Some people are stronger than you think...

Every day is a new set of amazing stories. I see so many different people in a day, and I'm amazed at what I get to learn, see and do.

Today was a really good day. In fact, this week has been a lot better.
I actually have the ability to chart on patients, I know where stuff is in the Pyxis (the medication machine), and my IV start scorecard has improved drastically. Like I'm at 80% now - I'm just working on stopping the bleeding after I insert the catheter.

Tentatively, I'm starting to feel like a *real* nurse. Sorta.
I took on two patients on my own today (the standard is 3 to 4), and I'm getting the rhythm of it. The most awesome thing about the ER is that for the most part, the nurses and the docs really help each other out. The teamwork is stellar. I've learned which nurses will leave you 4 straight caths and bloodwork to do at the end of their shift, which ones spend more time freaking out than working, and which ones see that you have a new patient and will help your other ones to the bathroom or draw the blood or help with a procedure when you're swamped. There are more of the helpful than the selfish ones in the ER, and that makes me happy.

This week has also been full of good lessons.
A 90+ year old man attempted to break my thumb today. He was confused, ripping out lines, his oxygen levels were low, and we had inserted a Foley catheter. Poor guy. I think I'd try to break someone's thumb if someone came at me with a Foley, too.
In any case, of course it came at the time that 1) we were supposed to take him upstairs to his med-surge floor on a heart monitor (and he didn't want the lines on him), 2) I had 3 other things to do for a patient going to CT scan who was worried she had cancer, and 3) I had to pee really bad (number 3 being the least important).
What do you do with someone who does that?
Me: "Hey that is NOT okay. You are hurting me. Let me go NOW." I grabbed his wrist, bent it enough to loosen his grip. I am acutely aware that I cannot hurt my patient.
Him: "I don't care if I hurt you. I don't like being here."
He releases his grip.
I sigh. I don't blame him. He's a DNI/DNR, and his blood pressure is sky high, his heart is working at 30%, and half the time he doesn't know where he is, and when he does, he's frustrated because he can't move very well.
We still got an order for Ativan to calm him down. When he tried to pull out his Foley (which sits in the bladder with an inflated balloon keeping it from slipping out) and his IVs, we had to. He was hurting himself.
And my thumb still hurts. But both of us are intact.

Yesterday I had my first violent patient as well. He called me every name in the book - and I told him to stop, that he had no right to be abusive towards me, or anyone else when we're trying to help him.
He fired me as his nurse.
It all started over a lost glove. Apparently the glove was more important than anything else, including the pain he had reported on admission.
The clincher was when he called the very large, formidable African-American security guard a "stupid, fat, n****r." You could have heard a pin drop. I think the patients all gasped and stopped vomiting. All of our jaws dropped. He continued to be belligerent, and demanded to leave. The patient was escorted out by numerous security guards. He obviously had some other major psych issues, but he was threatening the nurses, threatening security, and he swore at another patient. It was nuts. And a good lesson. I tried really hard to talk him down, and so did other nurses, and so did the Doctors and you know what?
It just didn't work. He signed out AMA, cursing all of us for losing his glove. It's the first time I really felt a sense of "good riddance." I feel sorry for him, and if he came back I'd try to help him, but there's a point where you have to cut off the kindness. I reached it.
The funny thing is that I don't think he even had gloves to begin with. It was a surreal experience.

And today, I had so many different people with different issues, it was amazing. From vehicle trauma (trauma!) to heart problems to a possible aneurysm, to Lupus flare-ups, to gallbladder attacks, to insect bites to Septic Shock with some very special circumstances... holy crap.

Kind of like nursing school, except - holy shit - it's real. I'm responsible. For people.

You can bet your sweet ass I'm checking every single medication. Is Vanco compatible with NS 0.9%? Is Toradol? How about Diphenhydramine? How much Fentanyl do you want to give IVP - his pulse is only 58? Hey Doc, you wrote the order for Morphine IM. Did you want it IM or IVP like you told me? Can you change that order?
These are the questions I'm asking constantly. I'm super anal about the meds. The seasoned nurses think it's cute, and they also respect it.
The other thing I'm stoked on is the critical thinking skills we got from UCSF. I can look at labs and have some sense of what's going on with a patient. I know where to look for info on Up-To-Date. It helps me anticipate what's coming, and it really helps in the ED.
I'm really grateful for our assessment skills.

Emergency. My dream. I still can't believe I'm here.
And you know what my feeling is at the end of the day?
I *really* love my job.

All Thumbs

First of all, I am totally lovin' the Emergency Department (yes, it's a *department* not a *Room* - so when I say ED, you know what I mean).

I have seen so much cool stuff in the past two weeks, and I feel really fortunate to be where I'm at.
BUT
I also feel completely bass-ackwards. Somehow, between the end of nursing school and now, I lost all ability to start an IV. In fact, yesterday, I was the anti-IV starter. I blew the most perfect vein I've ever seen, and I have no idea why it was one of those days. It just was.
The nurses I work with have been super nice, "Oh, don't worry, it's ok, we miss too sometimes." Oh yeah? You guys miss on the 99 year old. I missed on the healthy person with an antecubital beauty the size of the Mississippi river.
Ack.

Sigh.
And with precepting, I kinda feel like I'm in nursing school again, except I can actually sign off on insulin, heparin, and narcotics. I *just* got my ability to chart yesterday, and I still don't have access to the Pyxis. I am about 70% able to help patients as far as logistics go. That's frustrating. And I still don't know where things are.

And I miss my MEPN friends. I am finally making some new ones here, but it's tough, you know?

Growing, growing, growing.

Bites, car accidents and emboli, Oh my!

Today was wild. All information has been changed to conform to HIPAA.

I walked in to a new place, with my nurse educator on vacation, which she had told me would be the case. Not a problem. I was paired with an AWESOME nurse, also named Nicole.

Holy crap today was busy.

Pulmonary Embolus, or more specifically, R/O pulmonary embolism, fit the description of one of our first patients of the day. A 30 year old young woman, into exercising, with chest pain had a D-Dimer level of 5500. HUGE. The cutoff for a negative is <500.
Her CT scan showed some interesting stuff, but no clot, so we did what we could to keep her comfortable.

15 year old girl kicks the dog dish and gets bitten. Sucks. Maybe we don't kick things at the dog anymore?

Pneumothorax took the cake though. The Chest X Ray (CXR in medical abbreviation speak)
was amazing! I asked, "um, what's wrong with the left lung?" and the doc looked at me and said, "Wow! Yep, that's a pneumothorax." And all of a sudden a bunch of surgeons were in our ER and the patient was on a gurney, and I was helping the surgeons with the insertion, and I was silently thanking Pam for all of her lectures on chest tubes since I immediately knew how to set up the Pleur-Evac device. A pneumothorax means something is in the chest wall between the lining of the lungs and the lungs themselves: in this case, air. Usually it's caused by a hole in the lung. By placing a tube in the chest wall that keeps negative pressure on the lung and allows it to expand, you allow your patient to breathe and heal. Docs place the tubes, nurses monitor the tube and make sure the suction device (Pleur-Evac) is working. Very cool.

And then there were the psych issues. Wow.
And the pediatric patients.
And the people with heart attacks.
And the irrigation of a skin issue the size of a tomato.

Oh yeah, and there was that Stage II pressure ulcer I saw this morning on a patient when admitted.
I asked if we had checked this patient's back, and everyone shook their head. "Ok, I'll do it." So, sure enough, it stared at me like an angry eyeball, red, painful, and begging for healing. One of the nurses documented it, and then I repositioned our patient so there was no weight on that spot.
I felt like I actually did something there. I have no computer access, medication access, or ability to chart, but I *do* have the ability to care.

So that's what I did today.

When I stop caring, I stop being a nurse. And a human.

R.N.

It's official! I looked up my name on the CA BRN, and it was there, appearing like a little neon light in the morning.

I passed the NCLEX!

So, now I am DEFINITELY going hiking in Glacier.

85 degrees and 70% humidity.

Here's what the ranch looks like now. I was just caught on my bicycle in a lightning storm about two days ago in the same place I took this photo.

What did I do? I (fortunately) was on the stretch that had cell reception, and just 30 seconds before called for help from Will. I had looked up at the sky before I left- "oh, clouds, not bad - in fact, beautiful" but 30 minutes later on my ride, they were suddenly dark and had that this-looks-bad kinda edge to them. Black and thick, I decided, hmm, I might make it, but I'll call for a pickup just in case... That was the one smart decision I made.

When I saw the first bolt hit the field about a mile or so away from me, I have to tell you, it was pretty shocking (no pun intended).
There is nothing in the world like realizing you are the highest point in the field, sitting on a piece of aluminum.

I laid my bike down on the road and ran 100 feet away for the drainage ditch, where I squatted for the longest 10 minutes of my life. No, there was no water in it.
At least when it started hailing, the lightning stopped.
Will showed up with a truck like a knight on a white horse. I think I became a member of every religion for about 20 minutes that day.

So, humbled and more educated on Montana thunderstorms, not 10 minutes later it was sunny and 85 degrees again.

The saying here on the ranch is, "If you don't like our weather, wait 15 minutes."
Yeah, I guess so.

Ok, other fun pics from the trip so far.
Here's Idaho:




And here are my friends in Bozeman, during the pizza-and-champagne evening we had. It also included PBR, never fear:




So that's what I've been up to. We also went to an airshow in Helena, MT - where we watched the Air Force Thunderbirds perform, and got to check out some cool helicopters and planes. The focus on the military here in Montana isn't too surprising; it seems like a lot of folks are middle-America Apple Pie, and a lot of the kids go into the Reserves.

That's Montana for now. Off to Glacier soon.

Relaxation and a Roadtrip.

That's a photo of my ultimate destination, where my honey is, taken in March of this year (it's a lot greener and warmer now).

Since the MEPN year has finished, I've been a busy little bee.
It's almost unbelievable that the year is done.

What's also unbelievable is the fact that I'm discovering as I type just how well pepper jack cheese cures a hangover. Delicious.

I drove from Reno, NV to Bozeman, MT yesterday. Why Reno? I used to live in Truckee, CA and the night before I hung out in Reno, we had a little BBQ with friends at their house on Donner Lake. I'm on vacation, make no mistake. Truckee was fun - low-key and chill, beautiful weather. I also embarked upon my first bike ride in a year. I refused to ride my bike in SF after a few friends were hit or run off the road by cars, so that's one thing I've looked forward to in Santa Monica; however in Truckee I used to ride all the time, specifically the 35 mile round-trip from Truckee to Tahoe City on the bike trail. Beautiful.

Some of our Truckee friends, disenchanted with the smaller size of the quiet mountain town, moved to Reno, where you can still buy a house with a yard without paying half a million dollars. Yes, you can pay that much, but by and large it's much easier to be a homeowner. Not that they are, but hey, the option is there.
In any case, Reno was a fun adventure. Nope, no gambling, but we met near the Truckee River kayak play spot, then went off to my FAVORITE bar, the Roxy Bistro which is located in the El Dorado. The Roxy has over 102 martinis on the menu, and I am all about good martinis. Especially when they're made with vanilla vodka, chocolate liquor and have a rim of white chocolate on them. Yum.
From there we ventured out looking for sushi, but, alas, Reno is the red-headed stepchild of Vegas, so that was difficult to find at 11pm on a Tuesday. Instead, we went to get an Awful-Awful at the Little Nugget, which was the most awesome place EVAR because it combined a burger joint with a bar, and there was Karaoke Tuesday to boot. Perfect for a band of lost river guides in danger of being too drunk who need food and have to be functional the next morning. The burger was huge. My friend Shelley and I split it, and then I proceeded to karaoke Don't Stop Believin'.
That was awesome.
I got up early Wednesday and had a beautiful (albeit slow) drive from Reno to Bozeman, fraught with greenery, wildflowers, poofy little clouds, and people driving 10 miles under the speed limit. Sheesh.
When I arrived in Bozeman, my friend Heather greets me with, "Want a glass of champagne?"
Um, yes.
Then she looks at me, "Oh, it's Veuve. Is that okay?"
Hell yes.
Thus began the evening of drinking champagne, eating pizza, drinking more wine, and me passing out around 1 wondering if I drank enough water (I didn't).
Hence I'm still horizontal, nomming on pepper jack cheese wondering if my friend (who apparently drank more than I did) is okay, and wondering if I should go get breakfast makings for her. Hmm.

I'm gonna start driving to the ranch where Will is this afternoon, which is a short trip, but I have errands to run for him (he's in the middle of nowhere), so I gotta get movin!

I love chillin' out!

NCLEX done!

By the way, that's a photo of Mono Lake I took in December of 2008, which has nothing to do with my blog entry. It's just pretty.

So, I took the feared NCLEX-RN, which is the National Counsel Licensing Exam for Registered Nurses, and it's in the format of a computer-adaptive test.
What does this mean?
It means that the computer senses how well you are doing and gives you more difficult questions if you answer correctly. This feature would be all well and good, except that the minimum amount it takes to determine whether you can practice at entry-level competency is:
75 questions
The max? 265.
I think I would freak if I went to 265.
So you don't know when the computer determines your competency at 90% accuracy, you just know that it *could* shut off at 75, or the computer could decide that it doesn't know if you're competent at 75 and therefore you have to answer more questions. Yikes.
And it's not about getting questions right per se, it's about what level of question you get. Ugh.
Combine that with a bunch of over-achieving A students who like getting high scores, and you have a recipe for an anxiety disorder.
Around question 20, mine became insanely difficult, and the computer shut off at 75, which I was excited about at first, but also felt a little unnerved about.
"Did I pass? Or did I fail?"
I came to the point of not caring. It's done. I'll find out soon enough.

And bonus! Our transcripts aren't in yet, which means that we can't find out results with the Board of Registered Nursing in California. Yay. They won't release results until they know we've actually finished a nursing program.
Double bonus: California's not a "quick result" state anyways.

So, to avoid obsessive-compulsive searching for my name to pop up on the BRN site (it's our unofficial way of finding our license), I'm heading out, driving, to Montana where my honey is working as a producer for a show that's going to be aired next year.

The vacation has truly begun!