Long weekends

Right now, I'm trying to motivate myself to finish just ONE more paper. The work is pretty endless. It can be all-consuming if you let it. I've started studying in cafes, just for a change of pace.

Last week I again dealt with HIV. How long has it been since HIV was discovered? Yet it still has a feeling of stigma. Whenever I work with someone who is HIV+, it is hard not to wonder how they contracted it, or how it has affected their life. I've never talked about the disease with someone who actually has it. I'm interested in what their experiences are. It is a conversation I'd like to have at some point.

This week will be a busy one with exams, papers, and clinicals. Thanksgiving had better be here soon.

Papers and paradise

Here's a quick note, because I'd rather be blogging than writing the billions of essays that I've got to do this weekend. O.K., not billions, but two. I've got papers for my research class and for clinicals, and a test to study for on Monday.

Today I accompanied a patient to the operating room at Strong. It was the first time I'd been there. It felt like Chicago O'hare airport on Thanksgiving. There was a huge computer screen outside the entrance listing about a hundred arrivals, departures and delays. It constantly changed and updated with the latest status. It was interested to read on the board the variety of surgeries going on. There were adult circumcisions, kidney removals, amputations of polydactyly (sixth fingers), stent placements, bone grafts and splenectomies.

The whole OR set-up is in the basement, so it has an other-worldly, bomb-shelter feel. The room that the patients go to immediately before and after surgery is one huge long ward with the walls on either side lined with rows of beds. There is very little privacy. It actually felt a little like a shipping dock. The patients move in and out as fast as they can get them there. When one is ready to go, they slap a sheet of green paper on the end of the bed that says "Ready for OR". I wonder if I jumped into one of those beds, and slapped a paper on the end that said "Ready for Hawaii," would they send me off to paradise?

Staying busy

Every day seems like a huge accomplishment. Sometimes I wonder if it is just the newness of everything, and if nursing will hold the same excitement in five years, or ten. I'm convinced that the answer is "yes".

Every room you walk into, and every patient you interact with is a brand new learning experience. If you thought you knew the most basic skill, like taking a blood pressure, try taking it on a crying two-year-old, or on a teen on a cell phone, and then on a child in a room with ten family members celebrating a birthday. The same skill always new.

I also hadn't realized just how varied nursing is. Most of the doctors I see have specialties. For one, it was epilepsy. He'd done epilepsy for 20 years, and was the expert on epilepsy, diagnosing it, and treating it. Every day, all he saw was epilepsy. The same is true of the pulmonologists, anesthetists, or any other medical specialty. Yet when a pediatric nurse walks in the door for the day, they may have a patient who is a 2-year old waiting for a kidney transplant, a 15 year old eating disorder patient, and a cystic fibrosis patient with diabetes and strep throat. And they have to know all of the meds for all of them, the etiologies of the diseases, and all of the care. It is a lot to learn.

Today, I put together my first full IV piggyback and new IV tubing. I did all the calculations, and programmed the Alaris infusion pump. I gave a subcutaneous shot. I removed an IV from a toddler. I took a stool sample and did billions of vital signs. Another busy day in pediatrics.

Pain Meds

My patients was is terrible pain. She was writhing in discomfort when I woke her up to take her vital signs. She tossed and turned, and her IV kept on getting kinked. Her eyes were pinched shut, and her she was in too much pain to talk much. When I asked her, she rated her pain a 10 out of 10.

Most people assume that nurses just follow the doctors orders, and give the meds that they prescribe. In fact, it is much more of a team effort. I get the impression that the doctors value the nurses' input for their intimate knowledge of a patient's condition. Today I made my first medication decision, that affected the care of a patient.

Part of the nursing assessment is that you have to actually DO something if your patient reports a problem, and then follow-up afterwards to see how the pain-control measures worked. All of this has to be recorded on the record.

I suggested all sorts of measures to her... hot packs, cold packs, changing position ... but none of them would satisfy my patient. Finally, I remembered seeing some medications prescribed for just as-needed pain medications on the back of her med sheet. I suggested this to her, and she seemed to agree that taking a pill might help.

I ran out to find her nurse, and ask if I could give the pain meds. The nurse gave me a blank look ... I don't know if she even knew which as-needed meds were on the prescription. She didn't see a problem with it. I ran to the med room, retrieved the pain medication, and went to my instructor. I told her my patient's status, and that I wanted to give her the extra medication. Great, my instructor said.

I dashed back to the room with the pain meds and a glass of water. I went through the full protocol of checking the patient's name band before watching her take the pills. I couldn't believe that the nurses and instructor had trusted me fully to give as-needed medications like that. I was a little nervous. What if I somehow accidentally gave the wrong thing? What if it was a medication that was contraindicated? What if I gave the wrong dose?

I had to calm my self down and remind myself that I prescribed this medicine for myself all the time. It was Tylenol.

Fall colors

Just to keep you posted on the Rochester weather, autumn is here! Yes, I'm studying 10-14 hours most days, writing papers for research class, doing clinical write-ups, or studying for exams. But I did sneak in a little bike ride. Here are some photos of what to look forward to if you ever see the fall in Rochester.

Mental state: comatose

I accomplished a lot in clinicals this week. For the first time, I was fully responsible for all of the care for two patients. I gave all of their meds, did lab samples, did vital signs and 5-minute assessments, and did all of the documentation. I even put together a nebulizer on my own for the first time (Fitting the tubes and pieces together was easy, like tinker-toys). And I had to keep on schedule to make sure that all of this was done on time.

Even more challenging than giving my patient a nebulizer or meds, though, was simply getting him out of bed.

Ever tried to wake up a teenage boy? It doesn't work, especially tough if you're a softie like I am. I waited and waited, walking into the room once an hour and checking, hoping that it would happen spontaneously. But finally, I couldn't put it off any more. I went in, and started talking.

"Morning! How are you today?"

No response.

"Ready to get up? Breakfast is already here!"

No response. I turned on the lights, and pulled back the curtain.

"I know you want to sleep, but I've got to take you're blood pressure."

No response. I pushed a button to raise his bed to a sitting position. This elicited a small reflex movement of the facial muscles.

"O.K, time to get going. It's just about time to take some meds..."

He opened one eye, and looked at me reproachfully. He obviously was hoping I was just a bad dream that would go away soon.

An hour later, I managed to get my vital signs and give some pills. As I was recording the assessment I looked at the next entry. Level of consciousness? "Altered," I thought. Mental state? If I wasn't such a softie, the answer would be "comatose".

(authored with creative input from S.A.)

Talking to teens

One of my biggest challenges so far in working with teens has been communication.

The past week, I was taking care of two teens, and neither one gave me more than a few words in response to anything I asked all morning. Even eye contact was a rare event. Most of the time, their eyes were riveted on the TV , their x-box games, or People magazine. They weren’t impolite, but they seemed to regard me as a necessary evil that they’d tolerate if they had to have their vitals checked.

I missed having some kind of contact or bond with my patients. I began to feel like no more than a medicine-dispensing robot. Where was the human interaction? I wondered if this was what real nursing was like on the floor, if you have six patients, and no time to even remember their names. Or are teens as a species just silent and uncommunicative?

So after lunch, I decided to bite the bullet, and see if with some determination, I could get past the Ninetendo and nail polish world that these kids live in. I walked into one of their rooms, and asked if I could talk with them.

I basically stood in the room and had a conversation with myself for what seemed like an hour. Then, finally, a miracle happened. The teen asked me which movie stars I liked. It was a major break-through. I realize now, though, that it takes more than a morning to build trust with a teenager. I also realize that their silence may communicate a lot if you listen. Their silence may be saying that what they really want is a chance to talk.

Snow

It snowed! For about 10 minutes last week, there was real white stuff coming down from the sky in big, lucious flakes that stuck to my shirt. Of course, the minute I saw it, I ran out into the night and danced around in it. It was beautiful.

Then I realized that the snow was also cold, and the shirt I had on was the warmest garment that I'd brought with me from California. Clearly, I was in trouble.

Thankfully, the weather in Rochester is changeable if nothing else, so if you don't like the weather now, you can be assured that it will either get better or get worse before long. The one thing it won't do is stay the same.

Two days after the snow, it was a clear, sunny 72 degrees, and I was wearing shorts and a t-shirt as I went out to buy myself the warmest down coat I could find.

I went to the GAP, which had several down jackets on sale. I debated for a while between a short jacket and a slightly longer style. Finally, I asked one of the sales people which one would be better to get me through winter in Rochester. Would they be warm enough?

"Yes, they should be fine," she assured me. "After all, you're not going to be going outside, are you?"

pediatric driver's license

Today was my first full day of the new pediatric rotation. It is really a whirlwind of adjustment. Each unit we go to has a different way of charting, different procedures, and slightly different models of equipment. This unit uses a different model of pulse-oximeter and different types of blood-pressure machines. They even have a special thermometer in pediatrics that reminds me of a magic wand. You take the temperature of the temporal artery by pressing the thermometer against the forehead, and moving it around the crown of the head and left ear in a big arc, keeping it pressed against the head the whole time. Whenever I wave the thermometer around to take a temperature, I want to tell the child to make a wish. Then I'll wave the thermometer around their head and say "abracadabra... you wish will come true!"

Today, I was assigned to take care of a child who uses an electric wheelchair. One of my assigned tasks for the morning was to take the patient's weight. Easy, you say? Think again. While the child was still in bed in the morning, I decided to try to get the wheelchair weight, so that I could subtract it from the wheelchair plus child weight. In our whirlwind tour of the unit the previous day, we'd been shown the scale. It was an electric platform with various buttons and levers, none of which I knew how to operate. For all I knew those buttons might take the weight in kilos or set off an atomic bomb... I just hoped I remembered which one to push.

The mom was busy brushing my patient's teeth, so I asked if it was easy enough for me to drive the wheelchair on my own out of the room to the scale. "Sure," she said. "Here's the 'on' button, and use the joystick to steer." Then she added as an afterthough, "By the way, that chair cost [here she stated an unimaginable sum]. O.K., no pressure now. Good.

I walked up confidently, positioned myself behind the unimaginably expensive chair, and hit the "on" button. Then ever so gently, I touched the joystick, and the chair promptly backed over my foot. That's 300 pounds of metal on tires with the treads of a tank that went over my foot. Ouch. But it's amazing how fast you learn to drive with negative feedback like that if you mess up. And if pain is a good teacher, humiliation is even better. No way was I giving in.

Now that I'd figured out which way was forward, things went smoother. With tiny little pulses of the joystick, I nudged the chair out of the room. I only caught my feet a few more times, but promptly backed off of them.

I made it into the hall, and onto the platform of the scale. I pushed buttons on the scale for a few minutes until the screen showed a weight that seemed logical. On the drive back to the room, walking next to the empty chair, I was doing much better. I even managed a 180 degree turn in a very short radius.

By the time I got back to the room, I was convinced that if they were marketed at Christmas, every kid would have one of these chairs. They have powerful acceleration, the steering is responsive, and they're very fun to drive. And as I learned, they run over pretty much anything.

fallopian tubes

I was in the labor and delivery unit again, and business was slow. When I overheard talk of a tubal ligation (female sterilization procedure) that was going to be performed, I decided to see if I could get involved. I'm always hesitant to bother the nurses, since they are very busy, and I feel like I'm in the way. But I plucked up some courage, and asked a nurse standing nearby if there was going to be a tubal.

The man sitting next to me overheard, and answered yes. It turned out he was the anesthesiologist. He said it was up to the physician performing the procedure to decide if I could observe, and he'd help me ask.

The physician in charge of the procedure, it turned out, was none other than the chief of staff for the whole department. He was already going to be teaching a resident how to do the procedure, and when asked if a nursing student could stand in, his immediate response was yes.

The procedure was beginning in a few minutes. I rushed to put on a paper hat and mask. I introduced myself to the patient as we walked to the operating room. I tried to stand in a corner, out of the way as they prepared the anesthesia, but the anesthesiologist motioned me over.

"I need you to talk to her, and make sure she's stable sitting up," he said.

I was thrilled to be of any use at all. I stood in front of the patient, and tried to make some encouraging comments as they started the epidural anesthesia. When the epidural was done, I retreated back to the corner. The physician in charge then walked in.

"Do you know anatomy?" he asked me brusquely.

"I hope so!" I said, surprised that he even noticed or addressed me.

"What's attached to the uterus?" he asked.

"Well, the round ligament attaches the ovaries to the uterus," I said.

"Right!" he said. "And it doesn't do much good to cut them!" I think he expected me to give the obvious answer of fallopian tubes. Did he think I didn't know what a tubal ligation was?

The procedure began, and the physician was soon immersed in assisting the resident, who he was teaching the procedure to. He went at a leisurely pace, and was patient with every step. I drew a little closer from my corner as they cut the incision, and used the small hole in the abdomen to try to visualize the fallopian tubes. They then drew the fallopian tube entirely out of the abdomen, to identify the medial portion. As the physician instructed the resident, he continually glanced at me, meeting my eyes to make sure I was following the procedure. When the tube was severed, he asked me directly if I could see the actual tube itself. "Come over," he said. So I stepped right up, and he showed me the severed tube, so small it looked like a swizel stick in a cocktail. I quickly asked him a question about the fascia attached to the tube, and he showed me the broad ligament. Then the procedure went on.

"How long after the procedure before the patient feels pain?" he quizzed the resident.

The resident looked confused. "Twelve hours?" she guessed.

"Right!" he said. "Now why twelve hours? Why not right away?" he asked.

The nurse, resident, and scrub tech all looked perplexed. No one knew the answer.

"Come on! Anyone! Why isn't the onset of pain immediate? Think about the blood," said the physician, clearly enjoying the teaching.

Still, everyone was silent. I didn't want to speak out. I was just the nursing student, the least experienced person in the room. But the silence was too tempting.

"For $1200, I'll guess that it's the iron degrading from the blood!" I guessed.

"Yes!" he said. "The blood becomes more acidic as it degrades."

The nurse turned to me, and through her mask, gave me a smile, and a punch on the shoulder. The doctor went on with the procedure, and after over an hour of pulling at fallopian tubes, it was finished. I had learned how to do a tubal ligation, although I can't say it's something you'd ever want to try at home.

As I left the O.R., and pulled off my mask, I called the doctors name, and said "Thank you." I don't know if the Chief of Staff realized that a few questions over fallopian tubes had just made my day.

busy days

The pace of classwork and clinical work has definitely picked up. The past few weeks, I've spent every spare moment just keeping my head above water with the reading.

The summer was a relative walk in the park compared to the pace of classes now. In addition to lots of reading, there has been a lot of discontent with grades on exams. The average scores for tests have been in the high 70 percent range. Many classmates have felt that some test questions are unfair. However this type of exam is the reality we will all face next summer when we take the NCLEX, the national nursing licensure exam.

The most exciting part of the program for me is definitely the clinical experiences. After just five or six weeks in a unit, you feel like you know everyone there and are part of the routine. However, every patient and every experience is so unique, that I could do the same assessment 100 times on 100 patients, and learn something new each time.

I continue to be amazed by how much we are allowed to see and do. The past rotation I've been in labor and delivery, postpartum care, and in the newborn nursery. What have I done there? Just about everything. I've seen c-sections and tubal ligations, and I held the forceps on a circumcision (not the prettiest of procedures!). I've seen amnioinfusions, induced labor, epidurals, and watched amniotic membranes being ruptured. I've learned how to read fetal heartrate strips for late, early, and variable decelerations. I've helped new moms nurse babies, and done vital signs on newborns. I've been a part of families' lives for a few hours as they've given birth. It is an amazing experience.