behind these walls

On the ground floor of UCSF Long Hospital, down a hall, around a corner, down and then up an oddly placed ramp is the Endoscopy unit.  The end of this meandering route couldn’t me more an appropriate location to perform the unique spelunking procedures navigating the caverns of patient’s bowels with a sterilized endoscope.

The unit has a factorial efficiency, with a large room used for admission preparations and recovery monitoring.  There are four procedure rooms where the physicians will send the scope down the throat or up the bottom to explore, take pictures, or biopsy with a claw-like jaw that slices bowels bits.

I had the pleasure of observing four separate procedures and as I hopped from room to room, seeing open throats and exposed behinds I was mostly amazed at the unique expertise required of the endoscopy physician jumping from room to room, arriving after the patient has been sedated and therefore blessed with a limited experience of patient interaction made primarily of a Blair-witch style camera view of the patient’s innards.  These physicians have invested a good 10 years of their youth in an academic career to end up being camera wielding bowel spelunkers.

It is hardly admirable or glamorous and I’m sure that the repetition hour after hour, day after day, has numbed them to the strangeness of what it is that they are doing.

there is a first time for everything

Scanning through the pages of this blog, I observe a catalog of new events that will one day, with practice, become second hand.  As is certain of time the habits of my practice will fail to inspire the reflections I chronicle here because with habit, all that is novel will certainly lose the luster inherent in the freshness of new experience.

However, I’m hardly at the point where I’ve grown fully accustomed to all the practices and skills required for nursing care.  I must admit that my sage like introduction above is partially a ruse to segue into a discussion of a first-time experience that many will find vulgar and disturbing.  So, if you have small children listening in the room you may want to turn down the volume.

I had not expected to begin my day giving a suppository to a 66 year old woman.  She had had a kidney transplant three days prior, was taking on a lot of fluid, had not had a bowel movement, and needed the help to get things going if you catch my drift.  Sure, I knew that giving a suppository would be an inevitability in my nursing career, but fingering a stranger’s rectum didn’t give me the same excitement I got when I first drew blood.   Of course, living in San Francisco I’ve stumbled upon many a conversation that celebrates such an act; however despite the propensities of my environment that realm of the human body hasn’t really interested my youthful explorations.  I don’t mind if you can call me old fashioned, I am who I am.

So, of course I had a little anxiousness about my first exploration into the nether world. It was even more awkward considering that my broken Spanish and her broken English were the only words of tender communication we could share to explain what I needed to to do to her.  Getting her onto the bed was easy, as was getting her to roll on her side to expose her bottom, but then I had to roll back layers of flesh to find the spot.  While holding onto the lubed up slippery little devil, I placed my finger up into her, completing my brief mission.  Despite the clumsiness of it, as I reached around to find the knuckle-length distance where my finger and the suppository would part ways, I was overcome with a strange sense of peace having performed this act.

There is a unique trust that is placed in the nursing role.  If this woman and I were found on the street in our daily clothes, I would be arrested or shot for such a violation.   But here, in this place it is permitted and accepted as a necessary intervention to improve the woman’s health and well being.  She in her gown and I in my scrubs are different people than we are walking the streets of the city.  We have defined roles, and the role of the ill accepts the role of the health-care provider to conduct intimate and profound acts because the foundation of that acceptance is a hope that the interventions will improve their health and change their role from being one who is ill to one who is healed.

The novelty of performing this act will fade as my future self will have performed it hundreds more times. However I won’t forget her, and I won’t forget that what I do in this profession is done because I too hope that people such as her can reclaim the dignity found in a healthy life.

there’s no pill in team

This past Monday was clearly my most frustrating day on 9 Long.  Although both of my patients were easy going and I felt that I had developed good time management with two patients and even felt ready to take on a third, the frustrations were from the lack of teamwork that I experienced with my partner.

This RN named Getrudes was independently motivated and not very adapt at being a team communicator.  It became apparent that she had a routine that may make her a very good and efficient nurse, but not a very good nurse educator.  She was very focused on giving medications within the first half hour of the administration time of 0900 and it seemed that being on time was much more important than allowing me to learn or practice care.

Having prioritized the care of my two patients, I already had a plan for my medication administration that didn’t really jive with Getrudes’ agenda.  One of my two patients was eating breakfast late, so I was holding off on giving his medication until 0845, which seemd fine, because I wasn’t going to give my other patient his medication because he had a fever and needed Tylenol, but could not receive his Tylenol dose until 0915, since he was on a 4 hour limitation.   By time I finished with the first patient Getrudes let me know that she had already given the patient with the fever his medications.  This was completely contradictory towards the plan I had set out and communicated with her.

What’s worse it that it wasn’t until almost noon when I was giving this patient his additional medications that I realized that he had not received his Tylenol.  This was very frustrating because I had a plan of care that was curtailed by the other RN’s agenda and poor communication.  Now this patient was running an increasingly higher fever that could have been addressed much earlier if the RN had properly communicated with me.

Second case in point: the doctor’s rounds for both patients were both near noon, however Getrudes pulled me away from participating in patient #2’s rounds to give patient #1 his 1200 glucose check.  I found this unnecessary because I had already learned that this patient was a slow to start eater, preferred to walk before he ate, and had not yet had his walk because the doctor’s just complete rounding on him.  The task-oriented practice of giving medication or performing interventions on time doesn’t always fit with the patient’s specific needs.

It seems that the biggest lesson I gained from the day was that I had to double check my own work, double check the patient’s charts and medical record to verify what has been done without my knowledge, and maintain frequent communication with my patients to identify what interventions the other RNs may have already completed without my knowledge.  I suppose that the day was a nudge towards my own independence.  I’m grateful that I was paired with this RN this late in the semester and not the first few weeks because I would not have had the skill or knowledge to walk away from the day with anything more than frustration.

paranoia draws the line

This past Thursday morning I received an email from the nursing department that the SF Department of Health was providing the H1N1 vaccine at select clinics distributed throughout the city.  Having been told multiple times by my instructor that this was a requirement for all health care providers, including students, I made plans to go the closest clinic that evening since the vaccine would only be available Thursday, Friday, and Saturday.

When I drove up to 24th Avenue and Judah, I was prepared to wait in line for at least an hour, but in no way was I prepared for the mobs of people lined up around the block.  It wasn’t until later that evening that I learned that some people had begun lining up as early as 8 am to secure their vaccine dose.  If I knew that before I parked my car and got in line I would probably have given up and gone home, but it was a beautiful day, and I had my books with me to study; standing up outside or sitting down in a cafe, I would be doing the same thing: studying.

I had gotten in line just before 4 (when the clinic was supposed to open) and promptly at about 4:05 there was a jolt in the crowd like a car revving into gear as we felt the first movement of people enter the clinic around the block.  However that first jolt became a distant memory as 4 turned to 5 and I hadn’t moved more than 300 ft.  By that time I knew I was going to be there for the long haul, much later than the 7 pm closing time that was originally posted.

Most of my neighbors in waiting were families with small children and I found some amusement watching the kids making friends with their line buddies, running around to pass the time with innocent glee.  As I watched them, I wondered what association these kids would develop with lines after they had spent precious hours of their short lives to not ride the Matterhorn but to receive a needle in their arm.  Would their future selves harbor an unconscious fear of lines that caused them phantom pain in their deltoids?

As 7 pm rolled around and we had made it up 25th and onto Judah, I was surprised to hear a man yell, “Pizza here, come get some pizza if you’re hungry!”  Someone had ordered delivery of 12 pizzas to share with his fellow vaccine seeking victims.  It was just in time too, because I could see the hunger in the empty, eager little bellies as the children ran to get a slice.  Simple things like that man’s generosity are such a beauty and mystery.  I found it ironic that just 10 minutes later we were ambushed by some opportunistic proselytizing Jehovah’s witnesses; it was apparent to me who really carried out the mission of Christ that evening.

When I finally reached the clinic at 8:45 I never thought I’d be so eager to get a shot.  I really just wanted to sit down and rest my feet.  Why was I doing this crazy thing? Why did so many people set out on this evening to receive this vaccine that for all we know, may not even be effective?  Was this paranoia, collective hypochondria, or have we all been duped into some dubious hope that we were dodging this latest disease?  I don’t believe that these people were fools; the display of patience and desire was a testament that a portion of the population believes in preserving their health and is willing to invest hours of their lives to curtail the days and weeks that could be potentially lost if they were to come down with H1N1.  However, this reflective perspective may be skewed as I struggle to place value in my patience.  I’m aware that I was in that same line, giving 5 hours of my life to the foolishness of hope.

can you just shut up

She’s screaming for pain, her abdomen is distended, the phone is ringing, there are STAT orders for a blood draw, and the previous shift is giving a broken, abbreviated synopsis of what little information they know.  This is going to be difficult.  My partner and I look at each other with disbelief.  As the patient moans I answer the phone, it is her daughter and she wants to talk to her mother.  I hand her the phone and all she can grumble is that the stupid nurses can’t do a damn thing for her pain.  I review her medication orders and see that she can receive 2 mg of morphine every 2 hours.  The prior shift had indicated that they had given morphine but they didn’t say how much, and they didn’t document it in the record.  Shit.  I place in a page to call one of the two prior nurses and over the phone I get broken information that they gave “half a vial,” well that would be about 1 mg, so I determine that she can get more morphine.  She’s crying and moaning and I know I need to give her the morphine through one of the two IV lines to calm her before we can ever get the gastric suction complete.  And then just after the morphine and the blood draw both my partner and I are interrupted by two new nurses who tell us that we have to go to a staff meeting and they are taking over.  I communicate how much morphine has been given by myself and the prior shift and show them the medical record, indicating that no matter how much the patient screams and hollers, she has already received her maximum dose and should not receive any more.

And just like that, as quickly as it started it is over.  My partner and I exit the room and go into the anteroom were we can see the next shift perform their duties through the one-way mirror.  This was all a scenario with a mannequin patient hooked up to a computer.  There were 4 teams of 2 students working together to deal with this troublesome patient. With 15 minutes each we could hardly get through the orders with all the distraction of the patient’s yelling and the phone ringing. As the six of us watch the last group we see Michelle prepare another injection of morphine, what, no! I told her explicitly not to.  She gives it to the patient through the IV.  We all watch the pulse and blood pressure drop on the monitor, and then Michelle and Angela’s faces drop too as we can see them realize what they’ve done.

After it is all over I ask Michelle why she gave more morphine despite my direction to not giver her more and Michelle explains that the patient was screaming for more morphine and the doctor on the phone was yelling at her to go ahead and administer more because the patient was obviously tolerant to the drug. We later learned that the drug was sitting in each of the two separate IVs and that when Michelle flushed the lines the patient received a triple dose all at once.  Thank God this wasn’t real life! We collectively damn near killed this patient. Of course the scenario was set up to challenge us and we all learned from the hectic hilarity.

In reflection, I wonder about our quickness to give pharmacological relief to this patient’s protestations.  The patient’s pain would have been relieved much earlier if we just performed the suction to remove the fluid that was obstructed in her bowel.  All eight of us were quick to appease the patient and give the morphine and even the doctor that was screaming at Michelle on the phone was adamant that more medication was the only way to alleviate the patient.  I know that in my own head as I was preparing the morphine I was looking forward to the quiet calm that would follow after she received the dose.  It was difficult to focus on anything other than trying to get her to shut up and I wonder if administering the morphine was more for my benefit than the patient’s.  Isn’t it easier to deal with a doped up patient than one in pain? I wonder how often does this mentality infect the real clinical setting and how it can alters the level of care provided to the patient?

great balls of fire

The evening nurse that handed off my patient had mentioned a vague warning about the extent of my patient’s ascites and swollen sctorum, but this verbal communication had not prepared me for the visual discomfort that would overcome me when I performed his morning assessment. When I pulled back the sheets to inspect his abdomen, it was swollen to a good foot and a half the size of the scrawny man’s expected girth.  But that was just the half of it: when I pulled the sheets lower I was inexplicably surprised at the size of his swollen scrotum.  It was literally the size of a a football and was swollen beyond recognition of any resemblance of a male sexual organ.  It was a single “ball” with a catheter extending from an unrecognizable penile orifice. Not only that, but I had to adjust the “walnuts,” as he referred to them, to prevent a pressure ulcer from developing in the swolen sack of nuts.

The sight was unearthly, strange and the feeling of that football sized sack of fluid in my hands was frankly, just dumbfounding.

How could this man live like this? Well, one unfortunate symptom of liver disease is “third” spacing, where water flows from the vascular space (the veins and arteries) into tissue due to imbalances in the proteins that the liver produces.  This man had alcoholic cirrhosis, and was being treated for TIPS, a procedure reserved for patients that had less than six months to live and were awaiting a transplant.  Knowing that his condition was induced by a life of alcoholism, I couldn’t help but wonder how anyone, even an alcoholic, could allow their disease to progress to this extent.  At what point does the disfigurement of something so near and dear to a man prompt one to seek treatment?

For the first time in my program I have felt squeamish.  I know that this feeling has a lot to do with my own sense of self and manhood, in a cathartic form of self-preservation.

the sound of metal on bone

Peering into the window of one of UCSF’s many operating rooms, we could see the patient lying on the table, hip fully exposed.  The sight of the exposed muscle and and bone just 10 feet away was exhilarating.

And then the surgeon began hammering at the hip: clink, clink, clink.

The sound of metal on bone was undistinguishable from any other sound.

I turned to look at my classmate and friend Ryan and knew that the glee I saw in his eyes could be seen in my eyes too. This was just our introduction to the OR, a brief 1 hour tour to orient us to the layout and protocols.  The brief exposure to an actual surgery made us giddy with excitement for the day we would be presented with the opportunity to witness an entire surgery.

A lot of people are uncomfortable with the sight of blood or the thought of body fluids, let alone the invasive exposure to a surgery.  I notice this apprehension most clearly when I go to work on Tuesday, the day after my hospital clinical.  My colleagues will ask me, “how’s school?” and I’ll share my excitement of getting to do new things like drain a chest tube, give meds through a nasogastric tube, or draw blood; however my excitement is usually cut off with trepidation by colleagues when they say, “Oh, you can spare me the details.” … pause … “I’m happy for you.”

I wouldn’t be pursuing nursing if I didn’t have a sense of comfort with the macabre.  I’ve always been interested in the mystery, miracle, and balance that makes the body work.  That interest is what directed me to study biology in my undergrad career.  It is what drives me to serve as a nurse.  Call me sick and twisted, but I thrive on the exposure to illness and injury.  It reminds me of the delicate balance of life, how brief our time is here, and what a gift it is to be healthy and alive. That appreciation is what motivates me pursue this career, to care for others who struggle with that balance.

covered smile

In front of his room a sign reads:

Droplet Precautions
No admittance without personal protection equipment

I put on a face mask and protective gown, and hesitantly open the door. This is my first exposure to a patient with anything more than a blood-borne contamination precaution, and therefore I’m somewhat anxious for what to expect, how to behave, and what protocols I should follow. My anxiety is only exacerbated by the fact that I have this patient on my own, without the benefit of an RN to shadow.

Behind the door I’m surprised; the room is dark, musty, and dingy. I hear water dripping. The walls are brick. A wood platform in the corner serves as the patient’s bed. He’s pale, hunched in the corner curled in a fetal position of self preservation.

The feelings that overcome me are horror and appall. Is this really what happens to the patients that are a risk for infecting others? They’re shoved off to some abandoned closet and left to wither away, isolated and forgotten?

And then the alarm goes off. Its 5:40 am already and I already have to get myself out of bed and get ready for my day at the hospital.

What was that all about?

The previous day I was in the hospital to read up on my assigned patient and develop his care plan. In reading his charts I noted that he currently had the flu and was on droplet precautions to prevent contamination to others. This seemed strange to me because the prior week my instructor wouldn’t let me in to administer medicine to a patient with Tuberculosis who was on airborne.  Of course airborne is a higher level of precaution than droplet and I was not permitted to provide care to that patient because I was not fit-tested for a respirator mask and would therefore be at risk for contamination. However, the line seemed a little blurred, was my instructor aware that my current patient was on droplet precautions and was I permitted to provide care to him under my current scope of practice as a student? I tried to call her but didn’t get through.

The net result of this concern was that in the evening before going to bed I read up on my fundamentals of nursing care to ensure that I was ready for this new challenge the following day.

Apparently, as was made vivid through my dream, no amount of knowledge can suppress the anxiety of being faced with something new.

Was the anxiety needed? Not really, my patient was a sweet man who was on the unit awaiting a liver transplant. The recent flu infection was the least of his worries. As I popped in and out his room, I couldn’t help but wonder what he felt, as every nurse, doctor, and family member that encountered him was a pair of eyes and a covered face. He hadn’t seen a smile in four days: what does that do to a man, especially a man with end stage liver disease stuck in a hospital room for almost three weeks?
Whatever the result of my anxiety the prior evening, I do know that it helped me to be more prepared, and more present for this patient of mine. Having read up on the protocols for precaution, having voiced my naïveté to the attending staff and my instructor, I was prepared to move past the bumbling mechanical tasks of something new and focus on the human aspect required to be present for patient’s care.

don’t know anything

Driving over the bridge and listening to NPR I heard a story about New York’s new policy requiring all health care workers to take the flu shot before the end of the month. No one will lose their job if they refuse, however they will be forced to wear a respirator mask at all times on the job if they don’t comply with the vaccination requirement.

The main concern voiced in the story was regarding the loss of freedom since individuals won’t be able to make their own choice whether they’ll be vaccinated or not. That is all well and good when it comes to the general public, but we’re talking about health care workers here and I don’t really understand why this has not already been a precaution. To me it equates to the police force not choosing to wear a bullet proof vest or keep their guns clipped into their holster. Such precautions protect both the policemen and the public they serve by preventing anyone from taking the gun from their holster to maliciously harm others.

What really struck me about the story was a soundbite from a nurse who didn’t want to take the flu shot. Her reasoning was that ‘they’ haven’t given her any information, and that she didn’t know what the side effects would be.

What?

Nurses administer all vaccines, and when administering any medication they (we) should not only be aware of how to administer the drug, the nurse should be educating the patient about what the drug does, what the side effects are, and how to recognize and respond to any adverse reactions.

At least that has been what I’ve been taught.

I’ve also been taught that the practice of “patient centered care” is a relatively new philosophy within health care and that there are many licensed practitioners and nurses who are resistant to this model of practice, partially because it is less “task” oriented and requires more work, such as reading up on the medications before administering them.

I also thought to myself as I listened to this story that this nurse had to be a union girl. Why else would she be expect to be hand fed information critical to her profession? I guess this is one symptom indicating the need for nurse leaders to educate and improve the nursing practice within the industry.

I see a challenge down the road and I can only do my best to be ready for it.

there will be blood

Injecting and hanging blood on my own. Life in my hands!

Such power!

Really though: I feel as though I’ve reached a minor milestone during my past clinical shift. Not only did I have the responsibility to manage and carryout all of my patient’s care without the need to shadow an RN, I gave my first shots and plenty of them! I also had the opportunity to hang and administer the full gamut of blood products (albumin, plasma, platelets, and red blood cells) and monitor my patient for adverse reactions to the presence of foreign life in his own veins.

We take it for granted in our modern medical age, but it really is quite crazy to think about what I really did, I put someone else’s blood into the veins of my patient.

As for the injections, I had given an injection for the first time only that morning under the supervision of an RN. She instructed me what do do and where I should inject her patient in the stomach. Well, after proving my worth, the RN granted me the access to provide Procrit, which promotes growth of blood cells, to my patient without any supervision. After collecting my supplies and entering the room, I casually talked with my patient.

Lucky for me he wasn’t watching, otherwise he would have freaked out about how my hands were shaking as I went to inject the Procit subcutaneously into his upper arm.

I’m sure that as the years pass and I’ll have administered thousands of injections with a steady and practiced hand, I’ll fondly laugh at my my nervous shakiness at the opportunity to inject a patient on my own without the supervision of others.

It seems humorous and silly, which it is, but I recognize that the root of my nervousness is awareness of what I’m doing. Awareness that through the injection the drug is manipulating the inner workings of this man’s blood supply. That is hardly something to take for granted.

Blood is life.