Nine months of labor....

It's been about 9 months since I've written anything partly due to the sheer exhaustion of job hunting and partly due to the nuances of working full time as a night nurse...it took about a month and half after passing boards, but I landed a job, thank God (which by today's labor market for new grads, was lightening fast!)

Acute medical surgical telemetry...which means you get it all. Sick, sicker and sickest. Sepsis, pneumonia, post ops, chest pain, GI bleeds, MRSA wounds, vacs, UTIs, psych, dementia, DTs, knees, hips, pelvis, abdominal this and that, and an occasional prolapsed anything. Atrial fibrillation, PVCs, bigeminy and an occasional third degree block. This is the menu on my unit and there is always something new. In nine months, I have only seen one patient who had a family member present at the time of death. Every other patient died alone, except for their nurse who is always present.

Working nights, I have lost contact with a lot of my daytime friends and family. This is the only drawback, otherwise I have adapted to the changes in sleep, because my family has made the adjustment with me. We have a do not disturb button on our house phone and since all of us have cell phones now, we don't miss the ringer on the house phone. When I started working noc shift, I marveled at my co-workers ability to eat anything in the middle of the night, but within 3 weeks, my body clock shifted and I found myself famished at 0200. I usually wake up at 1600-1700 without any breakfast pangs and then force myself to eat something before 1900. By 0200, I am hungry. I eat one more time..usually at 0800-0900 and that is it for my work day. I eat twice per day. As a result, I lost about 20 pounds since starting work. It is so strange what your body does to compensate for the shift change. I wake up in the middle of the afternoon after working all night and the first feeling of disorientation is so strange (i.e. where am I, what time of day - should be morning but my brain realizes it is late afternoon, early evening) Some days, after working three 12 hour shifts in a row or an occasional 16 hr shift, I will wake up at 2100 (9 PM) and stay up all night. It's the most surreal feeling to live and work like this when your family lives on an opposite pole. I noticed during the holidays, everybody shifted to my schedule and stayed up later and slept later...so we could spend more time together.

I can say with certainty that I have no regrets about becoming a nurse. It is the hardest, most rewarding career. Everyday is different. After 9 months of labor, I still feel like a baby. I have wonderful colleagues who teach me something new all the time...it's a wild ride worth taking..and I hope I still feel this way 5 years from now.

Now what?

"So, Mom, did you get a job today?" greets me daily when the kids or hub arrive home from work and school. Looming on the horizon are several things that have me excited and terrified at the same time. One of the kids is graduating high school in May, heading off to Europe for month a half and is hoping to go to college out of state in the Fall. The middle child wants my car, literally. The baby isn't a baby anymore and I am weighing whether to send her to private school. So, in lieu of the hopes of dreams of three older children wanting to spread their wings, is a new nurse mother desperately trying to land a position as a nurse, somewhere...anywhere...hello nurse shortage, I answered the call ~ are you there?

I have applied for 150 positions. Five are in limbo someplace between recruitment and management and no interviews yet. I have tried calling, emailing, facebooking, and physically driving to see nurse managers. The words "new grad" taste like poi at the Luau. You know you have to eat it, but it doesn't taste good. How much can one emphasize one's maturity. Just look at me.

I have modified my resume 20 different ways, and yet the phone doesn't ring. In the meantime, I am selling my nursing books and homeschooling books. It is keeping my mind off the fact that my phone isn't ringing, and will hopefully buy my oldest a round trip ticket to Europe for graduation. I have a lot of books.

In the meantime, my suit is pressed, all my paperwork is in order, my license fresh off the press, and certifications updated for basic and advanced care life support. What more can I do? I have thought about catering lunches for units looking for nurses; seriously gone are the days of signing and referral bonuses. Whining.

Patience, I know. I think pray, hope and don't worry. Ok. Loans come due June 30...something has to happen before then. I'm better than poi.

4 AM....Train pulls in...

2 AM: I checked the BRN page and the system was starting it's update. I went back to bed. My stomach has been hurting all weekend.

4 AM: My husband gets up and goes out to the family room. He comes back into the bedroom and says you might want to come see this. I stumble out of bed and look at the computer. Beautiful sight after 30+ years of imagining..and 3 years of hard work. My nursing license. A train never looked so good.

NCLEX..waiting for my train to come in...

Nothing can prepare a nurse graduate for Boards and how you feel after you take them. In my mind, I envisioned hours of testing,thinking about the nurses who took paper pencil tests on every aspect of nursing from neonatal to geriatrics.

My boards were over before they began. I had taken a Kaplan prep course to practice questions and brush up on content I might have missed in school. I did everything Kaplan required and then got utterly tired of doing questions. I simply couldn't do another Q-Bank. I stopped the day before to rest and ended up getting a pedicure and massage. I went to bed early, thanks to Melatonin...and woke with the roosters.

Packing a bag of snacks, eating breakfast, two cups of coffee, listening to happy tunes, saying my prayers. Checking in. All these things I imagined. Then I took a couple deep breaths, put in my ear plugs and began.

Question 1...nothing looked familiar. Question 2....I don't know and so on..This went on for 80 questions and then the CAT screen went to black. What the hell? What just happened? Did I answer those correctly or did I just throw three years of schooling down the toilet?

I don't know...it felt awful. It was surreal. Two other classmates where there taking at the same time and they experienced the same reaction. How can this test that I just took in 2.5 hours determine if I am competent to be a nurse?

This is day 4 of my wait. I don't know what is next. I have 45 days to retest. If I didn't pass, I wouldn't even know where to go to resume studying. Is this the last bit of torture, or is just the nature of nursing..to always be exhausted, psychologically tested and wondering where you stand.

In the meantime, I am standing on the platform, waiting for my train to come in.

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.