Ch-ch-ch-changes.

Getting up at 7am again is tough. Getting up at 5am tomorrow is the most daunting activity I can think of. If I didn't have an automatic coffee maker, I don't think I'd make it through this first half-week.
So, the class is now divided into two: Schedule A and B. The A team has advanced med-surg nursing this quarter with a communication class. The B team has Community Health and Labor & Delivery with a class on Socio-Cultural issues. We're bummed as a class to be split up, but it's also really nice to have such small classes.

I'm following the A schedule. We're back on the same floors, and now there's only two MEPNs in our transplant world - not counting the nurses from previous MEPN years. Some guy passed two of us dressed in our conspicuous green tops/khaki bottoms in the hospital hallway, smirked and whispered, "MEPNs..." which made us giggle- he waived and wished us luck. I wondered when he had graduated, or what portion of the master's he's in.

My boyfriend took off to do hurricane relief in New Orleans for FEMA. Actually, we both work for a subcontractor to FEMA, and we are well paid for our work. Helping people get the aid they need is a difficult job sometimes- getting the proportions right when reconstructing property can be tricky. I couldn't go: they require a two week commitment. Will is there, doing housing inspections, and we're all holding our breath to see what happens with Hurricane Ike. They're still doing some cleanup from Gustav, and Ike is forecasted to be even worse than Katrina. I'm hoping everyone evacuates and stays safe. The Texas coast is supposed to be walloped.

Back to school:
I'm excited for this quarter, more excited than I thought I'd be. For one, we have a super stellar professor from last quarter. My advisor was co-teaching with her, and left (and I totally support her- she's a phenomenal clinician from whom I'd love to learn, but she has stuff going on that's important We get to hang out in the ICU, the ED(Emergency Department) and the OR to observe.

We start 12 hour clinical days as well. Tomorrow is the first one of the quarter. We'll see how it goes...

Sorry this entry is so short, but it'll be an early day mañana.
And I'm totally absorbed in House. Heh.

Good things today: met my super-awesome MEPN buddy, hung out with friends, had a great conversation with a nurse/professor I admire, re-connected with some of my favorite nurses on the floor, had a short clinical day, almost got to paddle outrigger canoe.

I had some real connections with people today. Whenever that happens, it qualifies as a great day.

***********************************
Today is September 11.
Take a moment to remember.
Take a moment to look forward.

That's all.

Magnesium and Bananas, Oh My.

It's the little victories that rock my world.

Today was awesome. NB, readers, I'm going to be writing more and more about my clinical experiences, and be assured that they all comply with HIPAA. Identifiers have been changed to protect patient privacy.

Okay, now to the good stuff:

Today I felt like a nurse. We (my nurse and I) had 4 patients, 3 of them a bit more intense than others, and the other one was being discharged (of course, we got one to replace her, a pre-operative transplant patient).

Our patient being discharged was a cancer survivor. I say survivor because that woman has moxie, and said to me, "Failure isn't an option. I've got way too much to do in my life." Rock on. When she refused a cocktail of electrolytes before she left the hospital because it would have kept her there another 2 hours (after she had been there almost a month), I saluted her. Her NP said, "Just make sure she knows to eat some bananas and chocolate."
No problem.
Her energy and enthusiasm made my morning. She'll be back for more treatment, but not for very much. Sweet. I'd go home asap too. Hospital food sucks, and having home around is sometimes the most healing thing to have.

Those little victories keep me going.

The short version of today: assessed a distended abdomen, caught diminished lung sounds, discovered people had been taking blood pressure on someone with a fistula on the lower arm, in a place where the cuff was too small... remedied that by taking it on a lower extremity, changed a central line dressing using sterile technique, rinsed a lot of commodes, talked with the rounding team of docs about getting better/different antidepressants for a pt who really needed them (and when I came back from lunch, psych was there! They rock!), took out a Foley, did a bladder scan, researched a 5 page MAR for another HIV+ transplant recipient, got a pt to laugh who hadn't laughed in 3 weeks. Oh yeah, and changed a colloidal dressing. Took a few blood glucose levels. Saw a patient with a pancreas transplant. How cool!

I took a very short lunch.

The long version of today? I gained people's trust, identified a female patient's discomfort with having male nurses deal with her perineal area and alerted the nursing staff to that - which they were happy to accommodate (which made me happy), hunted down the all-important lip balm, charted correctly (huge accomplishment), followed C. diff precautions (had an ET moment... Eliott), and got a very distant patient who has huge failure-to-thrive potential to be more engaged, aware, and tried to give her a goal.
She's the one I made laugh. I hope it works.
Sigh.
That's all you can do, you know?

It's interesting. I wrote about what an *honor* it is to participate in patient care. I mean, truly- think about it- you're helpless, you can't pee, you can't get to the bathroom in time, you're puking, you feel like crap... and you're vulnerable.
And there's this person there to help you out.
I'm that person.
I feel honored to be trusted with those: the most vulnerable moments. It's not about "cleaning poop" (although I certainly went through waterfalls of it today- not kidding), it's about knowing that the patient trusts me to be there in a pretty dark hour. And not judge.

If you've ever sat up with a friend who is 1) way too drunk or 2) way too high on whatever or 3) in the middle of a high-drama breakup, you can get some understanding.
It's sorta like all of that at once, and then add fear to it.

I feel so grateful to be able to sit here, sipping on a cocktail, writing my blog. I come away from my day with appreciation for the little things. No matter how tired I might be after a shift, I could still go back. We're only at 8 hours on the floor right now, but that's going to change in September.

For future MEPNs, and to myself 2 years from now: what I do daily is awesome. I like raw humanity. If you shy away from that, you run the risk of having a difficult time, no matter what nursing program you go into. Remember that honor. Always remember that honor. You have the opportunity to help someone in a way that nobody else can. As a MEPN, you might feel helpless, but you know what? Nobody else has spoken to that patient you just spent a half hour with, because nobody has time. Nobody else took the time to listen to fear, anxiety, to let that patient tell you about her dogs, his trip to a foreign country.
Or maybe you speak a language that the nurses don't speak, and because you speak Mandarin/Spanish/Russian/Thai/Swahili you can connect with that patient in a way that nobody else has time to, and you give them a glimmer of understanding of what the hell is happening.
I am taking full advantage of my student status. Look stuff up. Educate yourself. Ask questions.
Okay, that's my rant/rave.
I worked with an awesome nurse today, and I hope I get to work with him again. By far, a naturally easygoing person with infinite compassion and highly intelligent. Great combo.

Oh yeah, and learn to let go at the end of the day, if you can. And good luck with that.

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
Alice.

`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.