Blogging, Exhaustion, Anonymity, and the Four Agreements.

Today after clinical skills lab, I felt deflated, defeated and just drained.

Part of it is due to last week's drama, and drama is something I've been cutting out of my life, but part of it is just sheer exhaustion.

One of the MEPNs, on our way out, took me aside and thanked me for my post on week 8.
"I felt so exhausted and strained, and I was wondering if it was just me, but when I read what you wrote I felt like, ok, I'm still here. I can keep going."

Awesome. I nearly cried, except I've cried so much since Thursday last that I couldn't muster the tears. I should have hugged her but all I could think about was getting home to sleep.

In any case, you know who you are, and thank you so much for making me feel like I have a purpose, because if I help one MEPN, I've done my job in blogging. Otherwise I feel that "big brother" is reading this stuff and judging/grading me on whatever I write, and I tend to stifle myself. You, MEPNs, who are reading this make me brave. Thank you.

That's the problem we who blog face: simultaneous "fame" without anonymity. NurseSF was smart in keeping herself hidden for a while; there are days I wish I had that freedom. I wonder if it would be smarter to have kept myself quiet. I'm not so good at that, but hey, I deal with whatever comes. It's the river guide in me.

Sleep well - I will be. And remember, no matter what, revert to the four agreements, which I will review:

1) Be IMPECCABLE with your word.

Let that sink in. Words have power. Language structures consciousness. No matter what you say, it has the ability to echo in someone's head for years.
And that means being careful about what I say. And that means not modeling the language that was thrown at me, recently. Ever.

"Words are like arrows, once you let them go, you can't get them back."

2) Don't take anything personally.

Often, when we are attacked on a personal level, it's not who we are or what we have done, it's the perception, it's *that* person's interpretation of what we've done. Obviously if we've truly done something wrong, we need to be accountable first and apologetic second. A good apology does not start "I'm sorry, but...", a good apology is simply a heartfelt, "I'm very sorry" (not a stoic one). So, my point is when people speak harsh words at you, listen to what's being said and glean from it what may help you in the future; however, don't take it personally. Let it be the energy that it is. We have the choice to take on negative energy or to emulate positive.
I choose the latter. I choose the positive. I personally detest drama, I avoid negativity, I avoid deception and lying, and I choose not to take anything personally, even if someone else does. Although I'm having a somatic, viscerally negative reaction to the world over the past week- I am consciously and constantly redirecting to the positive, because that is my choice. It is better for me.
We are capable of our own consciousness. Remember this.

3) Don't make assumptions.

People will generally tell you what they need from you. I wish that in the heat of the moment that people would take this agreement more to heart, but I am not everyone else, and I can only speak for me. The world runs on assumptions, yet I still feel that I could make an "ass" out of "you" and "me". Heh.

I realize how many people have read/do read this blog, and I am very conscious about keeping things harmonious. I like harmony. I like being friendly and happy with people.
MEPN wasn't gonna be all sunshine, rainbows and lollipops, I knew that. Thank goodness for the ruby slippers, the professors we have. And thank goodness for my classmates.

4) Always do your best.

This agreement is one I truly practice, and I can say that with complete integrity. Last week a nurse on our floor who I wasn't working with/hadn't worked with directly asked if I was going to apply for a job next year because I had been so incredibly helpful (made sure someone who fell multiple times in a night had emotional support and physical support the next day- got her laughing and up out of bed safely, made sure she didn't fall). I felt so honored by that question, and at the same time, totally humble, because I didn't do anything different from what my clinical expectations were. That question was a bright light in my day. I didn't even get to share that with anyone else because other stuff was happening that wasn't so bright. In any case, it was a reminder that my best is sometimes seen and heard, and for that I am humbly thankful.

I gave everything that day.
I give everything every day.
I am always giving and doing my best.

I like adding a "fifth agreement": Laugh at yourself.
When we stop being able to laugh at ourselves, we stop growing.

In any case, life goes on, and it's week 9. The faculty in this program continue to be awesome- our actual professors are incredible on so many levels, and they have been sources of sanity for me and many other students. Encouraging, responsive, and warm are characteristics I would pick to attribute to them.
My fellow MEPNs are amazing. This class is very unified, and we've been helping each other out tremendously - someone posted notes for Pharmacology that were great, some of us have been outlining chapters of reading - we were told yesterday by one of my favorite professors that this class is "very collegial." Hell yeah.

I leave you with the four agreements. I'm mulling them over, and have been, which transitioned nicely into the lectures on spiritual care and end-of-life care we just had.

Be impeccable with your word.
Don't take anything personally.
Don't make assumptions.
Always do your best.

Interlude... Burning Man.

After reading a fellow classmate's blog, and realizing how much this blog needs a little extra touch on life outside nursing school, I decided to focus on what's keeping me sane:
Knowing that no matter what, I'm heading to the Playa.

Unfortunately, the weekend-warrior thing absolutely sucks to do out there, but on the up side, I get to go (once school is over). I didn't think that was the case when I started, and I've been looking at my costumes hanging in the closet rather sadly, dreaming of "out there."

When you hear people say "Burning Man," and you're not a "Burner" (ie one who attends Burning Man, one who likes to light random things on fire in a desert environment), do you think, "Oh right, that drug festival in the desert?" or do you feel a visceral "hipper than thou" reaction? I hope not.
Burning Man is based on the idea of forming a community, well, okay, let me backtrack- I should say the building of Black Rock City:
The temporary city of up to 40,000 people that forms every year out in the Black Rock desert is an experiment in the best of human giving and living.
It's all based on self-reliance, a non-currency economy (although you can bring money to buy ice and coffee), and amazing art pieces.
It's unlike anything you've imagined.

First of all, it's hot, at 4000 feet elevation, and dry. That combined with usually a bunch of cityfolk who aren't used to what my river peeps call "hydration, hydration, hydration" can make for a quick visit to the med tent for an IV. Add alcohol, any other substance on top of that, and you can see how taking care of yourself becomes very important.
But the fun to be had if you can take care of yourself is awesome. Imagine a life-sized Operation game. Yep, exists. Yes, you get shocked for real if you mess up and touch the side of the bread basket. Heh.
Imagine the "Billion Bunny March" where bunnies march for bunny rights. How the hell did that start? I don't know, but there's a Carrot Liberation Federation that marches against their Bunny oppressors and they generally have a peace summit every year that involves drinking. There's the largest light saber fight ever that takes place yearly at Center Camp at sunset on Thursday, where 10,000 people battle it out. There's Cube, a 3-D LED sculpture that is solar-powered and AWESOME, programmed to make various "moving" pieces in its spot, so it looks like it's raining or has a rainbow or all sorts of stuff.
And the costumes. The costumes range from Renaissance style to Mad Max. Incidentally, the Thunderdome is there, and it opens every night with opera. I kid you not. It's huge:

And you thought Dance, Dance Revolution was awesome? Try "Dance Dance Immolation" where you wear a fireproof suit and try to follow the steps. If you mess up, you get blasted. Yes, with flamethrowers. It's RAD. Safety third...

And every morning, bacon wafts around the Playa. People greet each other with Hugs, not handshakes. Artcars take you on adventures. YOU take yourself on adventures, and mostly by bicycle. It's the most amazing place I've ever been to, and I've been to a lot of really cool backwoods spots.

That's my rant. I can't wait to get out there.
My point is, if you like Costumes, freedom, artwork and the unexpected...
and bacon (bacon is a known trade item at the Burn- many friends are made via Pork - and why not? Salt, electrolyte replacement and protein after dancing all night? Yum!), then the Burn might be for you.

It's a place of absolute fun, amazing invention, and human connection. And although I'm not going for the entire time, it's really home for me, so I'll be there for a few days this year. I never thought I knew where I belonged until I went to Black Rock City.
We also had a really interesting talk this week on end-of-life care, and on how we let go of things. If you're familiar with the Temple at Burning man, then you know that it's a non-denominational sculpture, meant to be burned, where people can go and write all week long, bring pieces/mementos from their loved ones or their lives or ANYTHING you want to let go of, and on Sunday night, after the Man burns, the Temple goes- and everyone is silent.
It's beautiful.
It's an amazing ritual, and one I do not plan on missing.
In any case, there's some insight to my world other than nursing.

Ruby Slippers

It's been a while, mostly because I've been trying to figure out how to put the experiences of the past few weeks into words, and also because 8th week is hellishly exhausting.
There's a light at the end of the tunnel.

In essence, the best way to describe my emotion right now is humbled, a little confused, tired, and very very determined.

8th week is when you're most tired, but you can also see the light at the end of the tunnel. It's when everyone starts to break, when tempers go, when people get sick of dealing with each other, and when we all start to snap. But, remember, from those breakdowns come rebirth, rebuilding, re-shaping, and a stronger, clearer consciousness.

I will also say that I had no idea regarding the depth of my classmates' compassion, empathy and support until this week. I knew they were good, but they warmly surprised me, and I am very grateful.

In any case,
Thank goodness for two things this week: Bikram Yoga and Ruby Slippers.

Bikram yoga has been a source of sanity for me for a while in my life. Aside from being hot yoga and a great workout, it's really about controlling your breath, and about being grounded and situated in the moment. It's main message is to be mindful.
Lord knows I need that.

Ruby Slippers have supplied my sanity in the form of a 4'11" Italian-from-Boston smart-as-a-whip nurse(CNS)/professor who could arguably be dubbed an unofficial hero(ine) as far as our class goes. If you end up in the MEPN program, are in it now, or have done it in the past two years, you (will) know who I'm talking about.
I had a tough situation this week, created a bunch of crap for myself- totally my own fault- and just when I thought I couldn't take it anymore, right when I was about to crumble, she walked onto my floor, put her arm around me, and whisked me away.

Until she walked around the corner, I was a complete wreck.
Her energy is so incredibly positive, so clear, so *real* that you can't help but drop any defenses, because you don't need them.
We took a break in her office, to chat and let me get myself together.

Hell, I would have gone to Kansas when she came and got me if it meant just taking a break from where I was, but I ended up in a place with a friendly vibe, the radio playing one of my favorite songs, and I immediately relaxed. Anyone who has Wizard of Oz commemorative items on their walls is okay by me.
There were more Ruby slippers in this room than you could ever imagine.

Something about sparkly red shoes just makes everything alright.
In fact, when I asked her about them, she said, "Hey, sometimes I just need to click my heels too."
Rock on.
We had a really direct, poignant conversation that was incredibly helpful. I felt like I had the ability to keep going, which was not the case 15 minutes prior.
Perception and reality; these topics I was left to ponder, and you know what? I got it. I understood what was up, and knew exactly what I needed to do to make the bumpy road smooth again. Instead of feeling defeated, I felt inspired.
She encouraged me to get back on the horse, make the day a new one, and go forward.

When we left, I felt like I was wearing a little of that sparkle. I had to check my shoes a couple of times that day.

So, a reminder to myself and to others, slow down. Slow down in our processes, slow down in the intensity of this program, slow down and take a breath and think, slow down and just take a breath.

And if you need to, click your heels three times and take those 5 minutes to yourself. When you don't know what to do, just breathe, and let the answer come to you. It's not about fast, it's about learning, about doing things right.

And ultimately, it's still about your patients. If you can't be there for yourself, how can you be there for them?

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.

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.

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...

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.
Sigh.

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.