learned that you cannot, no matter what, give more than 10mEq of Potassium per hour or you will cause a dysrythmia. And I have not done so, thankfully.

I've learned that if you call a nurse "honey," s/he will cringe. And will lag at getting what you need.

I've learned that a good charge nurse is really awesome.

I've learned that even a jerk of a doc can be a really awesome diagnostician.

I've learned that when the doctor says stop CPR, you stop. And you realize that you've done all you can.

I've learned that when you start an IV on a kid, you had better damn well get it the first time, but sometimes you don't, and that's okay.

I've learned that really, everyone who is sick and in the ER is afraid, and if you honor that, then you have a way better chance of connecting and understanding what's going on with your patients.

I've learned that the little things really go a long way.

I've learned that I have a helluva lot more to learn.

Adventures in Big Emergencies.

Yesterday was actually pretty good, sorta. I missed a cardioversion which went on just after shift change (8:00pm), but I was exhausted. The ER is either going to kill all love and sympathy I have for humanity, or make it grow, or both.

The morning was pretty mellow, basic, a few definitely emergent-but-not-life-threatening things happening, and then all of a sudden, things heated up.
Within an hour of each other, we received a stroke patient, a patient having a bigtime cardiac arrhythmia, and then someone who was pretty septic with dangerously low blood pressure, out of it, and was pretty much circling the drain.
3 patients, three real emergencies. Ready, GO!

Sigh. When starting an IV on my cardiac patient, I didn't put the best pressure on his vein, so he bled a little bit (not a lot), but a little. His BP was really REALLY high, too. And he was scared.
And I will tell you this:
If you're a new nurse or a nursing student, listen to me carefully:
ALWAYS give the patient the call button before you leave the room. Even if they don't use it, they cannot be (as) upset with you if they have a way to get in touch with you.

Someone who was doing a test told him when he asked for one of us (literally 2 minutes after he had been stabilized and when we had just finished drawing blood and left the room to send it) that he would be lucky if someone actually came. First of all, that attitude is BULLSH*T, and secondly it's not true.
So he peed in the bed instead of calling and asking for a urinal or a bedside commode.
If he had the call light, he could have called for me or another nurse. So, that's the call light issue. Oh yeah, and this patient was relatively young.
I guess later he also figured out I was newer and was upset - apparently about the blood that leaked from his vein when we were getting his IV in. On the up side, I noticed that his O2 sat had dropped when he told me he felt confused, I figured out, "Oh hey, maybe it's because your oxygen is low and you need just a little bit. Sweet." On the down side, later that day, I also watched communication breakdown happen with him (and with me! I love it when people make major decisions about a patient and don't tell the nurses). It was a recipe for disaster, but the patient is okay, and that's what counts, right? Sigh.
Part of me felt like, "Wow, I totally understand how this person is frustrated," and the other part of me felt like, "Um, we just saved your life. We have 4 other super acute patients and I'm doing my best to chase down the doctor to make sure you're ok. Couldya throw a thank you in there somewhere?"

Be good to your hearts, folks:



Our stroke patient had a whole 'nother story as well, but that one involved a good catch by me: "Wait a sec, we can't give this med- the blood pressure is sky high but the heart rate is under 60, we need a different one...." and some love towards the folks upstairs to get them to admit our patient with a super high BP.
The one circling the drain- well, when we get people that sick, our ER will drop nurses to 1:1 ratio, so that we function like a mini-ICU until people get stabilized. That works really well.

So, I still feel slow, my skills are slowly coming back to me, and for the most part, I'm getting it. It's week 4 for me in the ER, so I'd hope so. I'm glad I have another 20 to go before I'm considered a full nurse.