employment

The last few semesters my classmates had two foci of attention: passing the NCLEX and getting a job.  I grew quite annoyed at the lack of actual school subject matter that was discussed before and after lectures.  The purpose of our education had run its course about half way through our two year program and all anyone would talk about was the lack of jobs available for new grad nurses.  I was annoyed because it seemed like a lot of wasted effort in worrying to me since I knew that our primary goal was to finish school and that most economy reports indicated that 2011 was going to be an upswing.  I found myself trying to be a voice of reason, encouraging many of my friends and classmates that yes, they would pass the NCLEX and yes, they would find a job.  However, despite my calm outlook somewhere along the way, about a month before graduating I caught the bug of despair. Although the nurses on the unit I worked with at UCSF gave me a lot of positive encouragement, the manager only gave me uncertainty – she didn’t know when the hospital would be hiring and she didn’t even know if when they were, if she would be granted openings on her unit.  These uncertainties grew into anxieties that were magnified as I began to receive rejections from the countless jobs that I had begun applying to.  For those of my classmates that founds jobs, they were the ones that had already been applying months before me when we hadn’t even taking the RN license exam.  When graduation came around in December, my sense of accomplishment was  overshadowed by my sense of dread and I had a hard time feeling ready to celebrate knowing that I had amassed a load of student debt and would only be back at the same job I had been working at before starting this journey.  The month of January was hard on me and I wasn’t in the best of spirits. I began to dread the eternal question that everyone I knew kept asking “do you have a job yet?”  The question began to annoy me so much that I snapped and once told a friend that asking that question was akin to asking a single person if they were married yet.  I told another friend to just stop asking.  I hope they are both still  friends.  Despite my negative outlook a bright spot did open up when my old clinical site, UCSF opened a new grad application the first week of January.  However, when I didn’t hear back from them for the entire month I started to become despondent.  My attitude had taken a turn for the worse and I was losing confidence that I’d ever find a job.  My thinking went along the lines that if I couldn’t land an interview at a hospital where I was known and well liked, how was I going to land an interview anywhere?

Oh, what a fool I was.

Last week I finally heard back a month after applying and my old unit was opening up an interview spot for me.  What joy! However I was now faced with a new conundrum: I hadn’t interviewed since 2002 and I was a little rusty in my ability to sell myself.  Well, at the wise prompting of my girlfriend, I prepared for that interview like no other.  I researched online for nursing tips.  I asked friends who had interviewed how their nursing interviews went to see what I should expect.  I even reviewed all the journal entries I was required to write for school during all my clinical rotations and a couple of the papers I wrote.  All that work gave me plenty of material to reflect upon and when I walked up to that interview Tuesday morning I had full confidence that I was prepared for any question they threw at me.  And the interview went smoother than I could have expected.  I rocked the interview and was flying high after I walked out the door.  I told a friend that I was so sure that I landed the job that if I didn’t I was ready to join the carnival because something weird and twisted was wrong with the world.  Well, no such luck for the carnival, because just 32 hours after the interview I received a call of congratulations from my new manager letting me know that I landed the job.

What a dream! I’ll be working at a world renowned hospital that is within walking distance from my home. I’ll be on a unit that is general medical surgical with two beds for palliative care.  This will give me a wide breadth of experiences that I can take with me anywhere. My only regrets is that I lost faith in myself somewhere along the way and invested to much negative energy worrying. I wish I could have taken my own advice.

final breath

Throughout my final semester internship I had multiple opportunities of exposure to palliative care patients because my unit at UCSF has two rooms dedicated specifically to palliative care.  During my final week on the unit, my preceptor and I were assigned a patient who had illeocecal  cancer and had not had a bowel movement in over a week.  She had lost her fight with cancer, but had not yet been moved to palliative care because the husband was not yet ready to let go.  During the morning shift report, the night nurse indicated that the patient and her husband, who was staying with her, had not slept much over the night and that they requested to not be disturbed until the 9 am medication time.  Despite this report, my preceptor and I discussed all of this woman’s comorbidities and decided that it would be inappropriate to wait until 9 am before checking on this patient.  I quietly entered the room to simply check her respirations to find that she was in the middle of moving from the bed to the chair.  Falls are of course a great concern, especially since her orientation was altered, so I helped her to her chair and checked her respirations.  She had a respiratory rate of 36, using many of her expiratory muscles.   This is incredibly high and a sign distress, since normal respirations are between 12 and 20 per minute.  The husband was awake at this time and I introduced myself, apologizing for interrupting his sleep.  He was thankful that I was there because the patient had not had much sleep and was uncomfortable.  I indicated that I was concerned for her respiration rate and that I would return with her ordered dilaudid and to take a full set of vital signs.  After the vitals were obtained and I discovered that her BP was 65/40 and her heart rate was 115: I knew that her physician needed to be notified immediately.   The physician and I discussed her vitals and determined that despite the husband’s concern, the patient was best suited to be placed on palliative care.  A meeting was conducted with the husband and palliative care was initiated.  Dilaudid boluses were administered continuously as we waited for the pharmacy to provide the PCA, but she passes away by 11 am, before the PCA ever reached the unit.  The dialudid brought her comfort. but unfortunately, her passing was not peacful.  Her obstructed bowel came up in a vile vomit of repose.  The husband, who was beside her during her final breath, through a blanket over her face out of shock from her final breath.  Surprisingly, the husband handled the situation well, despite the grim image of his wife’s passing.  The husband was very thankful for the attentiveness I provided for his wife, providing the comfort that she needed, and after I assisted in cleaning her up due to emesis that occurred upon dying, the husband hugged me for my assistance and care.  It is a delicate skill of attending to the family of the patient as much as the patient because illness does not only affect the patient; it affects all of their loved ones as well. What was most striking to me about the situation was that if I had simply taken report and not entered the woman’s room until 9 am her discomfort in her last hours would have been so much greater; she could have fallen in her transfer to the chair and she may have died before palliative comfort measures were ever started if vital signs were taken 2 hours later. The incident reaffirmed that in all of my patient care activities I must be diligent in conducting assessments continuously because patient status can change dramatically between shift changes.

784310

It has been over six months since I have updated this blog.  My silence has not been due to a lack of experiences, but rather a lack of available time to catalog them.  The experiences have been rich as I have worked in Hematology Oncology at UCSF with long term and palliative care patients, psychiatric nursing with children at John Muir in Concord, a community health nurse position at a live-in SRO partnered with the SF Department of Public Health, and most currently my internship on a general medical surgical unit at UCSF.  I have worked with the poor, the pyschosocially afflicted, neglected children dealt a rough hand, adults afflicted with a myriad of disease processes, and those that have accepted that the final path to healing is the acceptance of their death.

Amidst all of this I have been preparing for the NCLEX, the nursing boards, an “adaptive” computer exam that is a torture in itselft.  I took this exam this past Tuesday, the 21st.  The exam was exactly as it had been explained to me.  Every question has at least two right answers, and the challenge is to pick the best of the correct answers.  The convoluted processing of this adaptive exam is designed to determine if the tester is competent enough to deliver safe care.  I haven’t killed anyone yet and apparently the BRN has enough confidence to give me a license.

http://www2.dca.ca.gov/pls/wllpub/WLLQRYNA$LCEV2.QueryView?P_LICENSE_NUMBER=784310&P_LTE_ID=828

no comprende

Over this past winter I had travelled in Peru and Bolivia for a few weeks and the experience helped boost my confidence in my limited Spanish speaking capabilities.  Although the three years of high school Spanish that I have rarely used in the past 15 years may have helped me book a room in a hostel and order breakfast, I recognize that the I’m lacking in the proficient medical vocabulary required to tell a four year that it is time for her medicine or that I need to take her blood pressure. 

Despite this barrier, I managed to fumble through the communication required to connect with my four year old patient and her mother who both only spoke Spanish.  With the help of a Spanish-English dictionary on my phone, I was able to identify the source of my patient’s pain as being an uncomfortable pizca, located in the pinching Oxygen saturation probe attached to her finger.  When I brought in a syringe of her prescribed steroids to add to her IV line I could calm her fears by explaining that it wasn’t un inyección y es solamente para la lieña.  This rudimentary communication got me through the day efficiently without the burden of calling the translator phone for simple tasks.

However,I recognize the perils that a primarily English speaking medical profession can place upon a diverse and

During my care, an endocrinologist entered the room to speak with the mother and educate her about her daughter’s condition and prescriptions.  Paperwork was handed to her with emphasis on how important it was for her to monitor her daughter’s temperature and to notify all of her caregivers and teachers about her cortisol deficiency.  Looking into the mother’s eyes I could tell she didn’t have the faintest idea about what the endocrinologist was telling her. I stepped in asking her if she understood, which she admitted that she didn’t.  So I found myself acting as translator for an endocrinologist, illuminating the finer points of care for this woman’s daughter, all in an ugly use of half understood words and broken phrases.

Leaving the hospital after completing my day, I couldn’t help reflect on how complicated and intimidating the medical system can be for the common person.  Learning about a child’s illness and how to properly care for it is nerve-wracking and stressful, yet how much more so is that stress when the system doesn’t speak your language?

Over this past winter I had travelled in Peru and Bolivia for a few weeks and the experience helped boost my confidence in my limited Spanish speaking capabilities.  Although the three years of high school Spanish that I have rarely used in the past 15 years may have helped me book a room in a hostel and order breakfast, I recognize that the I’m lacking in the proficient medical vocabulary required to tell a four year that it is time for her medicine or that I need to take her blood pressure. 

Despite this barrier, I managed to fumble through the communication required to connect with my four year old patient and her mother who both only spoke Spanish.  With the help of a Spanish-English dictionary on my phone, I was able to identify the source of my patient’s pain as being an uncomfortable pizca, located in the pinching Oxygen saturation probe attached to her finger.  When I brought in a syringe of her prescribed steroids to add to her IV line I could calm her fears by explaining that it wasn’t un inyección y es solamente para la lieña.  This rudimentary communication got me through the day efficiently without the burden of calling the translator phone for simple tasks.

However,I recognize the perils that a primarily English speaking medical profession can place upon a diverse and

During my care, an endocrinologist entered the room to speak with the mother and educate her about her daughter’s condition and prescriptions.  Paperwork was handed to her with emphasis on how important it was for her to monitor her daughter’s temperature and to notify all of her caregivers and teachers about her cortisol deficiency.  Looking into the mother’s eyes I could tell she didn’t have the faintest idea about what the endocrinologist was telling her. I stepped in asking her if she understood, which she admitted that she didn’t.  So I found myself acting as translator for an endocrinologist, illuminating the finer points of care for this woman’s daughter, all in an ugly use of half understood words and broken phrases.

Leaving the hospital after completing my day, I couldn’t help reflect on how complicated and intimidating the medical system can be for the common person.  Learning about a child’s illness and how to properly care for it is nerve-wracking and stressful, yet how much more so is that stress when the system doesn’t speak your language?

sad eyes

She touches his shoulder, urging him to move and respond to my assessment.  My 13 year old patient has cerebral palsy and is blind from septo-optic dysplasia, two congenital conditions that developed during his fetal life and have inhibited him from developing into a fully functional child.  He actually is missing the midline of his brain and therefore has pituitary insufficiency and Addison’s disease, further complicating his dependence on medicine and the devoted attention of a loving family to continue with his life.

This is my first pediatric patient at my rotation at Children’s Hospital in Oakland, and the amount of care I must invest in him is more demanding than the renal and liver patients that I had formerly cared for at UCSF medical center.  Communication is a challenge since he is developmentally delayed and only really responds to the familiar voice of his mother.  I find myself spending large blocks of time in his room to monitor his breathing and apply suctioning since he has been admitted to the hospital for a pneumonia complication.  

As I take his temperature he bites on the thermometer with a canine grip. Medicine is fed in applesauce only to be spit up.  His IV has infiltrated because he moves his arms in jerky, spasmodic action.  

In each action I conduct his mother is right there at my side, assisting in some way.  I come to realize that she is just as much my patient as he is, for she is entwined with him.  He left her womb developmentally delayed 13 years ago, but he never let go his dependence on her and she has accepted this as her call to motherhood.  As I gaze upon her, I can see in her eyes a sadness, a sadness towards this charge she has born and carries.  I wonder if those eyes mask regret. 

There is a nobility to her acceptance, her love.  But none of the world’s nobility can mask the weary sadness she bears within.

the knee bone is connected to the thigh bone

 

The flesh of the knee was sliced open about a foot up the mid-thigh to expose the bony femur.  Wearing full body covered hazmat space suits to protect them from the splatter and the patient from their breath, the two surgeons and the operating nurse were huddled around the patient as the calf and knee were being flopped around like a limp jelly fish. 

This was orthopedic surgery and I was in for a ride.

I had missed the first incision, having taken my lunch break after my morning of observation of an abdominal aortic aneurysm, so when I walked into the operating room, the procedure had already begun.  And by the looks of it, it had progressed along nicely.

The patient himself was young, only 24 and a victim of osteosarcoma, or bone cancer.  He had a tumor the size of a baseball on his knee. Five to ten years ago his diagnosis would have warranted a total knee amputation, but on this day he was receiving a total knee replacement.  The plan was to take a biopsy of the femur high enough and check for cancer cells, if the pathology lab confirmed that the bone was cancer free, then his femur would be chopped and a new titanium knee would be inserted to replace the cancerous bone.

Next to the surgical table was an array of prosthetic knees of varying sizes tools, saws, hammers, and unknown sterile gadgets ready for the surgeon’s disposal.  I learned that prior to inserting the patient’s new knee they would insert a tester, to fit for size.  After the size was right, then the permanent knee would be inserted.  The tester had been in the open leg of hundreds of prior patients; it has since been washed and sterilized of course.

The grinding of the saw on the bone moved surprisingly fast, but it is hardly clean.  As the little chips of bone go flying this way and that, the necessity of hazmat suit becomes immediately apparent.  Despite the flying bits of blood and flesh, surprisingly bone can be cut quite neatly when the proper tool is used.  

The hunk of knee and femur came off like an apple plucked from a tree. A very bloody tree. 

It was placed in a tray and inspected by the surgeon.  The surgeon didn’t like what he saw.  There was a large artery running off of the cancerous tumor. From the words of the surgeon’s mouth “this is bad.”  It is an indication that although the cancerous bone was completely removed from the patient’s body and now sitting in a tray on a table three feet from him, outside of his body, there was a very high risk that rouge cancer cells were flowing through his blood and most likely would set up metastatic shop in the lungs.  Bone cancers don’t metastisize as often as other cancers; the surgeon said that this was the first case like this he had seen in 12 years.

Poor guy, only 24 and receiving a total knee replacement.  Now this.

The surgery progressed despite the finding.  The perfectly uncancerous tibia had it’s top chopped off to make way for the implant of the artificial knee.  More sawing and grinding.  The empty cavity of the lower thigh flopped this way and that.  The lower calf and foot were connected by skin, muscle, and hope.  The marrow was sucked out to clean the bloody flesh.  The surgeons walked back and forth tracking blood throughout the room.  In went the tester, more drilling and hammering, and chinking away at bone.  Orthopedics has a sculptured art to the skill.  Once the size was right the permanent knee was cemented in, all shiny and robotic.  A few tests of the hinge and then the muscle and flesh are folded over the knee to let healing run its course.

I follow the patient to the post anesthesia care unit to await his awakening.  We monitor his breathing and the beating of his heart as he dazes in and out of awareness.  About an hour later he begins to have some lucidity but he doesn’t feel anything in his legs.  I don’t want to know what he’ll feel when he finds out about his risk for lung cancer.

give an organ give a life

A few of the nurses chatted with me about this Monday being my “last day,” and how I felt about it. I wasn’t sure how to respond, because although it may have been my last day for the semester, I still have another year of school to go before I’m finished with this academic pursuit towards becoming a nursing professional.  It seems like this semester came and went in a blink of an eye, yet unlike the passing of any other academic semester, I do feel that this brief time of clinical exposure has made an impression and changed me for the better.  I feel ready to take on patient assignments, because in essence I’ve been doing exactly that. 

My last day did include two first time experiences: I cared for a donor patient and a first day post-op patient for the first time.  The donor patient was on his way to discharge after giving a kidney to his daughter and the post-op patient was an older woman who had just received a kidney after being on dialysis for seven years.   Caring for both spectrums of the transplant process was a special treat for me, because it allowed me to witness the unique confidence and loving demeanor of a man who had just given one of his organs to help better the life of his daughter, while at the same time witness the gratitude of a donor recipient who just went through a successful surgery.  Having that exposure allowed me to savor the unique miracle of the transplant process, how it transforms the disease process into an opportunity for new life.

I’ll definitely miss the nurses and patients of 9 Long.  Throughout the day I found myself taking in a considerable amount of time reading the personalized notes posted at the patient’s doors that thank the staff for the new life granted to each of the transplant patients.  My curiosity for finality even prompted me read up on past patients that were saved in my electronic charting patient list, and I was pleased to discover the progress of ailing patients who had long been awaiting livers who eventually received those much need livers and were finally able to go home, renewed.

sick!

The sniffles started and then the coughing came.  I only have two more days of clinical before the semester is over and I have to get sick now, the day before my once a week scheduled clinical day?

I’m definitely the type of person to go to work sick, get the job done, go home rest and do it all over again.  However I have all too soon realized how different nursing care is from any other profession. As the cold was creeping up on me, I was asked what percent sick do I have to be before you call in a sick day.  The answer is zero percent sick.

This semester I’ve worked with transplant patients, who are all immuno-compromised from the medications they must take to prevent rejection of their new organ.  That makes them all the more susceptible to infection, it would be contradictory for my snuffly runny nose to provide nursing care for these patients.

I tried to fight it. I still went in Sunday, read up on my patient, and prepared my care plan.  I had a big bowl of Thai soup for dinner and was in bed super early at 9pm to get as much rest as possible.  Yet to no avail, I woke up with the same cough and sniffles and had to call in.  Most people enjoy the opportunity to stay home ill, but strangely, I feel as though I’m missing out on quality experiences.

There is always next week.

am i numb?

Taking a quick break between procedures, I escaped off to a corner to rest my feet and sip on some much needed coffee.  Immediately across from me, one table over, I noticed a middle aged woman by herself texting on her phone. She seemed obviously distraught and distracted, communicating some bad news to a loved one or about a loved one. I can’t pretend to know her mind, but she caught my attention and my wandering mind began creating scenarios to go with what my eyes were seeing.

I had just come from a triple aortic graft surgery where the doctors were dropping f-bombs left and right because they were facing complications with the graft. During this procedure the largest artery in the body is clamped off, cutting the blood supply to all the lower extremities and abdominal organs.  It is an intense procedure because if the time to perform is excessive, there is risk of necrosis of the tissue below the abdominal aorta.  As I witnessed the pressure in the physician team I couldn’t help but imagine the worst was going to happen. And although the aortic graft was finished with no complication other than increased cortisol levels in the surgical team, as I witnessed the women in the cafeteria I imagined that she was the wife or sister of someone who didn’t have a smooth procedure.  She was alone, bearing the burden of sharing the news with her family.

And then a tear ran down her cheek.

I wished that I could hug her, tell her that it would be alright, but I didn’t know for what she teared, and it wasn’t my place. I was in need of my coffee and had to get back to the OR for the next procedure.

Am I numb?

Part of the beauty of hospital work is that it exposes me to the raw human condition.  There are hundreds if not thousands of people filling the halls of any hospital.  It is a place of activity, where miracles turn around lives and disappointments end some.  There will always be women like this crying lady in the cafeteria, I think that I’ve learned that I can’t do everything for every one.  There is a time and place, for everything.

I get up, throw away my paper cup, and go about my day.

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.