A year at U of R

Chest physiotherapy

2007-02-22T21:31:00.000-05:00

Today I did chest physiotherapy on a patient with cystic fibrosis. I've done it several times now with both pediatric and adult patients. The process is also called "cupping". It involves holding your hands like cups and then beating your patient's chest and back hard and fast with both hands for 20 minutes, with the patient in different positions. It helps to loosen thickened bronchial secretions. It is also a pretty good work-out for the person doing the cupping.

It is very bizarre walking past a room where someone is receiving cupping. It sounds like a blend of massage and karate going on inside. It is one of the few very low-tech therapies, but it's kind of fun to do. It's one of the few procedures that you can practice at home on your friends, and they'll still be your friends.

In the unit I am on right now, the repiratory therapist does the cupping. Generally, the patients have it done four times a day. I was watching the respiratory therapist, asking her questions about her technique. "Do you want to do some?" she asked, so I jumped in.

"How am I doing?" I asked my patient after a few minutes. "What grade do I get?"

My patient laughed and gave me passing marks.

Lectures on bladders

2007-02-12T19:47:00.000-05:00

The subject of today's lecture was urination. We covered the subject in great detail. We talked about distended bladders, incontinent bladders, urine leakage, and urine output. By the end of this first half hour, I was squirming in my seat, ready for a quick visit to nature. Thank goodness the lecturer called a stretch break. But then the lecture went on. We heard about water intake, stress incontinence, urine back-up, and urgency. In five minutes, I was once again desperate to take a whiz.

They say that when medical students learn about diseases, they tend to become worried that they have the signs and symptoms of the illnesses they've learned about. I haven't felt the least worried that I have Hodgkin's disease or lung fibrosis or kidney stones. But after three hours of listening to a professor talk about bladders, boy did I have to pee.

Discharge teaching

2007-02-05T20:35:00.000-05:00

Last week I did my first patient discharge. I was a little surprised when the nurse came up to me, held out a stack of papers, and said, "Here!" I think that most nurses hate the paperwork, and are more than happy to push it off on a nursing student. I'd watched one discharge before, but I really didn't have any idea of where to begin. But I figured the discharge was one more sink-or-swim challenge. How hard could it be?

I went into a corner, and read through all of the papers. I tried to figure out what each piece of paper was, and where the patient needed to sign everything. It felt a little ironic that what I was reading for the first time one moment, I'd be teaching the next.

I knew that the patient would be going home. I had worked with her the whole day prior, and I'd gotten to know her family and her habits. I had admired her embroidery, and chatted about her childhood. Now I'd be sending her home.

I actually loved doing the discharge. I'm sure I was far more conscientious about it than most nurses ever have time to be. I went over each prescription with her, and made sure she knew the dosages and times to take the meds. We talked about wound care and when to call for follow-up. I was enjoying it so much that I sprung a little pop quiz on her. "Tell me the names of the medications you are going home with." "How often should you take the Percocet?" I'm just a teacher at heart.

Once the paperwork was done, I didn't know how to actually send her off. The techs were all busy, so I went down to the lobby to fetch a wheelchair myself. Her husband got the car, while I wheeled my patient out to meet him. As I helped her out of the wheelchair and into the car, she turned, and gave me a big hug, and kiss on the cheek. The nurses really must forget how rewarding a discharge can be.

Pop quiz

2007-02-05T20:26:00.000-05:00

In class today, the instructor threw a pop-quiz at us. She put up some questions on the overhead, and told everyone, "Take out a blank sheet of paper." That's a sure sign of a pop quiz. But half the class froze, and looked at her in panic. "We can't!" someone told her bravely. "We don't have any paper. We have laptops!"

Things have gotten a little crazy here. This semester is definitely a challenge of cramming way too much work into way too little time. If my entries are brief, there's a reason. I'm passed out unconscious on my desk from mental overload.

A note on the digital age in nursing school...

Last weekend, I submitted a paper at 11am on Saturday. By noon, my instructor had emailed me back that I needed to re-write the paper. I sent him an email to clarify, and by 2pm, he said he had read my paper, and it was great. This is on a Saturday. On Sunday I took an exam for my Adult Health class. The 1-hour timed exam opened on Friday afternoon, and had to be complete before Sunday night. Someone should write some legislation to shut down the internet on Sundays, so we can at least have one day off.

Snow Nurse

2007-01-28T11:55:00.000-05:00

After the ice storm, is started to snow. It has been snowing gently, a few inches every day, for the last week. Enough snow accumulated to build a snow man ... or rather a snow nurse.

Ice Storm

2007-01-28T11:46:00.000-05:00

Winter didn't begin until the middle of January. It started with an ice storm. This wasn't much of a storm ... it was more like a freezing drizzle than solidified on contact with the ground. It was very beautiful, seeing all of the trees encased in glass. Here are some photos of the ice.

Gastric bypass reversal

2007-01-28T11:08:00.000-05:00

Regarding my latest posting on gastric bypasses, I'll add that I've also seen clients with gastric bypass reversals. Gastric bypass isn't an easy procedure, and there are lifelong consequences in terms of diet, digestion and nutrition. Some clients, although they may lose weight, can't tolerate the side effects of the surgery. They end up having the procedure reversed.

Watching surgery

2007-01-28T09:36:00.000-05:00

Watching surgeries is always fun. I feel guilty that I'm so fascinated with someone else's insides. I'm always interested seeing the layers of skin and viscera, and trying to identify different internal structures. Unlike the colored and labeled models we learned on, when I see the real thing, I can hardly tell a bladder from a bowel. Good thing I'm not the surgeon!

For one of the surgeries I observed, the anesthesiologist chose to use MAC anesthesia, or Monitored Anesthesia Care. The client was given the same drugs as are used for general anesthesia, to induce amnesia, sedation, and for pain relief. However they were given in tiny increments as needed during the procedure. By doing this, the patient was just over the boundary of sleep, but maintained respiration on their own. However the boundary between sleep and awake was rather slippery.

The client snored through most of the procedure, but every few minutes, the patient would rouse and open their eyes a little. Several times, the client woke up wincing, and clearly said, "Ouch, it hurts!" "Sorry, sorry," the surgeons said quickly, and the anesthesiologist gave another tiny bolus of fentanyl or propofol. In a few minutes, the client would resume snoring.

It was a little disturbing to me that while I could see the client's insides, and the client was awake and complaining that they could feel it too. I asked the anesthesiologist if it was normal for the patient to wake up. "The patient won't remember any of it," he assured me. "And they're not really in pain. They might just feel some pressure. If the client was really in pain, you'd know it. They would be yelling and jumping off the table."

I still had my doubts. We were taught that if someone winces and says they're in pain, you believe them. I asked him about each of the drugs, and when the client's memory would return. I think that the anesthesiologist was thrilled to have someone take an interest in his art. He explained each drug, and then confided, "If I was going to have anesthesia, I'd never have general. Epidural anesthesia has fewer risks, and you stay in control. I'd want to know what was going on!"

After the surgery, it took less than two minutes for the patient to wake up. The patient was still on the OR table, as the doctors quickly cleaned up and removed drapes. The client looked around, and said, "Is Judy there? I like her!" I walked into view, and smiled. What an honor! I had been with the client through the whole process, from the waiting room through the OR. I had spent a solid hour getting to know the patient and their family in the pre-op area, chatting about their jobs and the weather. The client trusted me.

"Did I say anything while I was asleep? I bet I snored," said the patient. For the first time ever as a student nurse, I lied.

Gastric bypass

2007-01-20T21:40:00.000-05:00

Gastric bypass and stomach stapling weren’t what first came to mind when I imagined my surgical rotation this spring. I’d imagined the rotation as a drama-filled TV miniseries filled with gunshot wounds, heart transplants, and trauma. However as I’ve learned from all of my previous rotations, the only thing that will surprise me is if I’m NOT surprised by what I learn. If gastric bypasses are one of the mainstays of the unit, I’ll make the most of it.

On my first clinical day of this rotation, I flipped through patients’ charts, familiarizing myself with the forms. I felt sadly voyeuristic as I searched curiously for how much the many gastric bypass patients weighed before surgery. I was amazed by the Body Mass Indexes of over 50 (normal is 18-25). I would have to weigh almost 300 lbs to have a BMI like that.

I tried to imagine myself at 5 feet tall, and 300 pounds. I can hardly carry a backpack that weighs 40 pounds. How would I even move if I was carrying an extra 200? I wouldn’t be jogging or biking century rides. Would I make it up the stairs to my apartment? My life would be radically different.

Part of me felt very self-righteous about NOT weighing 300 pounds. I go to the gym. I run every weekend. I don’t buy ice cream or eat Oreos. I’ve earned my weight! So why can’t these people just give up Oreos too? Think of the health care dollars it would save!

However obesity may be one of the only diseases where people point the finger at the patient. No one would blame cardiomyopathy on the heart transplant patient. But society blames obesity on the victim.

I dropped the charts back in the rack, and followed the nurse I was shadowing into the patient’s room. The patient smiled cheerfully at us from her bed, and asked us how our day was going. She was delighted to learn that I was a nursing student. Her husband sitting nearby peppered me with interested questions. The two of them held hands, and bantered with the nurse. The couple radiated warmth and good humor. They were much more concerned about making the nurses’ job easier than in their own needs and care.

I left the room smiling, imagining the patient in a few years. Maybe the couple will be running down a beach or biking down a trail together, and doing the things I take for granted. Maybe they’ll be sunbathing in Hawaii! I imagined how much their lives will improve.

A gastric bypass seemed much less like a mark of someone’s failure, and more like an opportunity for them to regain a lost life. Maybe a gastric bypass is more like a heart transplant than I had imagined.

Talent

2006-12-15T19:05:00.000-05:00

The skills groups on the adolescent psych unit are run by nurses. Usually they pick an activity based on the needs of the teens who are in the unit at the time. We've done group juggling exercises, discussed smoking, watched videos on nutrition and worked on team building. For one of the skills groups in the adolescent psych unit, the nurse decided to work on building self-esteem. The theme was "What I'm good at." The kids found out about the theme in the morning. By lunch time, it had evolved into an all-out talent show. Several groups of girls took over the dining room to choreograph dance routines. The boys just gawked. It was teenagerdom all over. I felt like I was in the middle of a bad teen movie.

For the final show, one girl sang a song and another shared her drawings. One read some poetry she had written. The dance routines went off very well. I taught everyone how to say a few words in Chinese. The nurse read another poem she had written. We were a pretty talented group!

I was so impressed with the dance routines that I said to another nursing student, "Hey, we should get this on camera."

She grinned at me and pointed to the ceiling in the corner of the room. "We ARE on camera," she said.

Film du jour

2006-12-14T22:43:00.000-05:00

Today I switched with another student to the adult psych unit, to get a change of pace from the adolescents. The film-du-jour playing in the adult unit was "Seven Years in Tibet," with Brad Pitt. I only saw pieces of it but it wasn't too bad. I'll give it a thumbs up.

The adult unit was a different experience. It was a bit of a shift to communicate with adults for a change. But to be honest, I missed the quirkiness and drama of the teenagers. I missed being able to be a little wacky myself.

There have been a number of patients on the adult unit who are college students locally. It is finals time, and students stress out. Some have difficulties with the stress, and end up in the psych unit for a few days.

The other nursing students have all seemed curious about their stories. Yet no one has gone and talked to them. Maybe my fellow students felt shy about talking to them, since they are close in age and also students. Is it too close to home for comfort? It makes you realize that anyone can end up in the unit.

Well, I’ve changed a little during psych rotation, and I’ve learned to ask those tough questions. Today, I thought, “What the hell, I’ll go talk to the patient.” I went up, and we started a conversation. I asked about school, and we compared notes on classes. The patient talked about future plans and difficulties. The client was actually very sociable, and I was glad I’d had the conversation. It reminded me of what we learned the first day of psych. Don’t make assumptions. If you see a person with their head on a table, maybe they’re depressed, but maybe they’re just sleepy.

Movie therapy

2006-12-13T17:46:00.000-05:00

I wrote before about the movies that the teens like to watch when they have free lounge time in the psych unit. It is a pretty sweet clinical rotation when you can eat popcorn, watch a film, and get academic credit for it. The only complaint I've got is about the teens' taste in movies.

I've watched parts of "Independence Day" three times with them. We've also watched "The Truman Show." It was a little surreal to be locked in a psych unit, watching a film about a guy locked in a fake world.

Today there was talk of watching "Titanic." Thankfully they decided against it. I might have had to put myself in the seclusion room to prevent self-harm if I had to watch Leonardo Dicaprio drowning one more time.

Instead, they put in a movie called "Like Mike." I only made it through a few minutes of that one. I've been thinking that instead of bringing my drug guide to clinicals, maybe I should just bring some worthwhile DVD's.

Electro-convulsive therapy

2006-12-13T16:46:00.000-05:00

As part of my psych rotation, I accompanied a patient through the entire procedure of electroconvulsive therapy. I was amazed that we were allowed to watch what most people seem to view as horrific and medieval ... intentionally delivering a shock to a patient's brain. However the reality is somewhat different.

The procedure itself is very simple. Preparing the patient takes about an hour, including a baseline set of vitals and inserting an IV for the anesthesia. This is done by a nurse (some of the friendliest I've met in the hospital!), in a consult room. The patient then goes to the waiting room.

When the patient is called from the waiting room, they are taken to the treatment room, a tiny room with a hospital bed. It was crowded with various pieces of discarded machinery. Many of them had labels, "Not Maintained or Functional - Do not use." I had the impression that since ECT outpatient treatment is only scheduled a few days a week, the room doubles as a storage closet. It reminded me of the derelict robots in Star Wars.

The patient lies down on the bed in their street clothes. The only things they need to remove are any dentures or metal jewelry. They are then hooked up to monitors for the heart rate, blood pressure, and oxygen saturation.

An anethesiologist gives them two separate anesthetic agents via IV. One of them "puts the patient to sleep," so they have no memory of the event. The second relaxes the muscles, to prevent injury due to convulsions when the shock is administered. As the muscle relaxant flows into the patient, I could see the patient's leg and arm muscles twitch slightly as the muscle cells depolarized and relaxed. The doctors put an inflated blood pressure cuff around one ankle like a tourniquet, to prevent the relaxant from reaching one foot. This foot would remain reactive, and allow the doctors to observe convulsive activity. The rest of the body was paralyzed.

The scary part to me was that the whole body, including the diaphragm was paralyzed. This means that the patient couldn't breath. A resident at the head of the bed used a manual bag to inflate the patient's lungs, and give them oxygen. To me, however, it seemed like you've essentially "killed" your patient if they no longer breath on their own. The effect wears off in a few minutes after treatment, and the patient is asleep, so they are unaware of it. However it's still a little disturbing to think that you've stopped breathing. Here's my advice if you go for ECT: make sure you've got a great anesthesiologist.

The shock itself is really nothing. It lasts only a second. The electrical stimulation to the brain creates a seizure that lasts an additional 30 seconds. Before the days of anesthesia for ECT, patients would have convulsions strong enough to break bones. Now, because of the muscle relaxant, the patient has no motion during the seizure except their face scrunches up, and their one foot may shake a little. And that's it. At least that's how it's supposed to work.

The day I observed, something went wrong with the IV or the medication. They thought that the patient was fully paralyzed, and adminisered the shock. The patient's face pinched up, and their arms and legs convulsed for the length of the seizure. It looked like other epileptic seizure I've seen. The doctors called the seizure "partially modified." "But," they told me, "we'd like them to be much more modified than that." The only negative result, though, was that the patient might have muscle soreness afterwards.

After the treatment, the patient goes to the recovery room for 1/2 to 1 hour. They come out of anesthesia within about 5 minutes of the treatment. They monitor their vitals (blood pressure often spikes up during ECT), and then the patients go home.

What are my thoughts on ECT after seeing it? There are patients who we've worked with who've been depressed for years, and tried every other treatment. Nothing has worked. The patient may have attempted suicide multiple times, or be so depressed that they can't function or leave their room. Then they go to ECT, and within a day, the veil of depression is lifted. You can visibly see how much alive and better they feel. It is an amazing transformation. How can you argue with a treatment like that? Many psychiatric drugs have numerous severe side effects. ECT has only one ... possible memory loss.

However I wonder how it is being used. Some patients go for a single course of ECT over several months. Some patients have it regularly as an outpatient, once a week, or multiple times a week for years. I have to wonder about the consequences of shocking your brain that often.

Would I personally ever go for ECT? I think I'd rather shock my brain by jumping into an icy lake, eating a bowl of raw jalapeno peppers, bungee jumping off a bridge, or just about anything else instead of ECT.

Adolescent Psych

2006-11-30T18:30:00.000-05:00

I've started yet another new class and rotation - Psych Mental Health. Like the other rotations, I have didactic coursework where we learn about schizophrenia, mood disorders, suicide, etc. I also have a clinical rotation two days a week. In addition, I'll be attending Alcoholics Anonymous meetings and doing a day of observation at an outpatient psych clinic.

For the rotation, I was assigned to a locked, inpatient teenage psych unit. There are only three of us students in the unit, so it has a very intimate feel. There are about 17 patients on the unit. At any one time, there are two nurses, and several patient care technicians staffing the unit. The teens have diagnoses ranging from major depression, bipolar disorder, autism, attention deficit disorder, mood disorders and personality disorders. Often, a patient has a combination of disorders, sometimes combined with substance abuse. Almost all of the teens are on suicide precautions, and many are on violence precautions as well. You see lots of teens who are suicidal and homocidal. Many have pending conflicts with the law. Some have molested younger children.

I often wonder how much of the disorder is about the kids, and how much is due to the environment. Many of the kids have been abused, or have parents who are in jail or are drug addicts. Some come to the hospital from group homes, or from long-term psychiatric care facilities. Some will be discharged to long-term psychiatric care. Some of the patients can't be discharged because there is no where for them to go home to.

The saddest part about it is that I really like these kids. Most of them are cognizant of their problems, and surprisingly willing to discuss them with me. I get the feeling that for some of them, being in a locked psych unit is a much better environment than being at home.

They are also just teens. The some of the girls are real drama queens. They zig-zag around the halls in the morning, into and out of the bathrooms and each-other's rooms, with wet hair wrapped in towels. They spend huge amounts of time on their make-up, even in a locked psych unit. They come running to the nurses station to announce that "EEUUUWWWW, there is soap on the bathroom floor!" and "What should I do? My purple pants are still wet from the laundry!" My main function in the morning seems to be handing out mascara from patient's personal bags.

The boys are just as teenagish as the girls. They are gawky, awkward, and a little oblivious. They wear pants hanging so low that I can't figure out how they walk. Standard male fashion is also baseball hats, possibly to cover the fact that they haven't washed their hair since they were admitted.

During the day, the kids attend school hours, two hours a day in a classroom staffed by two public school teachers. They work on schoolwork from home. Since I don't have much else to do on the unit, I usually help out whoever looks lost in the classroom. Today I helped a patient write a paper on the Abolition movement. Yesterday I helped look up the genus and species of wolves, dogs, and coyotes. The day before, I went over to one kid who was poring over a math textbook.

"Can I give you a hand?" I asked.

"Sure," he said. "Can you help me figure out the derivation of this?" he said, pointing to an equation that looked complex enough to stump Einstein.

"What math level is this?" I asked.

"Calculus," he told me.
He spent the rest of the class hour teaching me how to use the quadratic equation. I never expected I'd spend my clinicals in a locked psych unit, relearning the quadratic formula from a patient.

The kids also attend other sessions, such as goals session, art therapy, and skills sessions. I usually participate in the session along with the kids, and talk to them while I do. Often, I'll sit down next to someone who isn't participating, and try to involve them.

Then there is free lounge time. The girls sometimes choreograph dance routines to the latest music, and sometimes they just mill around in the lunch room and talk. Often, one kid will put a DVD in the player in the lounge, and they'll all sit around on sofas and the floor, eating popcorn and watching a movie. Of course, since they're my patients, I watch the movie with them. So far, I've seen Independence Day, and part of the Truman Show. It's a very tough rotation!

One day, a fellow student was working on charting. She had a question, so she went into the lounge to look for the nurse who was monitoring the kids during lounge time. The kids were all there, intently watching a movie. And there was the nurse as well, fast asleep on a chair in the midst of the kids, snoring gently. My fellow student had to wake him up.

Signs of trouble

2006-11-08T20:20:00.000-05:00

Today was a busy day in my final week of pediatrics. It has been a challenging and exhausting rotation, and I will definitely miss it. I enjoy working with kids and teens.

I was pretty tired and distracted in the med room today, with my instructor. I couldn't find one of the meds in the patient's drawer. I was talking to myself, almost oblivious to my instructor. "Hmmm, I wonder if it's in the frozen food section?" I asked myself out loud as I opened the mini-refrigerator where some special meds are stored. My instructor cracked up.

Tonight I'm writing a paper. You know you're in trouble when the grading rubric for a paper, listing all of the information which must be included, is three pages long. What ever happened to conciseness?

Spilled milk

2006-11-06T21:54:00.000-05:00

Last week my winning experience was with a two year old. She was very shy, and in her world, any contact with someone in a uniform had to be painful. She cried anytime you touched her.

It took quite a while to take her O2 saturation. First I showed her the red light inside the monitor, and asked if she could see the red light. Then I put the finger clip on my finger, and showed her how the little red light shone on my finger. "Can I shine the light on your finger?" I asked. She was fine as I took the reading. Of course, I let her put the clip on her mom's finger too, just to be inclusive.

Next came the stethoscope. "Can you help me out?" I asked. "Can you hold this right here for me?" I said, pointing at her chest. She willingly took the bell of the stethoscope, and held it in place. "Now can you put it there for me?" I said, and pointed to another area. Once she was in control, it was no problem at all.

That was my moment of glory. I was a real nurse, a pro!

Of course, the illusion only lasted a second. With the parents and child all watching, I casually went about my next task, hanging a new bag of IV fluid. My instructor came in to watch as well. I deftly removed the old IV bag, grabbed the new one, and spiked it with the tubing. I guess I need to work on the spiking technique, because the minute I hung it up, the spike and 500cc of normal saline came gushing out on the floor like a waterfall. I cringed, and my instructor stoically grabbed a towel. The two year old, however, was delighted. She had never realized how much fun people in uniforms could be.

Long weekends

2006-10-29T19:00:00.000-05:00

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

2006-10-26T18:52:00.000-04:00

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

2006-10-25T19:01:00.000-04:00

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

2006-10-25T18:30:00.000-04:00

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

2006-10-22T21:30:00.000-04:00

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

2006-10-22T21:08:00.000-04:00

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

2006-10-22T21:00:00.000-04:00

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

2006-10-17T17:49:00.000-04:00

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

2006-10-12T17:47:00.000-04:00

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

2006-10-08T21:05:00.000-04:00

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

2006-10-05T16:35:00.000-04:00

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.

First time in an OR

2006-09-14T16:01:00.000-04:00

The labor and delivery portion of the clinical is supposed to be primarily observation for the nursing students. It has turned out to be fairly hands on, though. This week I was in the triage area, observing at the doctors and nurses as they prepared several patients for cesarean sections. I asked how long it would take. The nurse said it would be a while, since they had to give them anesthesia, insert catheters, and prep them. "Catheter?" I thought. "Bingo!"

"Would it be possible for me help do the Foley catheter?" I asked. Before I knew what I'd gotten into, I was in.

I had done one Foley insertion, the week before. However, as I'm learning, every single situation is unique.

This time, I was in an operating room. I was wearing ridiculously large surgical scrubs, since they didn't have size extra-small. I had a flowery paper bonnet over my hair, and a surgical mask tied over my face. I was absolutely freezing, since the operating rooms are kept at arctic temperatures. And I was listening to Faith Hill wafting out from the boombox in the corner. That was my first experience in an O.R.

The while the anesthesiologist gave an epidural, I helped hold the Mom's arm, so she wouldn't fall forward if she got dizzy. Then it was time for the Foley.

I don't think I would have felt nervous this time, if it hadn't been for the situation. The nurse whispered to me a last piece of advice, "You have to do it quickly! This doctor hates to wait."

OK, now I was nervous. The room was full of people ... the anesthetist, the M.D., a Resident, assistants, and a classmate. This time, though, bunny-suit or not, I knew what I was doing. I donned my gloves aseptically and with lightening speed. I tested the balloon at the catheter tip, following correct procedures. I swabbed the area, lubricated and coiled my catheter, and in it went! Success!

Crying over deliveries

2006-09-14T15:40:00.000-04:00

Last week during clinicals, some of my classmates got to witness deliveries. I saw an awful lot of labor and interventions, but no actual births. In the post-clinical conference where we debrief, I listened to them exultantly describe the experience. They all said they'd cried when the babies were born.

"Isn't that a little overboard?" I thought. "After all, it happens every day. Why all the sentimental touchy-feely-ness? Come on!"

Little did I suspect that I'd spend much of my clinicals the next week holding back tears and telling myself, "Come on, don't go overboard!" But the battle was futile. A birth is truly a Bambi moment.

The first one that got me was a mom in labor. She had been laboring for hours, sucking ice chips, shifting positions, trying to endure the pain with fortitude. It was exhausting just being in the room with her, and watchiing one contraction and waiting until the next one, on and on for hours.

When she reached the final stage of labor, the head of the baby began to crown. But by then the mother was spent. Each time there was a contraction, the nurse and doctor coached her to bare down. “Push a little harder, keep going, push!” they urged. I was standing at the foot of the bed. Each time she pushed, I could see a larger silver dollar of the baby’s mucous covered hair showing through the slit of the vagina. Then the contraction would end, and the little tuft of hair would slip back inside and disappear.

“Push!” the nurses urged. They watched intently as the tuft of hair came and went.

But the mother’s endurance had been pushed far enough. She had been in labor for hours. She hadn’t slept. She hadn’t eaten. She took a gasp, and began to cry with exhaustion. “I can’t do it anymore.”

The nurses stopped paying attention to the labor, and looked at her. “The baby's almost there, we can see the head,” they encouraged. She continued cry.

“Would you like to see the baby? We’ll get a mirror,” the nurse said, and dispatched me off to find a mirror.

Once outside the room, I realized I had no idea where to find a mirror. “The supply closet is over there,” the secretary told me. I found the supply closet, and opened the door. It was immense. It was a vast supply room, packed with row after row of instruments, supplies, birthing balls, and sterile kits. I had no idea of what kind of mirror I was looking for. I imagined the humiliation of having to go back to the room without a mirror, and ask one of the nurses to show me. I’d better find it, and quick.

I turned around, and lucky for me, there it was! Not the little mirror that they use in barber shops to show you what the back of your haircut looks like. This was a huge mirror on wheels. I think I broke the speed limit wheeling it back to the room.

Once in the room, I negotiated it around the tubes and IV’s, and positioned it at the foot of the bed, asking the mom if she could see. Just then, she had another contraction. “Push harder!” the doctor urged. “Keep going a little longer!” said the nurse. The mother pushed, but she was no longer paying attention to the doctor or nurse, or to the pain or exhaustion of her body. I could see from my station at the end of the bed, the only thing that the mom was seeing in the world was that tiny silver dollar of hair in the mirror.

Labor & Delivery clinical

2006-09-07T18:25:00.000-04:00

I walked out of the first day of the new clinical rotation thinking, "Everyone on the planet should be a nurse." They told us that the labor and delivery rotation is a one chance in a lifetime type of experience. I wish everyone could experience it.

All of the seminal events of life; birth, death, health, illness, families, emotion, used to be commonplace at home. A hundred years ago, births seemed a more integrated part of daily life. Now they are all hidden away in six story, billion dollar buildings with parking garages that charge by the hour.

The difference between the nurses role and the MD's role in labor and delivery is marked. The nurses are there non-stop with the patients, as long as it takes. They know the patient, the meds, and all the details. They take the mother all the way up to the birth. A doctor or midwife just comes in at the last minute to "catch" the baby. Which job would you prefer?

This clinical is supposed to be more observation, but today was definitely hands on. In addition to inserting my first foley catheter, I took the mother's temperature several times, helped change linens, wiped her forehead with cool washcloths, and assessed the average fetal heartrate and spacing of contractions based on telemetry data. I got to talk with the family members, and I even did a little teaching. I explained to them what pitocin is, and the effect it would have. I could follow the medical jargon of the nurses and doctors better than the family, so although I knew very little about the birthing process, I could occasionally translate a little for the family.

In one day, I observed an epidural injection, deaccelerations of a fetal heartrate, insertion of an IUPC, amnio infusions, administration of pitocin, and bolus infusions. Wow. Although I didn't actually get to see a birth, I saw plenty of life for one day.

Foley catheters

2006-09-07T17:28:00.000-04:00

Today, I feel like I summited Everest. In fact, all I did was insert my first foley catheter. It doesn't sound like a big deal, and it actually was very easy once I did it. But it was like the plunge a skydiver makes from an airplane at 14,000 feet. You have to get out the door before you can float.

I was in labor and delivery today. The clinical rotation in women's health is divided up, so I'll spend a few days in labor and delivery, a few days in triage and a few days in postpartem care. I started with the labor and delivery at 6:45 this morning. The nurses work one-on-one with the laboring moms in delivery, so I was shadowing the same nurse and the same mother-to-be the whole day.

The mother was very dilated when the day started, and in a lot of pain. To add to the pain, she was scared. I had never considered that anxiety could be such a factor in labor. It seems obvious to me now that the combination of pain, exhaustion, and fear of the process could make an expectant mom break down and cry. It is a lot to go through. I tried to praise her, and tell her how brave she was. Meanwhile, I was quaking myself, feeling totally out of my league with no knowledge of this whole new branch of medicine.

Labor and delivery is so different than the acute care I became used to. The nurses spend inordinate amounts of time recording notes on the tracking of the fetal heart rate every time the mother changes position. They also monitor the mother's blood pressure and vitals constantly. All of the vocabulary was new to me; "IUPC, Terbutaline, variable deacceleration" to name a few. But like anyone thrown into a a country where they speak a foreign language, you sink or swim. I just tried to pick up as much as I could.

I watched the mom get an epidural, and grilled the anesthesiologist for a while with questions about the procedure. He laughed, and joked that he felt like I was giving him his board exams. I learned to assess the level of the epidural by touching a wet alcohol pad to the mom's trunk, and asking at what point she felt it. If the level was too high on her trunk, the bed had to be raised to make sure the anesthesia didn't rise any higher.

An lucky for me, the epidural also meant that the mother could no longer sense a full bladder. She needed a foley catheter inserted to drain the bladder for her. When the nurse asked if I wanted to do it, I was inches from chickening out. I had just returned from a two week break. I learned how to do a catheterization how many weeks ago? Five weeks? Ten? Was I prepared? No way! But something in the back of my head said, "Jump!"

I ran to the other end of the unit searching for my instructor, to get permission to do the insertion.

"Go ahead," she said. She may as well have just said "cleared for takeoff" to a flying elephant.

"I'm a little nervous," I told her. Understatement of the century.

"Go through the steps," the instructor said. I told her exactly what I was going to do, and verbalizing it helped.

I dashed back into the delivery room, praising fate that because of the epidural, my first urinary catheterization patient wouldn't feel anything. But there was still her whole family in the room, watching me perform. Thankfully, the nurse was fantastic, and she walked me through it. I was so focused on the procedure that I didn't notice the family at all. I opened up a kit, and set up a sterile field. Once my gloves were on, and I'd swabbed the whole area, I inserted the catheter. Just like they told us in lab, urine started to come out through it. One more first out of the way. I wiped up the betadyne stains and hung the urine bag on the bed frame, thinking "Now I can float for a while."

Fall semester

2006-09-06T20:48:00.000-04:00

A quick note back after two weeks off on break...

Just two weeks ago, I was working with patients over the age of 60 with major organ failure. Today, my first new client of the semester was a 7 pound, 6 oz. smiley little guy with curly hair. What a change. Maternal health nursing seems like a different profession entirely. It is so calm and quiet compared to acute care. I must say, though, that I'm a little nostalgic for my old unit. I miss the nurses and staff there, and the familiarity. It's hard to jump around to a new rotation every 5 weeks.

This coming fall semester, I'm doing rotations in women's health, pediatrics, and psych mental health. For the women's health rotation, I'll spend 3 days observing labor and delivery, a few days assisting in a triage care area, and the rest of the time caring for moms and babies in the post-delivery area. I'll also get to watch the lactation consultant at work, and attend some of the parenting classes they have.

I can't believe I've been back from break for 2 days, and tomorrow I may be helping deliver a baby. I'm very excited and nervous. Check in tomorrow and see if I lucked out and got to observe a delivery.

I'm off to read more about the amazing birthing process. Five hours of reading down, another three to go...

A thankless job?

2006-08-19T15:02:00.000-04:00

I was chatting yesterday with one of the people I've worked with this summer at the HIP Teens research project as part of the Fuld Fellowship. I asked her, "would you ever consider being a nurse?"

"It's so thankless!" she said. "And you have to clean up messes, wash people. I don't think I'd want to do that."

I still get this response from many of my friends. Some of my classmates have realized that nursing, or at least working as a floor nurse, is not for them.

However, it's hard for me to verbalize how gratifying the experience is. By the nature of the job, the relationships with patients are intense and personal. You can't wash someone, listen to them cry, joke with them, shave them, and feed them breakfast without developing a personal connection. They make a deep impression on you, just as much as you make a difference to them as their nurse. It's a reciprocal relationship. You become, for a morning or afternoon, a small but important part of their life. If that isn't rewarding, what is?

Over the five weeks of summer clinicals, a number of the patients I've worked with have died, and more of them have terminal illnesses and won't be alive much longer. None have actually died while I was there. I wondered how I would handle that. To be honest, I've been happy for most of them, and felt that it was time. We have great technology for keeping people alive, and we have a culture doesn't accept aging and sickness. Yet sometimes it seems that death is the best treatment. At times, I'm glad I have some distance from the clients. Their families have known them when they were healthy, and they mourn the loss of the person they used to know. I only knew them when they were already confused, disabled or unresponsive.

I've also been challenged with patients whom I don't like. I worked with one client who, if I met on the street, I simply wouldn't like as a person. That was a challenge. At times, I could feel some empathy toward the client's condition. I could find one aspect of the person that I appreciated. However, sometimes, I just wanted to just leave the room. I guess there will always be a few cases like that. They seem to be a tiny minority, though.

Thus ends the summer semester!

I'm really amazed by how far we've come. After one summer, I already feel that giving an injection or giving meds is no big deal. I still feel a little awkward at times, but that's just a matter of time. I've worked with patients from age 18 to age 96, of all different backgrounds. Most of them have very compelling life stories. I wish I could write a novel about them all. I've seen kidney and liver transplant patients, AIDS patients and patients with strokes, epilepsy, diabetes and heart failure. I've suctioned a tracheostomy, given injections, written nursing notes in the client's files, and changed countless beds. I really never expected to be exposed to clients with this variety and severity of illnesses in just the first couple of weeks of clinicals.

By the end of our fifth week together, my clinical group of 8 students plus an instructor had really bonded. Our instructor actually works several nights a week in the same unit we were working in. She was really phenomenal with the amount she did for us. She was a great teacher, plus being very low-key. We all went out for margaritas and quesadillas to celebrate.

As a final close before the holidays, here's a photo I took on a bike ride. A farmer had planted a whole hillside with sunflowers. Very Van Gogh.

Uniforms

2006-08-18T21:06:00.000-04:00

The real question in everyone's mind before classes began at the U of R was, "What will our uniforms be?" Forget about textbooks or syllabuses, we just wanted to know what color we'd be wearing.

Up until this year, the uniforms were white pants and white shirts. Thankfully, due to continued pressure, they changed this year's attire to navy pants and white shirts. I think they look pretty good. We had to sew the patches on ourselves. What they didn't tell us beforehand is that you don't have to buy the uniform at the bookstore, so you can get different styles of scrubs pants, as long as they are navy.

I actually love wearing scrubs. You never have to decide what to wear in the morning, which is a blessing when you've got clinicals beginning at 7am. I think that we've all come to like the uniforms.

Around Rochester

2006-08-10T21:25:00.000-04:00

In the midst of clinicals, I made it out for an evening bicycle ride. The countryside is beautiful at this time of year. The corn is maturing, and their are fields of sunflowers and hay.

I took some photos on an evening bike ride with the Rochester bicycling club (on a weeknight!) after a clinical session. A great way to wind down. The sun was getting low on the horizon, and the evenings are quickly getting shorter. Seasons change very quickly around here.

Giving injections

2006-08-09T16:55:00.000-04:00

Today was my first day giving medications. We are closely supervised as students when giving meds. Each of my clinical group of 8 students is assigned to a different day to give meds. I was scheduled for the first day, along with one classmate.

Yesterday, I stopped by the the unit to pick up my patient assignment for the next day's clinicals. Low and behold, my patient was scheduled for no fewer than 12 different meds given every two hours, including a subcutaneous heparin injection. I read this and panicked. That same morning I had just attended the lab where we learned how to give injections. The next day, without any further practice, I was going to have to actually inject someone. To make matters worse, my patient was fully awake and alert. Couldn't they be comatose just this once???

I did not feel prepared. I'd read a chapter on injections, watched a 20 minute video on the subject, listened to an hour lecture, and given five injections of different types to a plastic dummy in lab. However injecting a piece of plastic didn't inspire confidence. Anyone can jab plastic. What about the real thing? What about flesh?

I dashed home, and spent the rest of the afternoon researching and writing notes on all of the 12 drugs I'd be giving. Then I reread the chapter on injections. I poked at myself with a ball-point pen periodically throughout the evening to practice technique. I went to bed with ink-dots all over my stomach.

In actuality the injection was very easy. It was over and done in a few seconds, and I'm happy to report I didn't feel any pain at all. Thankfully, my patient reported no pain either. However, it is the little things they don't mention in class that trip you up in clinicals.

What no one warned me about was packaging. Each individual pill comes from the pharmacy specially wrapped up in a little packet. For safety, these packets each get opened at the patient's bedside, and the pills are all dropped into one medicine cup.

So there I found myself, nervous as anything at the patient's bedside, with eight tiny packets to open. My instructor, the patient, and the patient's whole family were watching me expectantly. I picked up the first plastic packet, and tried to tear it. It wouldn't give. It was like your worst nightmare of trying to open an unyeilding bag of Doritos, and knowing that if you use too much force, the Doritos will end up all over the floor. I wasn't about to try using my teeth. Finally, my instructor gingerly took the packet from me, and tore it easily in the other direction. How humiliating. Instead of practicing injections tonight, I'm going to get some candy and lipton's instant soup, and work on opening packets.

Clinical week 2

2006-08-04T16:48:00.000-04:00

I'm still running an adrenalin after today, caring for a kidney transplant patient. It was really non-stop. It is amazingly exciting, I still feel very unprepared for it. Last March I was a graphic artist, and six months later, I'm caring for patients with serious conditions. I thought we'd start out on easy patients, with, say, sprained ankles or pink-eye. There's no adjustment period in this program. Half the time, I feel like a bumbling idiot in patient's rooms. I can barely find a pen in my pocket, much less locate the dorsalis pedis pulse. Then there are rare and glorious moments when I actually do something right, and feel confident and in control. Why are those never the moments when the instructor is looking in?

Today I had one of those beautiful text-book moments. I was taking some vital signs, and listening to the patient's heart sounds with my stethoscope. Low and behold, I heard a swoosh. I did a double-take. Is this right? I listened again, and with every heartbeat, there was a definite, very loud swoosh. It sounded exactly like the tapes we listened to in lab. I couldn't believe my ears. Had I identified a heart murmur? It is sad to admit, since it is a person's heart, but I felt like I'd discovered gold. I called the instructor over, and asked her to listen. She confirmed it ... systolic murmur. WOW.

Clinicals are developing a little bit of a pattern. In the morning, we go in and read out patient's charts (we are each usually assigned to one patient). We then meet briefly to talk about what we will do that day. There are eight students and one instructor in our clinical group. Then we go to see our patient. At this point, after six days of clinicals, we are responsible for independently doing all of the morning care. This includes giving a bed bath, shaving, teeth brushing, changing the bedsheets, changing adult diapers where needed, dressing the patient, feeding them, and recording vital signs. This can take just 15-30 minutes if the patient is ambulatory, or the entire morning if they are hooked up to tracheostomies, feeding tubes, IV's, etc.

There is actually alot of down time. For those who have "easier" clients, they then read charts, or help out with patients who need more care. However, we all spend alot of time waiting. Starting next week, though, we will be responsible for keeping track of the patient's medications as well. It is a crazy fast pace!

A second shave

2006-08-04T16:22:00.000-04:00

I did my second shave of a client's beard today, and happily it went far better than the first (see my entry from last week). I spent the past week grilling every guy I know about the male shaving experience. If you are a guy, and have anything to add on the subject, please feel free to post!

This time, I looked at it as a spa treatment rather than a medical procedure. I remembered about the hot, damp towel to soften the stubble. I was careful to note the direction of the hair BEFORE applying the shaving cream, and I applied the cream lightly with artistic finesse. It was an improvement over the first shave which was more like slapping huge gobs of mortar on a brick. I had about 10 disposable razors on hand, so that I could dump one as soon as it became dull. I wasn't taking chances this time.

The shaving was great ... nice long strokes with no repeats. Some areas were a little patchy, but I was working with about 4 days worth of stubble. I even got the upper lip. That was no small feat. And I did this all without clogging his nostrils with shaving cream.

Who needs to be a nurse? I'm opening a male spa!

Thanks to all of the men who offered advice and contributed to my success!

Subclavian line or lunch?

2006-08-04T16:02:00.000-04:00

I continued to be amazed by how involved I am already (on my sixth day of clinicals). Today was a busy day to say the least. I was on my feet from 7am to 3pm, with about a 15 minute lunch to sit down. Normally, I'd join everyone down in the cafeteria for a 45 minute lunch. Today, I took a short lunch to watch a subclavian line that was being inserted into a client's vein. Yesterday I took a short lunch to attend an epilepsy group meeting that is evaluating patients who are monitored in rooms 24/7 for up to 10 days while they deprive them of food, sleep, and submit them to strobe lights to try to induce a seizure. But more on that later.

Inserting the subclavian line sounds like a lot of drama. The doctors donned sterile gowns, gloves and caps, and there is some blood spurting. They use a needle and syringe initially to go underneath the clavicle to get to the subclavian vein. They know they have hit the vein when the syringe easily fills with blood. They then remove the syringe, and they put a guide wire through the needle into the vein. Then a plastic spreader and the actual line (a plastic tube), go onto the guide wire.

I stood by and tried not to get in the way. Occasionally I fetched some supplies that were needed, or helped re-attach an MD's gown. I talked to the client, and tried to give the client a hand-massage to keep the hand out of the sterile field. The MD's were particularly worried about this, because the sterile field was essentially the patient's entire draped body. So I held the patient's hand, and chatted when I could.

I would not want these doctor's jobs, though. Two of them spent about an hour and a half stabbing away, trying to insert the line. Finally, they called in another physician, who also couldn't get the line in. He then tried for the jugular vein, but was unsuccessful there as well. It wasn't exactly made-for-TV drama. Just lots of uncomfortable poking. Still, I found it fascinating to watch. It was the first bloody procedure I'd seen. I was a little worried that I wouldn't be able to handle blood, but it wasn't a problem. I was mopping up clots from the client's hand, thinking about how hungry I was for lunch.

Weekend activities in Rochester

2006-07-31T19:40:00.000-04:00

This past weekend was all about recovering from the first week of clinicals. Rochester has a surprising amount to offer for a tired nursing student.

On Friday night, I went with my neighbors to a bar called Lux. They have a huge outdoor beer garden with picnic tables. I hear that they show movies some nights projected on the outside wall of the building. There was a tarot card reading in the courtyard, and free pizza. On Monday nights, they have arts and crafts supplies set up. I imagine that the art gets better and better the more you consume.

Saturday, the Empire State games were going on. They are New York's own mini version of the Olympics, with all of the different events. Most of the athletes are the best high-school students from around the state, and there were master's categories as well. I watched some of the track and field and saw some judo and canoeing events.

Then it was dinner at an Ethiopian restaurant called "Abyssinia." I was surprised that Rochester has an inexpensive Ethiopian place. It was great ... lentil dishes and vegetable curries that you scoop up onto pancakes of Ethiopian bread to eat.

Finally, I went for a long bike ride Sunday morning through corn fields, past pastures with horses and dairy cows. Then, it was back to writing care plans for clients and doing reading.

Someone's hero

2006-07-29T18:18:00.000-04:00

By the end of our last day of our long-term care clinical experience (which lasted three days), I was getting a little frayed. I was exhausted from getting up at 5:50am, and pretty maxed out on new experiences. However I wasn't about to pass up on the chance to learn how to clean a tracheostomy.

To clean a tracheostomy, you need to maintain a sterile field while removing the long inner cannula (tubing that lines the inside of the tracheostomy tube) and cleaning it aseptically. I felt like a bumbling idiot as I tried to use sterile technique to get on my gloves. I got the trach tube out OK, but getting it in was another story. I thought to myself, "What's wrong with me? This is much easier than doing an oil change. All you have to do is stick the tube in the hole! Anyone who can baste a turkey can do that!"

However, imagine that you're tired, and you are sticking the tube down the throat of a person who is silently gagging and contorting, with the instructor looking over one shoulder saying "turn it, turn it!", while Spongebob blares out on the TV. A talking yellow sponge will now forever be ingrained in my head as linked to tracheostomies. It was just a little much. I could handle trach care or Spongebob, but I just couldn't take them both together.

Long term care has its good and bad points. The nurses in long term care are mainly the managers, who oversee a unit of nursing assistant. The CNA's provide most of the actual client care. Wound care specialists and respiratory therapists circulate through the unit each day as needed. The nurses manage the nursing assistants, write reports and distribute meds.

Much of what we saw was very sad. Some of it was end of life care, and some residents will be there for years. Some had limited or no cognitive awareness. Some were completely immobile. Some had very tragic stories. Some were comfortable, and some were not. The unit did an excellent job of caring for the residents and the hospital was an outstanding facility, but in some cases, we had to question the quality of life. It took only one day for me to personally feel very much in favor of assisted suicide. One classmate commented, "What kind of nurses are we??!! We want to kill our patients!" I think it was more that we very much wanted to relieve suffering, both physical and emotional.

There were very rewarding moments as well. I was able to take one client out for a walk in a wheelchair. Even if the client doesn't remember it the next day, for a few minutes the resident was outside in a garden. At one other point, another student was trying to understand what a client with a tracheostomy was saying. Finally she deciphered that the client was saying my name, asking for me. Wow. After only two days, I felt like someone's hero. I can see where if you worked there for a long time, you would know all of the residents very well.

Shaving a beard

2006-07-28T22:01:00.000-04:00

Yesterday I shaved my first clients face. It's not quite the same as the female shaving experience, and it is very different than shaving your own legs or armpits. Basically, we completely botched the job.

I think we were both a little panicked at the idea that we were going to scrape a guys throat with a razor. It ought to be easy, but neither of us knew where to start. We forgot about applying a hot washcloth to the beard for 5 minutes to soften it. My partner started with the shaving cream, applying it like frosting on a cupcake. There was shaving cream everywhere ... in the nostrils, clothes, you name it. I think the finger-painting technique might have worked better than the frosting concept.

Next I took a razor and started out on one cheek, while my partner valiantly attacked the other. I quickly discovered that male beard hair isn't quite the soft stuff of women's legs. I had to make several passes with a razor to get any impact. But I was petrified I would scrape off skin if I made more than one pass. I was trying to figure out the grain of the hair to go with it, but it was impossible under all that shaving cream.

On the throat, I seemed to remember that the grain went from the chin to the neck. My partner whispered frantically, "NO! you're supposed to do it the other way!" So we each simulateously shaved in opposite directions on our respective sides.

Neither of us wanted to try the upper lip, but I did my best at it. Finally, I grabbed a washcloth to try to wipe away the remaining shaving cream. Patches of beard still stuck out here and there. At least there weren't any cuts. Neither of us even thought about aftershave.

First Clinical Experience: Long term care

2006-07-27T17:34:00.000-04:00

Wow, do I ever feel like I was thrown in at the deep end. The first two days of clinicals have been a great experience. I've had a chance to be exposed to many, MANY new things. I feel fortunate that my clinical group of eight students was assigned to a floor that has many clients with more complex care needs. I think many other groups have clients who are more able, but I was mainly with clients who need full care.

But it's been a little overwhelming. Today, I suctioned my first tracheostomy tube. I've seen more tracheostomies in the past two days than I ever wanted, plus some. I'd never even seen a tracheostomy before, much less cleansed, dressed and suctioned one. I never realized the vast quantities of colorful mucous that comes erupting, bubbling, spewing and projectile-launching out of them. It's not a pretty sight. Normally, our lungs make that much mucous, but we cough it up and swallow it, unaware. To suction a tracheostomy, you have to basically shove a vaccuum-cleaning suction catheter down the stoma (hole in the trachea) a LONG ways until the patient goes into violent gagging contorsions. Then using your thumb as a valve to apply suction, you slowly pull the catheter out. The entire procedure must be done with strict aseptic technique, sterile gloves and a sterile field. Mucous gets everywhere, so wear goggles or a full face mask.

Today, I watched as a wound care specialist dressed a decubitis ulcer (bedsore) that was so large and deep I could almost have put my fist in it. It was deeply undermined around the surrounding tissue. It was impressive that any pressure ulcer could get so large. It didn't bother me as much as the mucous from tracheosomies, though.

In the past two days, I've taken care of clients with tracheostomies, stomach tubes and urinary catheters. Some haven't been able to communicate at all, some have communicated vehemently that everything your are doing is wrong and some have been very pleasant and smiling. I shaved a guy for the first time (it is a very different experience!). I've dressed immobile clients, given bed baths, put on compression stockings and used hydrolic lifts to put clients in wheelchairs. I've emptied urine bags, brushed teeth, made beds, changed adult briefs (adult diapers) and combed hair. I assisted with a stretcher bath for a client today. We used a special stretcher lift to transport the client from the room to a spa tub in a bathing room. All of theses experiences were very hands-on. I was right there helping with the soaping and shampooing.

Communication has been a huge challenge. I've tried to understand the speach of clients with tracheostomies, and I've gotten better at lip reading. Some clients have really limited awareness. How do you communicate with them? How do you ask them permission to take a blood pressure or feel their pulses?

It's also brought to light some intense ethical considerations. How long do you maintain a client with no cognition on feeding tubes? At what point does quality of life deteriorate to a point where it shouldn't be maintained? If the individual still breaths independently, but needs supplemental oxygen, has no musculoskeletal movement, and has limited cognition, what then? The more I've seen, the more I know that I would never want to be maintained in this way. However, since they are not on ventilators, there is no easy switch to turn off.

To add to a veneer of the surreal to the experience, it has all been done with Chuck Norris in the background. Many residents listen endlessly to daytime TV. All of these experiences have been done to Martha Stewart Living and various reruns of Days of Our Lives playing endless in the background. Here I am, looking official about 5 minutes after my second clinical.

Urinary catheters and restraints

2006-07-22T17:53:00.000-04:00

Here I am with an instructor, learning how to insert a urinary catheter. Labs are becoming rapidly more involved. Our last two days of labs have involved giving oxygen via many different types of masks and systems, applying wet dressings to wounds, inserting urinary catheters into male and female manikins, applying restraints, and helping clients use bedpans.

The teaching is fantastic, though. For the catheter lab, we broke down into even smaller groups, with six students per instructor.

It's pretty amazing that this is week 9, and we're already learning to insert catheters. The scariest part is that next week, we may have to apply all that we've learned.

I've heard via word of mouth that after next week, when we have clinicals in a long-term care facility, my group will be in the urology department at Strong Memorial Hospital. Wow, lots of opportunities to insert catheters there!

Here, I've managed to subdue a combatant classmate. He was getting a little out of hand. How often do you get to fight with your classmates, and then pin them down?

Fake germs and toothpaste

2006-07-18T19:18:00.000-04:00

The new quarter began yesterday with neon germs and toothpaste.

For the next five weeks, we have only one class, called "Inverventions I." It includes lectures, labs and clinical experiences all rolled into one. It should be a great experience.

Once again, the faculty seemed excellent. They've got a tough job, organizing all 100 or so of us into lab and clinical sections. We have three lab instructors for each lab of 25 people, so that's a 8:1 teacher/student ratio. Not bad. It also means that there are something on the order of 25 different instructors for this class.

The first lab was a lot of fun. We're learning basic care and hygiene for clients. We started with oral hygiene. I had my partner lie on his side and feign unconsciousness, while I propped his mouth open, donned gloves and brushed his teeth. It was a little strange at first ... sticking a gloved hand and toothbrush into my classmate's mouth while he drooled into an emesis basin. How often do you get to drool on your classmates? At least no one in lab had bad breath.

We then practiced putting pyjamas on and taking them off eachother. Of course, we all had several broken limbs to make the process interesting. We applied compression stockings to eachother, and gave sponge baths to a manikin.

Then came the germs. We rubbed hand cream from a dubious bottle labeled "fake germs" all over our hands, which made them flouresce under a UV light. We then had to use propper hand washing technique to see if we could get rid of them all, and have non-flourescing hands. Next time you need to entertain a 7- to 10- year old (or a bunch of college educated nursing students for that matter), I highly recommend fake germs.

End of a quarter!

2006-07-15T23:15:00.000-04:00

I've ignored my blog for the past two weeks or more, but for good reason. We had final exams, and all of the four classes from the first half of the summer are over. I've passed, and I'm certified, tested, and (according to them anyways), ready to start my clinical experience.

Next week is a full week of labs to prepare for it, and then we start our first clinical rotation. The clinical rotation is more than just being in the hospital from 7am to 4pm. We are each assigned a client and we have to pull their charts, review their records, prepare written nursing care plans and write papers on them. The didactic labs and lectures will also continue.

Am I nervous? You bet! I'm afraid I'll do something wrong, hurt the patient or let them fall. I secretly hope my patient will be in a coma so they won't be able to see me messing up. Stay tuned for more on the clinical experience...

Have textbook, will travel

2006-07-15T23:04:00.000-04:00

School isn't all about studying... or is it? Some people travel around the world, taking photos of themselves at famous landmarks. Well, Rochester may not be a world-reknown destination, but I've decided to start my own travelogue. It's called "have textbook, will travel".

Here are my first shots of "Physical Assessment Techniques" in the gym at U of R.

A 28 hour daily schedule

2006-07-15T22:44:00.000-04:00

Here's a little taste of what last Monday, July 10 was all about.

9am-11am
The day started with a bang at 9am, with a two hour review session for the upcoming pathophysiology class. Thank our lucky stars for the amazing assistants who run the sessions, or I think we'd all be sunk in pathophys.

11am-noon
Then from 11am-noon, there is a session on career advancement and electing class representatives to the student council. Many people skip out on this, and spend the time in the computer lab studying.

noon-2pm
At noon, we go to our last genetics class. Actually, we don't really go anywhere, since all of our classes are held in the same dark, windowless auditorium. The teachers all come to us. Today, the genetics class is two lectures by guest speakers, one on genetics and psychiatric illness, and one on prenatal genetic testing.Very interesting, with lots of graphic pictures of neural tube defects... little babies with huge masses of tissue protruding from their backs.

2pm-3:15
Nursing science is next. We have a panel of guest speakers at the front of the auditorium, who represent all of the members who might be on a health care team. There is a nutritionist, a social worker, a physical therapist, etc. Two students go up and act out a family medical crisis, and the team of experts demonstrates how they would approach the problem.

3:30-6:45 (but we get out early, YES!)
We end with pathophysiology. We go through two case studies that the instructor puts on the overhead projector, and we raise our hands, and try to diagnose and treat the patients. One is a 42 year old man who is pretty clearly suffering from a heart attack. After 12 hours, we are still trying to treat him, but nothing is working. We won't give up. But alas, our patient dies. It's very frustrating. With a problem that the instructor puts on the board, you want an answer. It's hard to accept that there isn't an answer.

What next? A little fun? "Pirate of the Carribean" part II? Nope, it's back home to study for as many hours as I can for the test tomorrow!

What's your ethnicity?

2006-06-30T09:52:00.000-04:00

Imagine walking up to a stranger and asking "How do you identify yourself racially? What is your ethnicity?"

Nursing is that is direct, honest and too the point. I always thought of nurses as caring, compassionate, sympathetic. They are all of these, but directness and honesty are more important to gaining trust. If a client asks you "Am I dying?", you tell the truth. If you are making an assessment, and a client exhibits signs of depression, you ask them, "have you thought of hurting yourself?" and "have you had any suicidal thoughts?"

The trick to trust is not to make judgements. You are just gathering information. If you're interviewing a client, you might ask, "Do you use crack? How about ecstasy or heroine? How many times a week? Does it affect your job and family?" They may answer yes to all and clearly have a health risk, but you don't comment on it. You record the data and move on to questions about their diet or family background. The client won't be afraid to answer further questions if they know you won't make judgements.

When it came to questioning about ethnicity, it brought out more than a little tension to the surface in our class. What if you don't consider yourself part of any one defined group? Isn't this information private? How do you tactfully ask someone who looks Caucasian or African American what their "race" is? However, for nursing, these are relevant questions. You have to get past your own discomfort at asking these questions and realize that it's not about you and your discomfort. It's about the client.

We've become very accustomed to asking eachother in lab "How is your urination pattern?" and "Can you descibe your last bowel movement?" If you're going to ask about their bowels, why feel shy about asking anything else?

Fuld Fellowship

2006-06-30T09:34:00.000-04:00

Yesterday, I started working on my project for the Fuld Fellowship. I applied for the Fuld when I was accepted to the U of R, and about 20 or 25 people received the fellowships. In return for them paying a large chunk of tuition, you assist in a research project, participate in a lecture series, and learn about nursing research.

I didn't even know that nurses conducted independent research before I came here. I had assumed that they just participated in or administered research projects where the chief investigators were doctors. All of the projects for the Fuld Fellowships are NURSING research.

The first thing we had to do was read a book and take a test to receive Human Subjects Protection numbers so that we could participate in research. It was interesting to learn some of the ethical issues surrounding human subjects. It is far more complex than I'd thought.

The project I'm working on is called "HIP Teens", or Health Interventions Project for Teens. It's an NIH funded project studying health intervention to prevent AIDS and STD's in teenage girls. They've currently recruited half of the 850 participants. The girls are assigned to one of two training groups, and meet for four group training sessions. They follow the girls for about a year and a half after the intervention, and look at how the training sessions have affected AIDS transmission and STD's.

Because this is research, and not an educational program, I won't actually work with the girls. Everything in the study is controlled, and all of the recruitment of subjects and educational sessions are highly formatted and monitored. I'll be working with data, helping around the office, observing a recruitment session, and maybe even redesigning a logo for them!

Case studies

2006-06-20T21:01:00.000-04:00

One of the most interesting parts of the pathophysiology/pharmacology class is case studies. The instructor tells us a client's history, and she keeps us guessing the diagnosis as she goes.

The first client history was a 26 year old woman who was short of breath, fatigued, and had gained weight in the past couple of months. When they listened to her heart, they found that the heart sounds were located in her shoulder, not chest! She had edema, swelling, and all kinds of other symptoms. They sent her home with anti-arrythmia medication and a diuretic, suspecting a heart problem. Three days later, she delivered a baby.

The second client history we did was a man who had recently had a vasectomy, and had all kinds of weird cardiac symptoms symptoms, a normal ECG, capillaries bursting in his retina and earlobes, no hypertension, and a sore kidney. He turned out to have subacute bacterial endocarditis.

In another week, we have a major paper due in that class, where we have to write up a case study ourselves. Very exciting.

An average day

2006-06-20T20:47:00.000-04:00

I thought I'd give you an update on an average day.

Classes began at 8am, with a 2 hour physical assessment lecture. We finished up assessing the cardiovascular system, and now we're learning the pulmonary system. We need to know how to percuss the chest with our hands, measure chest expansion, locate the position of the diaphragm during inspiration and expiration, and listen to a variety of chest sounds with a stethoscope. We also do a number of other tests where the client says different words, whispers, etc. Tomorrow in lab, we get to practice all of that. We're going to be drawing where the different lobes of our lungs are located right onto our partner's chests and backs.

Some people had lab after the lecture, but I had a couple of hours off. I studied for the next exam, and practice the cardiovascular assessment techniques on some classmates.

At 1pm, we took a standardized pharmacology test that we must pass in order to enter clinicals. It involved a lot of dosage calculations. Then we had a pathophysiology/pharmacology lecture until 4pm. It was fantastic. We did a case study, where the instructor reads a client's history and information to us, and we try to diagnose what is wrong using what we've learned about systems interactions.

Then, well, I went to the gym. I studied nonstop yesterday, so I needed a break. I cooked some dinner, and now it's 8pm, and I'm studying like crazy for the lab tomorrow, upcoming papers, exam on thursday, etc. It never ends.

I've got to say, the faculty are AMAZINGLY responsive. There was a huge outcry that students were feeling lost in lab. By that afternoon, the instructors sent out an email with five extra open lab sessions for us to go practice and answer questions.

My First Patient

2006-06-17T16:02:00.000-04:00

Here he is, my very first patient! This handsome, single, muscular, slightly syncopic guy is Sim-man. And for just $40,000, you could own one to. Heck, for $40,000, I'll lie there for a year and let people take my blood pressure.

Sim-man is worth every penny. He may not be very neat, he doesn't send birthday cards and he can't cook worth a damn, but you can palpate his radial, brachial, and femoral pulses, and take his blood pressure both arm and thigh. You can ausculate his breathing sounds and heart rythmn. What's more, the guy can be hooked up to a computer monitor, and you can give him any number of weird heart arrythmias, cardiac conditions, or lung problems. If his breathing noises get in the way of listening to the heart beat, you can just turn the breathing off. Can you hook your guy up to a computer monitor?

However, I was still horrified at the cost. I took figure sculpture, and I could certainly come up with a model for less than $40,000. So being really obsessive, I went ahead and made my own model for $7.39. It's not quite as dashing, but at least I can practice taking blood pressures without going broke.

Grades

2006-06-17T15:37:00.000-04:00

It has been a busy, stressful week because of that monster we all hate, GRADES.

The first day, they told us not to expect A's, that it is just the nature of an accelerated program. I started the program determined to keep things in perspective, and not worry about a bad grade here or there. In fact, I don't want to worry about them at all. My resolve was tested this week.

They meant what they said the first day about not getting all A's. The tough part wasn't getting a "C" on my paper, it was dealing with the reactions of the class as a whole. When papers were handed back in my lab section, it was like vesuvius erupting; spectacular from a distance, but no fun if you're in the middle of it. There was cursing, tears, explosions and fireworks! Oh, the drama would have made some excellent reality T.V. (late-night only, due to language). The stress was palpable. I heard that one lab section had to have a counseling session.

It got to be a little too much. It was impossible to escape the stress. "Really, this is ridiculous," I told myself. But it was almost impossible to go home an not wonder if anyone, myself included, was going to make it past the first semester.

My advice to the instructors ... get these students on some sedatives, give them chocolate, try hypnosis, anything alter the senses before handing out grades!

Life in a 300 yard radius

2006-06-13T10:13:00.000-04:00

I feel like my life has contracted down into a tiny little radius between the library, the nursing school and my studio. I'm not used to my life feeling so limited. I don't have much to tell my friends about except school, school and school. I think everyone feels the same way to some degree. The students with families have a tough time with multiple obligations, but they have the benefit of some forced diversion, which wouldn't be a bad thing.

That said, there has been some slacking activity going on. This weekend I went out for Tapas with some fellow students on Friday night, and on a fantastic hike for a couple of hours on Saturday. The tapas event felt a little like a sorority party - all girls! Other than that, the weekend was pretty much studying.

It's pretty incredible what the instructors do for you. They are online 24/7. I wonder if they ever sleep. At 6pm on Saturday night, I was taking an online quiz in genetics, when I got an email from the instructor about our written assignment. I emailed her back with some questions, and we ended up having an email conversation over the next half hour. This at 6pm on SATURDAY. The classes never end, but the instructors are right there with you.

Naked Lab

2006-06-09T16:04:00.000-04:00

Today was the first naked lab-fest. Yup, we all paired up, stripped down, and donned attractive hospital gowns to evaluate eachother's skeleto-muscular systems. None of the instructors got naked.

Some of the guys in co-ed pairs were a little shy at first, but basically we spent the lab giving each other back-rubs (called "palpating the spinous processes") and hand-massages ("evaluating metacarpal-phalangeal joints"). Quite relaxing. I felt like I was at the beach, only minus the sand, ocean, and sunshine. Next lab, I'm bringing my purple sarong and beach towel. I don't think the instructors would mind some mai-tai's. Maybe a few daiquiris and they'll be naked too.

Why don't you become a doctor?

2006-06-09T15:38:00.000-04:00

Why don't you go to medical school? Has anyone asked you this? I think most people, myself included, have only a vague idea what nurses do. Don't they just assist doctors? They take orders, do what the doctors say, and administer the drugs the doctors prescribe. Why wouldn't you want to be a doctor, then? Why a nurse?

Nursing at U of R seems to be treated 100% equally in its own right to medical school or dentistry.

I'm one of the Fuld fellow, a nursing research fellowship that is given each year. As part of the fellowship, I'll participate in a research project. I just had a look at the list of possible projects. They are all major studies doing primary research, funded by institutions like the NIH, conducted by NURSES (no, not M.D.'s)! I didn't even know that nurses were involved in conducting their own major funded research, published in peer-reviewed journals.

On a smaller scale, I expected Miner Medical library to cater primarily to medical students. I was amazed to find that the reference librarians at know all of the nursing instructors, the nursing curriculum and what each teacher covers. They teach us how to do primary research using all of the major online medical, clinical and pharmacological databases. Highlighted on the library homepage, right underneath OVID/MEDLINE, is the primary nursing research database of I think 6,500 different nursing journals.

I get the feeling that the medical, dental, and nursing schools all have fairly close ties. One day, the nursing school lecture hall was in use, so our class was in the lecture hall across the street at the medical school. For our genetics class, we'll have a doctor come over from the medical school to give a lecture in his specialty.

I could go on and on, I will at some point. For the moment, just know that I'm not becoming a doctor anytime soon.

Online Classes

2006-06-09T15:16:00.001-04:00

If you're planning on becoming a nurse, get online, and get used to it!

When I graduated from college in 1992, most people had computers in their dorm rooms, but laptops didn't exist. I survived college with a Mac Classic. Color monitors were to expensive to dream of. Then there was a geeky new thing called email...

Here at U of R, everything, EVERYTHING is online. Two of my classes are almost entirely online. We are graded on our class participation in the online chatroom, we hand in assignments in the virtual classroom, and we printout the powerpoint lectures before class. There are computers everywhere; the computer lab, viewing room, next to the hospital beds in the assessment lab, in the library, in the lounge. Next year, I believe they will introduce PDA's for notetaking during physical assessments in lab. They also have an amazing tech support department exclusively for the nursing school, to keep everything running. There is wireless connectivity around the whole building, so you can bring your laptop to class or lab, and connect to the virtual classroom.

This means that the classes never end. Professors send group emails out on the weekends, and at midnight. Got a question? Email your instructor, day or night, and you'll get a response. All communication within the school is via email.

The online lectures are really something. Log onto the classroom, click on the lecture, and media player opens to a video of the instructor teaching, coordinated with slides that play along side it with the lecture, and links.

For one class, we were assigned to watch a movie. No problem. Click on the link, and watch it on you computer, anytime, anywhere. All of the labs have video demonstrations that go with them. You can access them anytime, from any computer.

The end result is whether I'm in class, in lab, in the library, or just in the lounge, I'm always online.

Monday, Monday

2006-06-05T19:19:00.000-04:00

Today was "easier"... a two hour review session for tomorrow's exam, followed by 5 hours of lectures. I've been in a dark auditorium for seven hours today, and I'm feeling like I live in a bat cave. Get me outta here! I may be a nurse in a year, but I may also be blind and hanging upside-down from the ceiling.

I'm going outside to put in another couple of hours of studying for tomorrow's exam and lab. Wish me well...

The lab experience

2006-06-03T22:58:00.000-04:00

I really didn't know what labs were in nursing school before I came here. The labs aren't the typical science or bio labs with tables. Instead, the skills lab is a mock-up hospital ward. This semester, we are learning to do health assessments. Each lab we go through tests to assess a different body system. Then we practice the assessments on ... EACHOTHER!

First, we have to mark up all of the anatomical points of interest on eachother with magic markers. You see people all the time walking down the corridor with weird X's and arrows on their faces. "Ah, you just came from lab!"

Next, we practice assessments. I've had my blood pressure taken about 50 times in the past 2 weeks, and everyone gets very excited when a classmate has something abnormal. Thankfully, we haven't done any systems yet that you have to get naked to assess, but I'm told those will come. I'll be sure to post photos!

Here's a photo of the lab, and me with some interesting marks on my face, trying to assess if my brain is still there after 2 weeks of school.

What do nursing students eat?

2006-06-03T22:44:00.000-04:00

Here's some food for thought. What do nursing students eat? The frightening truth is right here for public viewing. This is a photo of my freezer, with my dinners for the next 5 nights.

I can't believe how un-green I've become, buying over-packaged salt-packed frozen dinners. But when you spend 10 hours or more a day in class or studying, something's got to give. I was a naive optimist when I packed those cookbooks to bring with me.

The nursing school does have a great coffee cart with chocolate pastries, and they also have a lounge with a refrigerator & microwave. Right across the street, the Med Center has multiple cafeterias, some of which serve just employees and med students. I highly recommend their veggie burgers.

I have gone out with classmates several nights, and Rochester's got some surprisingly good restaurants. We tried a Mediterranean place last night, which was fantastic. There is also a good Thai place nearby, and excellent dim sum downtown. Now if only I had a salary...

The First Exam

2006-06-01T06:53:00.000-04:00

Yesterday was the first exam of the year. The build-up was incredible. Everyone was endlessly reviewing what was really pretty straight-forward material. As usual, the anticipation was worse than the event itself.

All of the exams are given in the same format as the NCLEX (national nurse licensure exam). This means that for each question, you have to circle any of the answers which apply. There could be one answer or four answers to a question.

I felt like I knew the material, and studying any more wouldn't have helped. However, the format of the test was what we should have been studying! Each question had one clear answer, and several that could be valid .... but then again. We'll see what the results are.

This has been another frantic week so far. Because of Memorial Day, it is a short week. The lab yesterday was on how to do a complete neurological exam, and was quite detailed. It involved about thirty or more tests of every cranial nerve and muscle function. We then have to write up and turn in our results. I'm feeling a little brain damaged right now!

Memorial Day biking

2006-05-29T20:51:00.000-04:00

Today was a gorgeous, sunny day. After working non-stop since Friday afternoon, I felt somewhat caught up on work. What better way to celebrate than with a bike ride.

I'm living in graduate student housing called University Park, which is 100 yards from the park along the river, and the Erie Canal. I biked out along the canal path, and was surprised that with five minutes, I was biking through fields! I'd expected much more industrial ugliness, but the canal has really been turned into a beautiful waterway. There were kayakers (one with a dog in his kayak), rollerbladers, bikers, joggers... everyone out enjoying Memorial Day.

I branched off, and biked out of Rochester, through fields of wheat and rolling hills. This scenery may seem average to the natives, but to me the big red barns, plowed fields, and pastures are something totally new. I with I had a decade to spend painting here. It reminds me of a French impressionist landscape. It isn't a wild, natural landscape, but it has an ageless dimension about it.

I passed by Mendon Ponds park, and the greenery is astounding. Anyone from California has got to love the trees here. They increasingly lush as the season progresses. I've never seen oak trees that are verdant green like this before. The first time I saw a gopher here, I nearly called the police! I didn't even recognize what it was, it was so huge.

I've also never seen flowers quite like this. Every inch of grass in the park is covered with dandelions and buttercups. Enormous azaleas are blooming like popcorn.

Something else new arrived today... humidity. It took me a little while to realize what this strange feeling that I couldn't breathe was. The air had overnight become thick and viscous. It felt oppressive during the day, but in the evening, as I went for a stroll in the park (with pharmacology flashcards) it was soft and pleasant. The park was packed with people walking along the river.

It was a nice end to a busy weekend.

I've probably spent 9-10 hours reading and studying each day this weekend. This is in part because next week is another 4-day week. I've done as much as I can, and I've managed to complete most of the reading and writing assignments left over from last week and for next week. I wrote a journal entry for one class, wrote descriptions of Cystic Fibrosis and Depression for my Genetics class, and wrote a short piece on my views of professionalism & education in nursing. I read about a billion chapters of I don't know what. I did 3 sheets of dosage calculations. I watched an instructional video for lab.

I also met with the study group that I organized last Friday. It was very helpful for all of us to have classmates to check in with over the weekend. We went over our assignments, and we practiced taking eachother's blood pressure and vital signs.

To finish off, I'll start writing my list of Rochester's Top Ten Best and Worst

Top 10 reasons to love in Rochester:

1. Low cost of living (half what it is in California!)
2. Great biking (think Finger Lakes)
3. A traffic jam is 5 cars
4. Humidity makes your complexion 5 years younger
5. Gophers the size of polar bears
6. Some surprisingly good Thai and Chinese food (and a full Asian supermarket)

Top 10 reasons to hate Rochester
1. The Frontier and Roadrunner internet services are both terrible!
2. Someone always knows someone who knows you
3. Canada Geese that attack you at will
4...

To be continued, and finished once I've survived a winter here.

Check out the photos I took of flowers along the Genesee river, and some scullers on the river, with the University of Rochester in the background.

Accomplishments

2006-05-25T20:12:00.000-04:00

During break, I asked one of my classmate how her lab went. She told me it felt awkward learning the new procedures. At one point, she heard a classmate exclaim from around the curtain of a neighboring bed, “I want to cry!” We both laughed, since I think we all feel that way. It has been a very challenging week.

Day 3

2006-05-25T18:58:00.000-04:00

Did you know that nurses do testicular, gynecological and breast exams? Lucky us, it’s all covered live our Assessment laboratory!

This evening, after two lectures in Pharmacology/Pathophysiology and in Health Assesment, I went to watch the preparatory video in the lab. Some classmates were there, so we gathered around a station to watch.

The subjects were fairly basic ... how to take temperature, measure height & weight, and take blood pressure. However, they also gave a graphic film narrative on taking temperatures rectally. Hmmm... Hollywood doesn’t usually show anuses on the silver screen. Heated debate ensued on whether we had to practice this skill on eachother in lab. Rumors were rife, but word leaked out that although it is in our lab manual, we don’t have to do it on eachother.

Ahhhh...those quaint little delicacies they don’t mention in the glossy recruitment materials!

At least my background as an artist will come in handy. How many naked bodies have I spent hours observing in drawing classes?
Pharmacology/Pathophysiology lecture was fantastic. It is a fascinating class, with real-life histories of patients, and lots of discussion. I’m relieved that we don’t need to memorize individual drug doses, half lifes, etc. We need to learn to use a manual to look these up.

The Assesment lecture brought a lot of ethical issues to light... When doing a health history, when is information not confidential? What about elder abuse? How do you ask a client if they’re suicidal, or if they are being abused?

The week is almost over. Just one lab tomorrow, and then WEEKEND! I’ve got plenty to work on then....

Day 2

2006-05-24T21:58:00.000-04:00

OK, no kidding this program is accelerated. Today we had 4 classes, from 8am until 6:45pm, with a break to go to the bookstore and get photos taken. Everyone was pretty beat by the end. It was tough just to sit for that long, and it was dizzying trying to keep track of which class has what assignments.

Let me give you the low-down on the classes. For the first half of the summer I have four classes:

1. Pathophysiology and Pharmacology
2. Nursing Assessment (covers how to conduct a comprehensive physical exam)
3. Genetics
4. Nursing science (topics like the history of nursing, the nurse as an educator, nursing process)

For the second half of the summer, some of these classes will end, but will be replaced by our first clinical experience.

What really had everyone gasping was when we found out that in Nursing Assessment, we won't be working on dummies for learning the physical exam ... we'll be using eachother. That means dressed down and gowned up. I hear that we also get to practice giving injections on eachother. Oh joy!

The Pathophysiology/Pharmacology and Assessment classes will be the main ones. The other two seem easier, with short written assignments of a few paragraphs, or keeping a journal. Genetics and Nursing Science are primarily online.

Even though the day felt like a long international airplane flight ending with jet lag, the instructors were great. Amy Karch kept us all going in Pathophys by spending an hour presenting a fascinating case study, and keeping us guessing what the diagnosis was. It made us feel very medical!

I will say that I feel like I'm already behind in the reading! Things really start with a bang. I plan to spend the Memorial Day holiday catching up. This will be a very challenging, stimulating year.

Day One

2006-05-23T17:06:00.000-04:00

Another first in life... the first day of nursing school and the University of Rochester.

I'm pretty exhausted. This morning was mainly basic orientation material, covering the curriculum, introductions, etc. However the newness makes even the most ordinary information exhausting. Does everyone feel this way after only one day? I had to come home and play flute to decompress. One microwaved English Muffin pizza later, I'm somewhat recovered.

What were my impressions?

First, there are my classmates. I was relieved to see a huge range of ages and a diversity of talents. I'm definitely not alone in going back to school at 35 to make a career change. Many students were biology or psych majors, but there were two divinity students, a vocal performance graduate, and another foreign language major.

I was impressed by all the the faculty we met. They are a group of extremely intelligent, professional, and accomplished women (and one man). Their research is first-rate, and they seem supportive in every way. I'm confident that the dean meant it when she said to drop by her office, and made sure we knew her email address. All of the faculty made a point to say that they expected us to drop by and call on them for anything. Accessibility plus some!

It was exciting to see a line-up of primarily women who are so accomplished. They are all first-rate scientists, and there are none of the touchy-feely nurturing-nurse clichées to be found here. Yet at the same time, they manage to combine science with an understanding of interactions. They are teachers as much as scientists. What a fantastic combo.

The new building (which I didn't even know was being built) is fantastic. We are the first class to use the auditorium.

I could go on for pages, but first impressions change, and I've got another English muffin pizza getting cold.