Pinning ceremony December 10, 2009

Dr. Berman…faculty, family & friends.. my fellow colleagues.…The journey that began 11 and a half months ago is now coming to an end.

We told you last January we would see you on the other side of this…and you bore it all so patiently.

How fitting that Dr. MacIntyre welcomed you all to our pinning ceremony, because in many respects, he took this extraordinary journey with the ABSN class from start to finish, Our work with him, from January through December was an examination of conscience & intellect for the rest of our practical nursing curriculum, providing the framework by which we learned about nursing standards, scope of practice, ethics, application of applied research and evidence-based practice.

The most important contribution he made to our cohort, however, was the assignment of a book in November that for all intent and purpose is a book written about us, a book about him…and about some of the very special patients we had this year….The title of the book is “Outliers, The Story of Success” by Washington Post business & science reporter and author Malcolm Gladwell. If you have not read this book, you should.

Outliers are a misunderstood, unique subset of people who fail to fall within in the normal bell curve in standard statistics. They are so far outside the bell curve that when taken into consideration, it is difficult to understand them. They fail to behave the way one would expect, their results are often unanticipated, it is difficult to make predictions about them. Outliers cannot be put “into a box” because their outcomes fall outside the veil of normal experience and expectation.

Our cohort cuts across four different decades, from backgrounds as diverse as photography & psychology to biochemistry and the neuro-biosciences. Our class has civil and electrical engineers, physical therapists, social workers and exercise physiologists. We have a professional homeopathic doctor, an Eastern medicine practitioner, and a theologian. We are a class of educators, writers, and business administrators. In addition, we have a professional musician and a seasoned television news reporter who climbs mountains in her spare time. Several of our classmates plan to be nurse anesthetists and family nurse practitioners and one is planning to go to medical school.

These individuals at this particular point in time decided to become baccalaureate prepared professional nurses. They answered a vocational call to the nursing profession and committed to the intensity of an accelerated bachelor’s program. Who does that? … And arrives on this stage… December 10, 2009 after 11 and one half months?

That would be the Outliers.

Gladwell theorizes that outliers are surrounded by people that allow them to thrive and be successful. People, who happen to be very special family and friends. Wedged into their background is a broad life experience, and additional outliers who are their mentors and teachers and in many respects, nothing but Providence is responsible for this.

Therefore, let our charge be, in our future practice to watch carefully and diligently, for our patients who are also outliers, in order that we might apply our best practice, because no matter what we read in nursing textbooks, in nursing research…No matter what we hear in report, on rounds….or read in a patient’s chart, as nurses who are outliers, we must rely on our other tools and skills, our intuition, our five senses, our own assessments, listening tentatively when we’d rather not, looking for the outlier who defies the odds, rebounds when we least expect it or needs us to advocate for them when no one else will answer the call.

Outliers apply knowledge from a variety of resources to treat patients across the life span because of broad based experience and will go that extra mile…. because somewhere in their past, outliers have had their own obstacles, special challenges, problems to solve and yes, their own suffering to endure.

We banded together as I believe Dr. MacIntyre wanted us to, in order to effect change in the nursing profession …this class not only adopted each other as family; we adopted patients with the highest acuity, the homeless, the dispossessed, the young, the ones left alone to die, and the undesired who desperately needed to be bathed. This class tended after the wounded, the abused, and the burned. We cared for the ones with cancer and the wee ones just born.

This is the story of the success of this cohort who successfully navigated the ABSN program somewhere on the outskirts of the bell curve.

Congratulations to the Samuel Merritt University ABSN Class of 2009.

Catching the ball....run Forrest run.

The last few weeks were difficult for our unit. We lost three patients close together. Two of the three patients were patients my preceptor and I had the weeks before. Nursing puts us all in that delicate position of helping people at their most vulnerable hours of sickness and death. One of the unique aspects of what we all do, is that when we go to work, we never know what the day will bring.

This week, however, my preceptor allowed me to take the ball and run with the patients I wanted. I always try to challenge myself to pick patients who are the "sickest"...however, in oncology, everyone is usually pretty sick, so the two I picked this week were a great opportunity to exercise old skills learned in med-surg. Taking and giving report, assuming total care, planning, assessments, interventions and evaluations. How would I plan and approach the day? Since I had good role modeling from my preceptor, I decided to use "her" method and hit the ground running the way she does. We round on our patients in the AM, pull labs and meds and bring everything at once to do assessments. This allows for the unexpected admission in the morning, the surprise fall backs and any other delays that frustrate any nurses' best laid plans. It also allows us plenty of time in the room, avoiding the back and forth. So, while one med is running over 10 mins, I can assess other things, do a little teaching and reassess before the next one is given.

The oppty to reconstitute and administer meds, try things with patients with my PRNs to see if they would help. These are all the things I love about nursing and of course, patient teaching. I know I probably won't always be this optimistic, but I like to see nurses who still love what they do 20 years later. It is the kind of nurse I hope to be.

While my patients weren't as critical this week as they were in the previous two weeks, I loved the independence of trying to do everything on my own, classifying, and getting all my charting done and being able to measure over the course of several days how decisions I made, impacted my patients. Running never felt so good!

Seeing the big picture.....at the end of life.

As a student, learning in the Hem/Onc/BMT unit has been a positive experience primarily because we care for the same patients over a longer term. In many case, patients are in for new diagnosis, post operative, and/or being stabilized towards going home, the outpatient setting, or they are inpatient due to relapse and now our goal is to help them transition toward death.

I've had several opportunities to work with patients who are new to their cancer treatments and those who are at the end of life. Perhaps the most difficult case I've had over the last two weeks is a female patient with Ovarian cancer/mets throughout, whose spouse is in the worst case of denial I've ever witnessed. The patient has intractable pain, unable to tolerate any intervention including sips of water or touching her, and the poor spouse is thinking the next ABX or blood transfusion is going to be the magic bullet. I know how hope and faith serve in rescuing our loved ones in crisis, but this patient had already crossed those turning points. Her body was fighting every intervention and was shutting down in violent opposition.

This has been going on for months...with the last month being the most painful: 3+ pitting edema, an abdomen 10X it's normal size, full of cancer. While I was changing and packing her open abdominal wound yesterday, I told her that she needed to get him ready and tell him what she wanted (she wants hospice..he wants her to eat and gets mad at her for not eating. He wants PT to work with her and she is no longer able to bear weight on her joints and cannot tolerate being elevated or turned in bed.) She cries that he doesn't listen and refuses to talk about it. I told her that it is difficult for him to let go, and she needs to help him.

The situation is like a big elephant in the room everyone refuses to acknowledge. She doesn't want anyone touching her due to her intractable pain, but yet, she is a full code, meaning that when her BP, heart rate and respirations slow down or cease, our response is to intervene with full force, including but not limited to CPR, chest cracking/opening/manual massage, mechanical ventilation, vasopressors, fluid resusciation etc.)

Nursing is struggling with this particular patient because medicine has been slow to address it with the spouse. Social work is waiting for nursing and nursing is waiting for medicine and this patient potentially could code any hour and the husband is still thinking his wife is going to beat the end stage diagnosis/prognosis.

Yesterday, the chaplain came by and wanted to know how she was doing. After reviewing the case with him, he took the husband aside and asked him to consider making his wife a no code, explaining what a full code would look like. A body FULL of cancer that has intractable pain should not be cracked open, compressed and pushed full of more fluids. The amount of intervention in a full code would be agonizing for the dying patient. I also talked to the patient about the importance of getting her husband ready...telling him, even though it would be hard for him to hear it, that she wanted to die, that she was ready to die. The body goes through the shutting down process and she has already started that process.

Death is the big elephant in the room that nursing in concert with medicine and psych-social, needs to acknowledge in unison, in order that we might more effectively guide our patients toward the end of their life in a manner that promotes for their optimal comfort, preserves their dignity and assists their loved ones in their grief toward acceptance.

PS: I got a call from my preceptor today that this patient passed away last night, just a few hours after her code status was changed from full to DNR. I was grateful to hear that she passed away peacefully in her sleep, which was the last thing she said to me, "please...let me sleep".

Comprehensive RN Exam - ATI graduation assessment

Most nursing schools require that you demonstrate a certain competency in all nursing subjects prior to graduation. It is the precursor to the NCLEX exam administered by the Board of Nursing. In fact, when you finish the assessment, it scores your assessment against all students taking the exam and predicts the statistical probability of whether you will pass the National Boards on the first attempt.

I started studying for this in October and was cramming up and until late last night, with a quick review this morning. The exam was three hours and I took it this afternoon.

With great relief, I passed the exam, 4 percentage points above the national mean and a 95% statistical that I'll pass boards. Kaplan will be my extra insurance policy and brushing up on topics I missed on ATI will help prepare me for Boards. Thanks to St. Joseph of Cupertino for the help. I guess I can graduate now. Whew. (The film of his life is called 'The Reluctant Saint") It's a great story.

Let the Precepting Begin!

First day of clinical, we hit the ground running with(3) patients right off the top and actually, it turned out to be a great shift. Two cancer patients and one post op Crohn's patient. One of the cancer patient patients was post op bilateral mastectomy/lumpectomy; the second patient was a new acute leukemia diagnosis (2nd day)..which for me was a great opportunity to provide time to the patient and spouse to do some psych/social counseling and research on support groups. The patient happens to live in my neighborhood, so it was great to be able to tell her about Marshall Hospital's leukemia group which she and her husband can attend when she gets out of the hospital. It was also a great opportunity to share with her a copy of Bev Hall's book ~Surviving & Thriving (*thanks to the class for donating these!) The raw grief of the new diagnosis was something I hadn't experienced yet as a nursing student even though I spent alot of my med-surg time on the oncology floor @ Sutter Roseville and a lot of my peds time with the onc patients @ Sutter Memorial. One of my objectives was to work with a patient with a new cancer diagnosis & already this happened the first weekend of precepting.

It wasn't that long ago that I recall getting bad news about someone I cared about & how devastating that can be when you first hear the news. I could see it on the face of my patient and her husband. One minute you are walking the dog at the dog park and the next minute, you are unable to walk, your husband is taking you to the ER and the physicians are telling you that you have LEUKEMIA. *this is what happened to my patient. For a very active 67 y/o female whose been married for 45 years and living a very fit lifestyle prior to two days ago...this was very devastating. To be the nurse that cares for this person up front, is a privilege...there is a lot that can make the transition easier or even more devastating. The 1:1 time I had with her today was very rewarding. I was grateful for the opportunity to have that very intimate contact as a nurse.

It was fun to do procedures today. It was fun passing meds, assessing all three patients and learning all about blood products from the order verification/laboratory verifications and how the PRBCs are primed with NS and administered.

The best part of the experience for me was working with a preceptor who is also a SMU alumna from the ELMSN Case Mgr. program. She has been am RN for the last 18 months and loves working with students (lucky me).

To say that I love the teamwork on this unit is an understatement. I know I am going to learn a lot.

Community Health ...TNT Health Clinic

It was a bittersweet day ending out little clinic in the transitional homeless community, where we open for business and do assessments, administer OTCs and triage. We stocked up the medicine cabinet, cleaned up and put out a new sign that read, "while TNT clinic hours are done, we will be back as nurse volunteers throughout the winter to assist you with your health needs. Look for our doors to be back open in November.

We spent the last week doing a lot of patient teaching, handing out OTCs for colds, muscle aches and even assessed a client who had been in a motorcycle accident. Our clinic room houses educational materials, an examination table, medicine cabinet, scale and two desks where we park it during our clinic hours. We did smoking cessation, Hepatitis C education, followed a skin cancer patient and handed out goodie bags. We decided we'd partner up with the Recreation Social Worker intern and do a couple movie/education nights in the Rec Room in Nov. just to get people together and talking about their health. We were able see our regular HTN/diabetic patients and get a lot of homework done. There is something about an open door that says c'mon in, because people came by to talk and we listened...because that what nurses do.

57 Days to Pinning....

We are planning our class pinning ceremony with all the zest of people who are about to be released from captivity...not necessarily the serious POW kind, but in a sense, the walls of our classroom have no windows and some days feel like hostage crisis, Day 283, especially today. So with a little creativity and somewhere sandwiched between mental and community health, a couple classmates put their photography skills to work shooting headshots and candids of all our classmates for our pinning ceremony, to be held on Dec. 10, 2009, approximately 57 days from now (not that I have a countdown on my lap top or anything like that!)

As we approach this milestone, thoughts about the people I've shared my life with over the last 283 days are fond. We navigated some serious landmines in theory and clinical, shared a lot of laughs and tears. I made friends in nursing school that will be life long friends, professional colleagues I know I could turn to in a crisis. ABSN programs are unique nursing programs, pouring out insane amounts of learning wherein 38 adults from all walks of life, dedicate a year of their lives in pursuit of a common goal, supporting each other, knowing what we have emotionally, physically and financially invested in this journey. I can't begin to count the sacrifices we and our loved ones have had to make in order for us to get to this point. These are the best people...super human student nurses, supported by super human family and friends. The nursing profession is going to benefit from the heart this ABSN centennial class will bring to it. That's not to say there haven't been moments of sheer irritation. It's a lot like family.

Breathe. The roller coaster is starting to slow down. Hallelujah.

Psychiatric Nursing ~ Can we talk?

Psych nursing is different. You have the med room, the nurses' station and the hallway. Interspersed are bare bones rooms without any exterior trimming to allow for someone to harm themselves. The inpatient facility where we are rotating resembles a really old prison ward. There is a day room and a TV room. The facility is locked down and the LPTs wander the halls looking after the clients. The clients have access to meds (which they obtain at the nurses' station) from the med room nurse, and they have access to television. Other than that, there is groups during the day to attend, and meetings with psychiatrists/conservators and family members. If you are not insured, this is where you go and to be honest, if it were not for the generally optimistic people that work there; hell would be a picnic. Comrade X talked once about how painting a psych intake room the color pink would, in effect, calm a patient who was in crisis. After being in the concrete walled rooms of this facility, especially the intake/isolation rooms, I got the picture and thought it was research worth looking into. I've seen better dog beds at Costco. It's a sad indictment. Luckily, the best thing going at this agency, are the employees and it seems the long termers...the nurses and social workers, truly care about the patients.

My last day of clinical involved interviewing a paranoid schizophrenic patient with a long involved psych history and drug abuse history. This patient also had a history of violence and conduct disorder as well as developmental delays. It was not a situation where you would sit down and talk, much like the patients I met with who had major depressive disorders, bipolar and personality disorders. This patient was suspicious and tentative, was careful to keep his distance and took a very long time to get comfortable with me. I sat across the room so that he could get his bearings and then waited. It was a long wait. When he was ready, he talked. I didn't ask a lot of questions, because I noticed one thing about this patient that I had not experienced with any of the others...this patient made no sense at all. Disjointed sentences, with little connection between first and second thoughts, subject verb agreement, word salad...people inserted into thoughts that had no congruence or meaning. "I worked at a top secret place, my land lord dipped me upside down into a vat. She does not hear me. It didn't burn it did. He will kill me. They kicked me out. My parents are dead. I was adopted. I saw my dad today. I have 4 brothers. 2 brothers. Four years....and...."

This went on for an hour. Any attempt to redirect failed. Any thought became negated by another or an illusion. He could not maintain eye contact as he was always checking around us to see if I had moved was planning to move, or if someone else was coming. The affect was guarded and tense. As long as I wasn't talking, he was calm. It became apparent that interactions on the simplest terms could affect these patients dramatically, as if their sensory perceptions were all on another plane or out of whack or heightened or lessened.

I waited a long time to write about this because I realized that there was absolutely nothing I could do first as a student, or as nurse, other than listen, redirect, listen, accommodate and accommodate. Nothing I said mattered. I haven't been around someone whose defensiveness was so palpable. It was an interesting learning experience that I won't soon forget. Mental illness can not be dismissed or trivialized. How we deal with the mentally ill in society is certainly an ongoing subject that needs to be addressed, because obviously not much is left for the mentally ill other than hopelessness, despair, long roads and new challenges.

Longest baseball game & Precepting assignment

The best laid plans have side roads...and due to timing and circumstance, I will not be precepting at the VA after all. There is simply not enough time to secure a contract with my school.

In any event, I found out that I will be precepting as an oncology nurse for 7 weeks (120) hours at a local hospital with a reputable cancer program. So much ahead @ and only 71 days to pinning! I had no idea it would go this way. I hope I learn a lot in this last clinical rotation.

We have one month left in psych and community health. After that we slide into home plate with leadership, senior synthesis (policy) and preceptorship, in what will have been the longest baseball game of my life....nursing school.

Community Health - Homeless Transitional Housing

Having this rotation during the health care reform debate has been interesting to say the least. In order to better understand what homeless people have available to them at the county level, Trude & I went to the county to check out the services and waiting areas of the local primary care center. More on that eye opener in a bit.

Our community health site is located on a closed air force base. Volunteers of America and the county share responsibility over various work/educational programs affiliated with this transitional housing venue that utilizes what's left over from the abandoned military barracks. Most of the residents are recovering alcoholics, drug addicts, parolees, or simply those down on their luck. There are two sides to the resident program (a singles side and a family side). Trude and I have the single resident students. We go to their community meetings each week and staff clinical office hours.

Our office was an old apartment that had a lot of broken down furniture, bags of old stuff, expired medical supplies and dirt. After we cleaned the place up, Trude managed to get an old exam table and now it looks like a little medical clinic office. We have a locked medicine cabinet with OTC medications, first aid supplies and health education materials.

TNT Tuesdays (Trude & Tam) opened with people getting their BP and blood glucose checked. We have smoking cessation materials, movie nights (coming up) and have set up free teeth cleaning appointments and mammograms. We're always looking for health related materials for our residents.

It's been one of those experiences that started out with a lot of cynicism on my part (lack of available resources, budget cuts) and we're having to reinvent the wheel. Trude's got her creative juices flowing and a sense of optimism to outweigh my cynicism, so we're pulling rabbits out of our hats when we can. When the staff has us speak at the meetings, they refer to us as the 'nurses'. We talk to the residents, counsel them, teach them. Taking a little bit of knowledge and applying it in a dignified manner, respecting each person where they are at. Once again, the patient is the best teacher.

The biggest challenge currently being faced at this site, is the potential closure of the entire program due to a long term, ongoing county budget crisis. We attend the community meetings and have witnessed the despair the VOA staff members are experiencing in trying to convey the latest news to the residents. There is a Board of Supervisors meeting this week. We're going to try and get to the meeting to support the residents.

Now, back to the county health primary care center. The building is relatively new and is easily accessed. What blew me away was how apathetic, rude and mean the staff at the bullet-proof glass windows were. The waiting rooms were empty and the staff looked like they would rather have a root canal rather then be at the window assisting patients. No wonder no one wants to access the county system for health care. What a sad indictment on government run health care. At least the veterans get better care at the VA, currently, the highest rated health care system in the country.

Fall Semester~ Get to work!

Fall semester is the back end of our nursing program. It essentially takes the entire nursing program and puts what we learned into action. We are put back into the community in public health settings, psychiatric inpatient and outpatient settings, management and preceptorship nursing practicum, essentially where the whole thing ends (the icing on the cake of nursing school).

I picked a community health site that appealed to my sense of stepping outside my comfort zone. It is a transitional homeless shelter program.

My psych clinical site is a locked 16 bed facility. Patients are voluntarily admitted, or admitted on legal holds. Some are on conservatorships. It is a whole different level of theory and clinical that is bent more on service and safety.

Five weeks of Pediatrics - Putting it all together

I deliberately stopped writing Tales during my pediatric rotation for many reasons. My stress levels increased significantly over the summer and came to a peak and I was simply too exhausted to write anymore. We had a bunch of busy work and it seemed I was treading water trying to stay ahead of all the projects, papers, research and clinical expectations. So I shut down on the one thing I always used to de-stress...writing. Instead, I stayed above ground and when I wasn't doing anything related to school, I slept. Seems like we took a running leap into this program, kinda like leaping off an endless abyss, and the fall at the end of it was hard. It took several weeks, plus a summer break to come out of it. Sheer exhaustion.

When I started pediatrics, I was going into a facility where my kids have been patients. Specifically, one of my kids was critically ill in this facility and walking the halls was all too familiar. I also had memories of helping a family who had roomed with us say goodbye their child and part of our helping them was being there when their daughter passed away and helping them with the funeral. I know the room that MJ died in. I had patients in the same room she shared with my daughter and where my daughter's PICC line was inserted. It was surreal, but being there as a nursing student was different. Significantly different.

As I mentioned in the previous post, I asked to be put with the sickest kids for a reason. I wanted the cancer kids, the CF kids, the heart kids and the dying kids. I definitely wanted a NICU and PICU experience. I got everything I asked for and then some.

As a nurse on the other side of the nurse's station, I saw the other side of the story. The family dynamics, the innocence of sick children along with the functionality of strong families, coupled with the weaknesses of the broken families.

My patients had leukemia, hypertrophic heart problems, cystic fibrosis, sickle cell crisis, post op complications, brain injuries, respiratory and renal failure. The babies I took care of were preemies and had a host of complications, namely they were too fragile and small to be cared for outside the clinical setting; one patient I cared for on a Saturday NICU rotation had been a patient her entire life, 13 months to be exact. She still has a long road until they she can grow up outside the hospital.

There were heartbreaking stories in the PICU of viral meningitis, heart/kidney/respiratory failure, Valley Fever...and bad prognoses. With one admission, I looked into the faces of the parents and I instantly saw people I knew. My daughter recovered. I knew that theirs wouldn't.

After my clinical final evaluation, my clinical instructor asked why I wanted a generalized preceptorship. She thought I should specialize. "You're good with the patients and their families, you connect with the kids and have the critical thinking skills"

The answer is simply this...if you could guarantee that I could work two years with critically ill kids...without falling apart after every shift, I would consider it. The challenge is to find the area of nursing that is most comfortable, where I can give without losing myself and or ability to function outside the clincial setting. Dying kids is a tough job for anyone. Pediatric nurses are special. I'm not so sure I could do this for too long.

Still trying to put it all together.

Preceptorship???

Before we started our last summer rotation in pediatrics, our managing director handed out preceptorship applications. This was one of those things in July that stressed me out, because in a certain sense, I had no direction on what course to take with regard to specialty. I talked to my Labor and Delivery OB clinical instructor (she's been a nurse for over 30 years) and asked her advice. I thought she'd push me to request a rotation in maternity or public health since she wears her hats so proudly, but instead she asked me what I thought about my nursing school experience.

Contemplating the journey, I was at a loss for what to think because I came into nursing with so many preconceived notions about what I wanted. Initially, I thought, I'd be one of those ICU experts who would enjoy the 2:1 patient ratios, and 1:1 with higher acuity...I also harkened back to my experiences with my father as a patient, my daughter as a pediatric patient and those I loved who succumbed to cancer. Did I want onocology? Did I want pediatrics?

Pediatrics was about to begin and I had not idea what to expect. I asked to be put with the sickest kids to see how well I'd function, but this wasn't a part of the consideration for precepting, because the applications were due before the rotation began, so I stewed for about a week.

My clinical instructor asked me the following week and I explained my dilemma. She then said without missing a heartbeat. "You need a solid foundation, one that will get you employed at the end of this" Go back to basics...go to med-surg. Hmm...really? Yes, give a bunch of meds, do a lot of IVs, procedures, reports and care and refine your style of nursing...do that for yourself.

She told me about a nursing student at another school's campus who had idealized everything about her nursing school experience and was thrust into the Veterans Hospital for her preceptorship. She reluctantly went and found out that everything she ever needed to know she learned at the local VA hospital. That sounded very appealing to me. I contacted this nurse and she said she tried two different settings in my area, one a private, not for profit hospital and the VA. She preferred the VA.

This got me thinking about Comrade X (who is also a VA nurse) and it occurred to me that all the things I love about nursing; the advocacy, protections, education that nurses offer to vulnerable clients could be well served at the level of serving our nation's veterans. It was an epiphany.

I think the nursing director at my school was surprised by my request, but when I turned in my application, I was convinced that I needed to serve in this capacity to launch my nursing career. Giving back doesn't always necessarily mean making tons of money. Sometimes, it just means doing something that we feel called to do.

Post Partum last day - Week 5 - Newborn Nursery

I had the chance to hang out again the nursery at the end of my rotation. The baby assessments were interesting and fun. I enjoyed checking in on the new ones, showing the primips (first time moms) 'the tricks of the trade' when it came to taking care of, holding and feeding their babies. It was a great opportunity to share motherhood as well as nursing.

The nurses in PP were all long timers, meaning they had their teams in place, the colleagues they liked and trusted and physicians they preferred to work with. They were willing to work with the students who wanted to work hard and learn. Overall, it felt like med-surg without the meds. We did vital signs every shift unless orders specified more frequently, we took out a lot of c-section staples, talked to the moms about their babies and what to expect in the first weeks. Mostly, we had long philosophical discussions with our clinical instructor about the present state of nursing and health care. The agency I was at was a teaching hospital, so I enjoyed working with the medical students and nursing staff. Mostly, I loved welcoming new little people into the world.

Triage - IV practice, no laughing matter

I missed my triage day because it was scheduled on a day off...but that didn't stop me from eventually getting in there one way or another.

I had a very slow last shift of labor/delivery. I was following a grouchy nurse who wasn't a big fan of students, so we spent the first half of the shift playing hide and go seek. I stocked her patient's room, helped the OB put in an internal fetal monitor and then she did the disappearing act. Rather than play the game with her (I've seen this with my classmates), I headed over to triage to see what Trude was up to. She was super busy. She promised me an IV stick at the first opportunity. so when she called me in on a difficult patient second triage in as many days due to dehydration. I gathered everything I needed to get it started, prepped the patient, found the scant trace of a vein and went in quickly. She screamed. I could hear my sister from another mother snickering in the hall. Ooops. Three RNs and 4 sticks later, the IV finally was started. The care nurse signed my stick sheet with the words "a very difficult stick." All I remember is Trude laughing.

Patients who need moms...Score 2

Post partum day 2 found me with 4 completely different patients. The first was 19 and a first time mom. The second was 30 something and a first time mom. The third was almost 30 and gave birth to a set of twins (this her third time giving birth). The last was a post hysterectomy patient who came to PP as an overflow. She was in her 70s. After doing initial assessments on all four patients and giving my notes to the care nurse (probably one of the nicest encounters I've had with another colleague)...she asked me which one I wanted to assume care on...I thought about it in a split second. "I want the 19 year old." Before I explain why, my reason was simply this. She needed a mom who could also be her nurse.

When I first came into the room, it was dark. The shades were closed, the room was hot and the patient was down in the bed...curled in a ball. Her newborn in the bassinet looked small and jaundiced. The mother's affect was flat and emotionless. She refused to make eye contact with me. I had taken report and heard this first timer was "difficult." My care nurse was awesome. I loved her style. Pulling my patient up in bed, I explained to my 'baby' that we were going on a journey today. She was going with me, and we were going to learn all we could about her baby. This required me to take care of her, so that she in turn could take care of her baby. She looked at me totally surprised and asked "why?" Laughing, I told her to smile, she had a baby, it wasn't the end of the world. I went out and reviewed my plan with my nurse who belly laughed and said "good luck". Ok..it was a little too cheerleader. After I packed her hemorrhoids, gave her breakfast and a motrin, I pulled out supplies, and told her to put her baby in the window near the light because he was looking yellow. While she did that, I asked her to take a shower. A shower to wash all the labor and delivery away. A shower to wake her up. She had no idea how much her life had changed in 12 hours.

I reviewed her chart. She had a history of a neurological disorder and learning disability. The flat affect could be slightly explained with the neuro disorder, the psych problems were situational. So, after getting a handle on her situation, I went back into her room to talk to her some more about her support system. She had no parents. Mom was dead. Dad was absent. Boyfriend was dysfunctional and abusive. They were living with his mother in what could only be equated to a double wide in a bad neighborhood. This case screamed for long term support. I could think of a handful of couples I know who would take her baby and raise it for her. She chose to do this, but I wonder for how long and at what price.

After talking to the nurses, they called social services, who in turn, came in for a second eval. The first didn't go so well. It was decided this time, the patient would get a public health nurse home health referral. Score 1.

Throughout the day, as I gained the patient's trust, we talked about how the days ahead would be for her as a new mother. What resources were available to her and her baby and where respite care and services could be attained. We talked about depression and abuse. She looked at me like my teenagers look at me when I am giving them a lecture, but while talking to her I did so more as a nurse who was also a mother. Her boyfriend and I talked about shaken baby syndrome. It all sounds so simple, when I say I told him "don't do that under any circumstances" but if ever there was a candidate for something like that, it was him.

Perhaps the connection for me was in the questions she asked, the suggestions I made that she obeyed. She got outside while her baby when to the nursery for phototherapy. She came back and watched all the instructional videos and she asked me questions. At the end of the day, she smiled and said 'thank you'. Score 2. I did nothing but get her out of bed and into her new life as a mother with a future paved with uncertainty. The rest is up to her.

L & D Day 2 - Standing O for the G2, P1.

Day 2 of L & D started out with hitting the ground running with an active labor admission who came in dilated to 5 cm. I knew I'd be around when the baby was born, so I got report, met my care nurse (who is pregnant) and followed her into our patient's room to meet our patient, G2, P1 20-something. The patient was side lying and comfortable - ready to get to work. Her membranes ruptured, so we did a quick assessment, got a bedside report from the night nurse and talked about was going to happen next. My nurse was a pro. Mostly I admired how calm and soothing she was the patient who was breathing through some pretty good contractions. Her quiet reassuring manner was what made her such a great labor nurse. After she checked her, she looked up and said nonchalantly, "we're going to get going, she's at 10 cm." Cool. This mom had an epidural but only got a bolus of anesthetic so she was feeling everything, nothing was running. We got her into good position and as she pushed through her contractions, I could see the baby's head crowning. The patient, while in a great deal of discomfort, was totally in control of how she wanted this birth to go. Within 15 minutes of pushing, the residents showed up and caught the 9+ pounder who was mad as hell at having his wonderful uterine world taken away from him. Head full of hair, plumpy thighs and big belly, he was only happy when he was swaddled next to, and latched onto his momma.

While I watched this young woman give birth, great admiration towards her kept coming out of of my mouth as I recalled my own birth experiences. Holy cow, this birth was one where the panel of judges would have stood up and applauded how the whole thing went from Triage to Delivery.

I was more of a wimp when it came to childbirth, giving up before the marathon even started. My kids came by NSVG, but not without Pitocin and it's friend epidural. Pain is one of the greatest subjugators. I witnessed something in this birth that reminded me of how nursing teaches the teacher more about herself than anything nursing sometimes is able to impart on the patient. I was humbled and privileged to be part of this experience of welcoming this new life into the world. Wimpy loved it. Whether we like it or not, our patients give us gifts everytime we care for them.

L & D Day 1 - Disparity is alive and well.

Labor and Delivery...where everyone comes into the world one way or another, whether you are at home or in a hospital birthing center. Without regard to race, religion, status...we all get here the same way. How nursing and medicine facilitates it though is a story worth telling. NSVD, C-section, or VBAC. Day 1 in L & D, I was told by my expert nurse to observe and watch what she/he does/did. "You'll pick it up as we go." Here is what I picked up Day 1.

Single early 20-something, hispanic woman G3, P1 versus married physicians, mid-30s, G1, P0. It's the difference between a having pillows tucked everywhere around your cute little petite pregnant form, being served a carefully mixed juice cocktail, snack box, peace/quiet, an early epidural and collection of classical music and discussing your goals for the day, versus "oh yeah, can you get her some water...I forgot about that...c'mon breath through it...you're up next for an epidural...make him (the offending boyfriend) wait in the waiting room. What's with all the noise from those kids? Sigh. Tisk Tisk. Irritation. Stomping around and then the pass off to another nurse. Once that was done, feeling better. More time to schmooze and discuss goals for the evening with MPs. Whatever you decide...if you wish...we can arrange for a (C-section). "You look so tired...so concerned. Can I get you anything?"

Yeah I learned so much by the afternoon. Disparity is alive and well in nursing L & D. The thing is, we are all guilty of it in one way or another, no matter who we are or what capacity we are serving within. It's the difference between taking care of someone you respect, and someone you refuse to understand.

Small miracles...big machines

List of things to do: orient at a new agency, watch moms before, during and after birth, take care of newborns, wipe the smile off your face. Maternity rotation started last week. Love this part of nursing school...play with babies, coach their moms, teach stuff.

So stinkin' cute I can hardly stand it. My first rotation was in the newborn nursery and I had a boarder baby. A boarder hangs out in the nursery when mom is not on post partum. My little male was the 2nd heavyweight champion of the nursery for the day weighing in at a hefty 4200+ grams. Since he arrived by c-section, his head was perfectly round, his cheeks perfectly plump and his thighs in the sumo wrestler genre. Heel sticks, supplemental feedings and assessments kept the day busy. Was able to learn about hearing tests and how they are done. Listened to the peds interns give their group report and bought a really cool adaptor for my stethescope from one of the docs who had an extra one. My little guy had a murmur best heard on his left sternal border, which is exactly where you can here mine from time to time. Hopefully his will go away as he settles into life. I did my initial assessment of him when he was 8 hours old and he was pink everywhere (even his hands and feet.)

Basically, babies love to be locked in and loaded up. My buddy was perfectly content as long as he was swaddled in tight and loaded up with food. Later that afternoon, while showing Dad all the neat things he had to look forward to, like diaper changing, holding and feeding, I took Baby D's rectal temp and he passed the last of his meconium, giving his Dad a big smile. Small miracle yes...but also a major machine!

Last Three Weeks of Critical Care

This is hard to write about it because the last three weeks were times of real discouragement for me in school. The whole time I was in school I felt uplifted in support by clinical faculty, care teams and friends. The last three weeks felt like a desert. I had a terrible midterm evaluation, a clinical instructor who made it obvious that she didn't care for me, and had a lot of sleepless nights worrying about everything; school, family, missed friendships, and second guessing whether I made the right decision to go into nursing school in the first place. There is this "myth" out there that nurses eat their young. For 3 weeks, the emotional toll this took on me made me rethink a lot of the optimism I had about becoming a nurse, how I could help people, working in a constantly changing environment and adapt to multiple personalities and temperaments.

Week three I went back to Tele (cardiac care) for two days and prepped on two patients. The first was a deaf patient with pneumonia and the other was a late Friday afternoon admit, whose records were still being assembled while I prepped on him. I made as many notes as I could gather assuming I would finish all my history gathering the following day as I assessed and care for him. Since things change so fast in tele...we always risked full preps on people who might be discharged the next day. This always happens with me, regardless of the acuity level of the patient, and as I arrived on the unit the next day, the care nurse told me that she was orienting a new nurse and to essentially stay out of the way. Nice.

My 2nd and 3rd patients were interesting. One needed an adenoscan. Went with him to see what that was all about and decided that if I ever needed one of those, I would not consent to one. Essentially, adenosine chemically induces the effects of running a marathon while you lie still. My patient freaked out. As I tried to reassure him, he looked at me like I pulled fast one on him. The first patient I was supposed to care for, but ended up deferring to the new orientee was just a little too active for the care nurse so she asked me to restrain him. As I zipped up his vest, he looked at me and said "no, SN not you!" Feeling like 'one of them', I cried in the shower that night. Seeking refuge with a little sweet old lady who need ortho HTN vitals done, I rounded out the day talking to her about books we both loved. After renal diet teaching and discussing the importance of medication compliance with my young dialysis patient, I went home to update all the care plans..four pounds of paper later...zzzzzz.

Week 4 was in ICU: My patient was in respiratory failure. My nurse was a tazmanian devil and really sharp. We had a loaded unit with two suicide attempts. My patient's family reminded me a lot of my own. They were there all the time. Dad was really struggling with breathing and as we tried SAT and SBT trials to wean him off his vent, I witnessed the most rapid respiratory failure I had only read about in books. Being Sunday, all I could do was pray hard that we could keep him calm while the RT fetched the BiPAP machine. Holding this guy's hand, it felt oddly familar. That weekend wiped me out.

Weekend 5 was full prep with two patients. One had a decub that wiped out his heel at a SNF. Seeing someone with DP pulses and missing his heel tissue was another one I thought I'd only see in the books, but SNF neglect still happens. Boatloads of meds. I enjoyed getting this guy up in a cardiac chair with PT and giving him my farewell speech. We both knew he was going to lose his lower leg two days later in surgery - I tried to equate this with the problems my own father had following his hospitalization and I demanded this patient keep his gym membership and never give up. Everything about recovery is in attitude. He had several rough months in a SNF - he could make it. Shaving away the last remnants of his beard, he laughed at the amount of cream I put on his face...we had to laugh. There was so much to cry about.

As I left that night. I was sad and tired. Spent and frustrated. Second guessing everything. This was the hardest part of school for me. The biggest learning curve and the most difficult to navigate. My CI gave me my final review and I passed. For some reason, I was numb. My clinical group all made it. But we all had that same worn torn look of fatigue.

Are you still here???? Yep! Wouldn't miss it!

My partner & I arm wrestled for a CRRT trauma crush patient last Friday. I had first choice the weekend before so she took him. The next highest acuity patient was in the room down the hall according to the shift charge, so I grabbed the chart and started to prep. While prepping on my patient, I noticed the neuro doc stopping by to meet with the family. The code status was downgraded from full code to DNR. My patient 'Pebbles' had a brain aneurysm that ruptured and she was not doing well after surgery. I finished my prep at midnight and went to bed. The next morning I arrived to find that she had died two hours after I left the hospital. Picking a new patient, I got report, started reprep and began to take care of a patient with a brain mass, status post surgery, ventricularostomy and ICP monitor. I learned about calibrating his arterial line and ICP line, how to monitor intercranial pressure and doing frequent neurological assessments. My patient was affable, talked a lot and was very alert and oriented to his situation. I hung several IVPB medications and took care of his needs for the day. I was able to take out his arterial line, foley catheter and get him out of bed several times to assess how intercranial pressure would be affected with increasing levels of activity. Learning about brain compromised patients is fascinating and exhausting at the same time. I finished his care plan and helped with other patients on the unit. My partner's patient had a Swann Ganz line and an expert on the line taught us about it as we looked at his monitors.

In the midst of caring for this patient, my care nurse had a patient who also had a stoke, whose family withheld treatment. In that regard, we were providing comfort measures to him. His lungs were filling with fluid, so I was able to help suction and clear his airway to ease his breathing and offer reassurance. By the next day he was gone. Two patients in one weekend. ICU is fast and furious in one respect and slow and intense in the next. The contrast in the ICU was black and white. Such differences with each patient.

On Sunday my happy patient was downgraded and I re-prepped (again) on a new admission from a motorcycle accident who had broken his femur and ribs. He had a chest tube and his leg was pointing in several different directions in a Bucks traction device (something invented in the Civil War - much like a weight and pulley system) that stabilizes the bones and joint while the patient waits for his surgeon to fix his leg. I was able to do some patient teaching on pain management using a PCA device which is a button system the patient uses to deliver his own analgesics. Assessing his breathing was interesting. When someone has a pnemothorax (collapsed lung) due to trauma, their breathing sounds like hiccups..short inspirations which are cutoff midway. I made a bath blanket splint which he could use when he felt the urge to cough and help ease the pain from his broken ribs. We talked about his surgery and a few of his friends came to check on him.

That afternoon I went to the OR with my patient and watched his surgeon prep him and open his leg at the thigh. What resembled a car (up on a jack), ended up being huge rods, nails, pins, and drilling sounds with hydraulics set against the sound of Enya playing on the surgeon's IPOD. I saw more blood with this procedure than I saw with my previous OR rotation ( thorocotomy, total neck and ventriculostomy)...the blood was all over. Everything was done with X-ray for placement so we all had to wear to protective aprons in addition to our OR gear.

In the middle of my patient's surgery, one of the OR nurses came in to grab me to help with a trauma coming in (a self inflicted gunshot victim who had severed his popliteal artery which was being held closed with an EMT's finger ETA 8 minutes)...while the room was being prepped, I sterile gloved and waited with my heart racing as to what was going to show up. (Apparently, not realizing while cleaning his gun, a bullet was lodged in the chamber, it fired into his leg...owwwie)

As they wheeled in the man, his clothing was being cut off, I grabbed all the gurney materials, clothing and bags and sorted through the bloody mess to get the patient belongings into a separate bag. Throwing the gurney back into the hallway I re-gloved and went in to assist the prep. The patients legs needed to prepped and elevated for sterile wash and possible vein grafting. I had one leg and another nurse had the other. It felt like each leg weighed about 100 pounds each. 10 minutes later, the surgeon was there, draped and cutting into the leg to secure the leg to repair the artery. The anesthesiologist was the same one I had observed with my OR rotation and I was amazed at how fast he was able to get this trauma patient under and intubated.

With the muscles in my arms still shaking from holding the gunshot victim's leg up for so long, I walked back to the other OR to check on my patient who was coming out of OR and going back to ICU. I escorted him back to the unit and with my care nurse, completed the PACU assessments in the ICU, which involves assessing all his vitals every 15 minutes, getting blood samples and cleaning him up after surgery. My patient had been intoxicated when he was injured. Earlier in the day we talked about drinking and driving. My patient verbalized how fortunate he was to be alive and that his friend (riding on the rear) had not been seriously hurt. You wonder if it is a wake up call or a pattern of risk taking that will eventually catch up to the patient. We are there to treat and teach.

As my patient woke up, he looked at me and said, "Are you still here?" "Yep!" Wouldn't miss it!

Welcome to Neuro Trauma Intensive Care... Roll with it baby

Web photo courtesy: (Hartford Hospital Images)

Excited about the prospect of critical care for the weeks leading up to it, the 4 days prior to prep were nerve wracking to say the least. We finished last semester after being in a comfort zone with theory instructors and clinical faculty that I came to depend on. You go into this learning curve which I liken to a roller coaster; already defensive, the next loop might be the one you totally barf on- because so much time, resources, blood, sweat and tears is invested into the venture of this type of learning. It can be disappointing to be treated like you haven't worked hard enough, long enough or know enough to be successful.

I went to prep as early as permitted on Friday (just knowing how slow prep can be for me). I tried to pick the most complicated patient based on the recommendations of the ICU RN in the unit at the time. Little did I realize how fast some of these patients turn over either to a step down unit, transfer to med-surg, home or sadly, to the morgue. So, I wanted someone with airway problems, perhaps some brain issues and maybe some renal stuff..so that it would be complicated enough. Sure enough, my patient had a brain bleed, he had a craniotomy and a ventriculostomy (both of these surgeries were procedures I had seen on OR rotation, so I was excited about taking care of a patient post op in the ICU. This patient had airway issues too, with failed mechanical ventilation, a relatively new tracheostomy (something I already had experience with)...and renal compromise because I saw they were doing a 24H urine collect on him and I knew he'd be around for the weekend....it was that or I was looking at taking care of a patient with a hip fracture. Been there. Done that. So, I thought I had a good one.

Knowing how much of his care was multi system, I went to my old friend (Lewis textbook) and started looking up care plans for inter cranial bleeds/increased intercranial pressure..management of trach patient and (oh, my patient was also in DTs for ETOH withdrawal, so I had resources there). What amounted to be a NANDA compliant, medication compliant (I had 7 pages of medications I had to reconcile) and also look up this patient's labs and diagnostic studies, ended up amounting to an 11 hour prep including time in the neuro ICU making sure I had all the information from his chart that weighed about 15 pounds...head home...and 8 hours at home all night. With my own brain function ceasing at midnight, I collapsed into bed, a complete insomniac, because I was trying to remember the sequence on the crash carts. Imagining I would surely be working a code (the imagination runneth). In addition I was looking at neuro trauma information on the web from allnurses.com and trying to be sure I brushed up on things in case the docs caught us off guard. We hadn't worked 12 shifts yet and this was going to be a new first this weekend. So after drifting off at 1:30, I remember I hadn't done a patho-map (the one thing I've NEVER been good at doing well)...so I went to concept mapping (saw "uncontrolled HTN")..wrote on it that it was draft and I would do a real one the next night after I met and assessed my patient. (Note: We can't show up to clinical unless we have something...I had to get up at 5 AM to be at clinical by 6:30 AM). I dropped off to sleep at 2:45 AM and the alarm nudged me at 4:45. I shot out of bed like a cannon ball, showered, gathered up my stuff and headed out the door to find an open coffee shop. With 3 shots in my cup, I got to the hospital early, met our new group in the lobby and met the first of our two new CIs (clinical instructors). We went to our assigned units. My buddy and I headed up to Neuro Trauma, to get report from the night shift and meet our care team.

My care murse (male nurse) was a staff III nurse. We had a great day. He was very experienced, had a wealth of knowledge and allowed me to ask a lot of questions. I was able to work with my patient a lot and he gave me the space to also work with the patient's family. One thing I immediately noticed was how much my patient had improved in the 24 hours since I prepped on him. His ICP monitor was out, his NG tube was out and his trach was being weaned. I was able to take out his foley catheter, get his head shaved completely..because believe me, it looks kinda ridiculous to have half your head shaved and the other lookin like Bozo the Clown. He now had a nice Daughtry-esque appearance that made him more comfortable in bed. I did my neuro assessments and head to toe assessment and watched how my care nurse charted on the new flow sheets. I gave a lot of meds, changed EKG pads (because how else could my patient be smiling and in asystole at the time) and then watched how everyone else around me adjusted to life in the ICU. It was impressive. My buddy pulled an ICP, inserted a NG and did all kinds of cool stuff on her patient who was coming off a dirt bike trauma. The hours passed and I think I got home around 8:30 PM. I had been up since 4:45 AM.

I left the shift utterly exhausted and went home to hand sketch my pathomap with colored pencils and a sketch book pad...I updated notes on my care plans pertaining to my patient, logged med reactions, made sure the lab results were updated and did my self-evalution..After all that, I went to bed at 1:30, only to get 4 hours sleep and then rush back for day 2.

Rushing to the hospital, I made it in time for report. Different care nurse. Different clinical faculty. My patient looked great. We were able to repeat a lot of day 1, activities, plus shave his face and get him bathed. My second CI dropped by to look at my paperwork and asked me a couple questions about brain hemotomas and ACE inhibitors. Not knowing too much off the top of my head (at hour 5 of 12), I went to conference with the answers and decided I liked this style of teaching and interaction. She wanted to get to know us better and allowed us to say a little bit ourselves to her. She also passed around a bag of chocolate. We went to skills lab and reviewed a few things about different types of med pumps, and looked over the crash cart again for a quick brush up. I actually left this shift totally spent ,but relieved that I survived. I liked the high acuity level, respected the nature of people's perspectives and differences of opinion and learned a lot. Most importantly, I gained my patient's trust.

On the way out the door, I stopped by the floor where my patient was moved (as he had been downgraded - meaning he was improved enough to be off ICU) to say goodbye. It was sweet to wish him well and say goodbye, plus it was rewarding to hear a little gratitude from the patient and his wife for the 24 hours we spent together. Nursing is an intimate relationship that starts and ends quickly between a nurse and patient, but leaves an indelible mark on both.

Expect anything and roll with it. I guess I just want to be a nurse.

Week 10 - MCA II Finale - real cute boy

Picture: Courtesy of the Web: National Association Down Syndrome - Adult Center)

We rounded out our medical surgical rotation with a nice little final exam on ICP and other complications from neuro trauma and the like (truly you don't want this) and we had a wrap up in the other classes with presentations and potlucks. I'd collapse in bed at night ...wishing for the end of term.

Clinical found me in the Med Tower with a leukocytosis patient with very loose stools. Nursing students somehow always manage to end up with these patients. I haven't had one until my last rotation day. I guess I was saving the best for last.

As I completed his assessment he asked for a hug and told me that he was a 'real cute boy.' How could I disagree? My patient was a middle aged adult with Down Syndrome. I practically pulled the rug out from under Trudy to get this patient. I have a real fondness for my friends with DS. Giving him a hug and holding his hand, I let him listen to his own lung/heart and bowel sounds. He had ticklish feet and the assessment felt like a fun little game, rather than a chore. Even when feeling like garbage, my patient was happy, albeit in a sore, dehydrated and slightly elevated temp sort of way. He didn't have a care in the world.

My last hours in MCA II were spent watching Bonanza with him and cleaning up some of his 'loose ends' ~ For some reason, I managed to go an entire 10 weeks without a single splash down until the final day. As Trude fetched me some linens and pads (probably relieved that it was me dealing with this for a change) I was intrigued with the notion that I didn't mind how unglamourous it can be (sometimes, it is dirty work)..but there we were -chatting up a storm about Hoss, Little Joe and Pa.

He giggled and laughed about everything and nothing at all. The 7-up tasted good. The rash hurt, the wash cloth felt good. The incentive spirometer was an exercise in futility. I think I needed it more than he did. I charted and tried to figure out what I could do about the perianal rash that was developing due to the two day advent of acid laden loose stools. After a nice paint job with barrier cream, we talked about friends and how everyone had nice eyes, pretty hair (especially care nurse Jaime). We talked about eating slow (I should really take my own advice) and not eating so much. He wiggled his toes, sat up in bed and wanted more 7-up. I remember thinking that the idea of 7-up sounded so good....

I think it was rather cathartic to end the term on this happy note...a pretty rank and dirty splash down...strip bed, paint job, one med, a couple hugs, ticklish feet and a real cute boy.

Bless your heart buttons...

Back to oncology this weekend. I had picked two patients on Friday- that one of the AM RNs said would be around for the weekend. One had INR issues and the other was supposed to have a chest tube inserted so she assured me they wouldn't be discharged. I prepped on both and discovered they both shared virtually the same diagnosis...malignant cancer of the lung. One had a stage IV pleural effusion that needed to be drained. The other was coming off chemo with a persistent fever of unknown etiology and needed to be stabilized before his next round of chemo.

After prepping on my patients, I knew I was going to learn a lot this weekend because one was a retired health care professional in a specialty that involved his own diagnosis, and the other was an independent retiree who reminded me of my dad. Nothing was keeping "my guys" down. They had loving, well educated spouses who had been married to them for over 40 years. One of the spouses was a retired ICU nurse and the other was a fireman's wife.

These men both enjoyed long fulfilling careers in their fields. They were fighters through and through. The medical guy knew exactly how things were going to go for him and he taught me a couple things I'll never forget about respiratory assessments particularly. For example, he suggested that the best way to ausculate the lung fields is from the back side and if you ask the patient to say the letter E with each field through all the points of ausculation..and it gets to a point where the E sounds like an A...that's the point of effusion in the lungs and you can mark it with a pen. Since he had a chest tube inserted, I got him out of bed and tried this technique. My care nurse and I were both amazed that the E does sound like A..and we didn't need an X-ray to know where the effusion was in his lungs.

It is difficult to explain what it means at the end of the weekend when you are either discharging your patient home to an uncertain future of months or days or whether you leave them not knowing if they will be back next week because of an infection or recurrence of their symptoms. I always try to say goodbye to my patients because the time spent changing their dressings, assisting with personal care, medicating them, injecting them or teaching them something important about their care, is a time when a bond of trust is established. I feel the same way about the families who stay with them. When I left Sunday night, I knew my 'teacher' wouldn't be there the next day. He made eye contact with me, wished me well with nursing school and we bade our farewells...he might be back soon because his diagnosis is terminal, but knowing him, he will prefer to be at home when that time comes. It's the kind of person he revealed himself to be and I was certainly humbled by the inherent dignity our patients possess when they are the most vulnerable to us as nurses. I was able to medicate him, obtain cultures, humidify his oxygen and change his chest tube dressings. The best thing I did for him however, was switch out the remote control on his television set. He went a whole week waiting for one. Mostly, nursing is about listening. I haven't always been a great listener...because I like to talk. I am learning to be a better listener.

One LOL (little old lady) was on my unit this weekend with an acute bout of pancreatitis. I could read the body language of her son, who was irritated to be summoned to the hospital and it made me mad because he wanted nothing to do with her. As I took out her IV, she rubbed my arm and said "Bless your heart buttons." She was a dear. As a total stranger pulled up in the Lexus SUV to pick her up to take her back to the board and care home; they wanted us to scratch off the prescriptions we transcribed and phoned to the pharmacy, because they didn't want to pay for them. I knew the sweet LOL wouldn't be getting half the medications the doctor ordered for her because they owner of the board and care wouldn't pick them up at the pharmacy. As she waved good bye to me...I wished in my heart that her son would care enough and that she would never realize that he didn't. Bless her heart...sweet little button.