awake or asleep

{ June 4, 2009 @ 9:41 am } · { Uncategorized }
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i am the first; i should be the second. or i wish i were.

the turnaround from day to night is no easy task. kind of like chronic jetlag. as if i’m in india yesterday and today, in new york for the weekend, and back across the globe on monday. only with working instead of flying. or sleeping – i’m not sure.

waiting for the tylenol pm to kick in, which it should have done an hour ago. wondering whether i should risk a headache for the surefire sleepiness in a glass of red wine. at 10:23 am, for goodness sake!

meanwhile…. should i think or not think of the images from last night? it’s not as if i can choose anyway – they chug through my mind’s eye with the inevitability, the inscrutability of an open boxcar on a slow-moving train. the woman this morning who came in after enacting one of my own personal worst-case scenarios: looking down the platform at the oncoming train, getting dizzy and being hit in the head by the train. even as i write it i think, how ludicrous, did that actually happen? could it? i have always comforted myself by the thought that it could not.

the resident who warmed the cockles of my heart when he ordered an IV on a hugely obese woman with invisible veins, only to immediately come help look for a good spot… or the one who raised my hackles by referring to me as “my nurse” on the phone with the lab when she hadn’t even bothered to introduce herself to me…

the personalities of my coworkers… of the patients… a feisty lady in her 70s who had been stuck there waiting for a bed upstairs for the better part of 24 hours, and though she fussed about it somehow managed to maintain her sense of humor… the pungent old fellow that my partner on my team picked up – he came in saying he had chest pain but it turned out he didn’t have a place to stay and sorely needed a shower. but he sure knew how to get in the door.

all of it cycles through my mind again and again – the anxiety of uncertainty, the relief at getting through another night with everyone still alive (myself included) – remembering things i should have done, should have documented, should have noticed or mentioned at the change of shift.

i handed off to my preceptor this morning. i suppose i should say former preceptor, since i’m oficially done with orientation… but somehow i still feel in-between. guess it’s that kind of a time right now. in between everything.

Super in the promises!

{ May 30, 2009 @ 7:05 am } · { Uncategorized }
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no luck yet finding a roommate. i’ve started to think about looking for my own place/other options. it’s really quite sad to think of leaving this lovely space. and yet… who knows, perhaps it’s time. however, trolling through listings which contain the likes of this post’s title is already making me feel demoralized. kind of like internet dating. the vast majority are improbable, impractical, or just don’t spell well.

busy busy busy busy night

{ May 24, 2009 @ 7:32 am } · { Uncategorized }
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now i finally know what everyone’s talking about.

for much of my orientation, i’ve somehow ended up having relatively relaxed days. people keep warning me that it’s much harder and busier at night. it’s not that i haven’t believed them – i just hadn’t experienced it.

so finally, last night, after a slow but steady shift, the craziness started rolling in. first a woman who was completely out of control of herself, brought in by the police after her son called them, handcuffed to the stretcher but somehow still managing to tear her clothes off and writhe all over the bed, all the while cursing everyone roundly and screaming that she wanted to go the psych ED.  meanwhile another patient was nosing around, shouting out supposedly helpful comments, throwing a bedsheet on the psychotic lady, and looking like she was generally celebrating the mayhem. it took a while, but in the end some pharmacologic interventions put an end to both their fun.

before i’d even had a chance to write the note on her and catch up with my other patients, we got a notification for a car accident… then a second one… and then when the first ambulance arrived, we found out that they were bringing all 6 passengers from a car that had overturned. as soon as we got our first patient stabilized, we moved her out and another took her place – we had three stretchers with everything going in the trauma room, three more waiting in the hallway, all the trauma residents marching around, emts, police, you name it… all while we are sweating away in our plastic gowns… blood everywhere… dirt and glass and leaves from the accident… putting in ivs, giving meds for intubation, hanging sedatives and fluids, watching the vitals, drawing labs, etc…  it had all started about 5:45, so just in time to keep us busy right up til the change of shift.

and to top it all off, who did i see on the train platform on the way home but the nosy lady?? just a little reminder that i am still in community health, after all.

from somewhere along the way

{ May 4, 2009 @ 8:28 pm } · { nursing, writing }
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i really haven’t been writing much about my experiences at work over the past couple of months. in some sense it feels like a loss – it’s been such a rich experience (actually that’s an understatement – it’s been a complete overload on every level…. rich seems to suggest some element of enjoyment but it’s been too much too fast to enjoy!) and seems like it would have so much material for reflection. in another sense, it feels like writing about the experiences i’m having will just make me re-enter them, something that seems just too tiring at times.

but then i realized – sometimes when i am sitting at the computer at work, composing my narrative notes that what is happening with the patients starts coming together. as i write, i realize what i forgot to ask or start to see a pattern or direction forming. of course for time management and documentation purposes, i need to focus on being very to the point and getting just the relevant stuff in.

yesterday i walked in and got the impression that the ED wasn’t all that busy. there weren’t many people in the waiting room, but once i got inside i saw that my preceptor already had plenty of patients, with some quite-sick folks. it turned out to be a busy day. i learned so much.

we got a notification that there was a patient coming in on the ambulance who was already in cardiac arrest. when he arrived, he was intubated and had no pulse. the EMTs had given him meds on the ambulance, with no response. we hooked him up to the monitor, did a bedside ultrasound and saw no activity in the heart, and called it.

he was a tiny, frail man. i’d taken care of him a week or two ago. in fact, he was still wearing his hospital bracelets. when he was with us then, he got stuck in the ED for more than 24 hours, waiting for a bed upstairs. though obviously in extremely poor health, he was stable then, just waiting quietly. he refused all his meals. his veins were terrible and i hadn’t been able to draw blood from him. i think i gave him some IV antibiotics, did vital signs a few times. the following day, i came back and he was still there.

there wasn’t much to do but take care of his body. another nurse, one of the techs (who is phenomenal and from whom i have already learned many things) and i finished up after everyone else had left the room. we took off his clothes, put him in a gown, removed his soiled diaper, put a clean sheet underneath, removed the leads from the cardiac monitor, unhooked the fluids from his iv, closed his eyes, crossed his hands and feet and tied them, put a plastic sheet around his body, covered him with a bedsheet, straightened his head. the tube stayed in his mouth, the ivs in his arm. instinctively, i still eased his body from side to side, as if i could hurt him if i weren’t careful.

i was gone before his family arrived.

there isn’t a lot more to say. his moment of death had already passed; still, there was a quality of last rites. there is a strangeness to an ending that comes among strangers, however compassionate they may be.

we ended the day with another patient, a woman who came from a nursing home with severe sepsis. the treatment she needed was simple: IV antibiotics and fluids. but not so simple if we had no IV access. her arms and hands were swollen and her veins were terrible… it took three physicians an hour and a half to get a good line. the whole time her blood pressure was low, low, low… dropping into the 50s over teens. they tried everything – neck, femoral, neck again, both sides of both, couldn’t find anything for so long… the whole time she was awake and totally oriented and aware of what was going on. once we finally had access, we started everything…. fluids, antibiotics, and levophed, a drug that raises blood pressure. her blood pressure came up and she started looking a little better.

she said she’d been feeling bad for three or four days. i asked her afterwards why she hadn’t come sooner. she just said, “i fought it.” after seeing her make it through all of that, i wasn’t surprised that she’d gotten her way.

do these stories mean anything? i write them and feel so far away from them. i was there, i did things, but i still have a sense of distance from this work. i try to keep engaged, try to keep present, but my mind is always full of so many things. ironically, though i often feel scattered, i also feel like i get tunnel vision. that’s what i became conscious of today – the sense sometimes of going blindly through a task, thinking of nothing but finishing it. there are flashes of flow, but things still feel pretty piecemeal. there’s so much further to go…

a breather

{ April 22, 2009 @ 7:45 pm } · { Uncategorized }
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back to work today – not a normal day but just taking critical patients. there were only two all day, unfortunately (from a learning standpoint). but it was still really helpful to be able to really focus and get a sense of what i need to be thinking about with these patients that need a lot more care. i felt that so much more was coming together. so now, the next thing is to be able to take care of those heavy cases and at the same time deal with all kinds of other problems. but i think having some time and space to absorb this information has also helped get my head back in a better place. and now that my confidence is coming back, it’s just time to work on getting up to speed. and pharmacology, my old nemesis, is also back. i forgot that one of the main things nurses do in the hospital is give medicine. lots and lots of medicine. and in the ED, lots and lots of crazy hardcore medicines.

both of the patients we had today were there for significant brain hemorrhages. both have virtually no chance of recovery. the two situations were entirely different, but both had family or friends present. i had some conflicting thoughts and emotions around their presence – part of me was so focused on doing the nursing care that needed to be done that i found it difficult to fully engage with the emotional experience of the families. another part of me that was feeling good about the day as a learning experience and feeling relieved and successful about the job also felt that in a way i was profiting from their losses and distress. kind of a strange feeling. i guess that if i hadn’t been just focusing on the critical patients, i might have felt that i was just taking care of them. and i think that with one of the families, it actually made a difference to them that i was there more frequently and paying more attention than i could have otherwise. and one thing that my previous work taught me was to be fairly comfortable talking about issues around end of life and choices about care.

i’m looking forward to the time that i will be able to do all the tasks that i have to do with less effort and concentration (though not with less caution!) so that i can also be more available for emotional support and decision making for and about a person who has suddenly become sick or injured.

meltdown!!?

{ April 21, 2009 @ 12:13 pm } · { Uncategorized }
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the past 2 weeks have been… challenging, to say the least. i made this change largely because i wanted something new and different – it’s turned out to be giving me a completely different sense of myself as a learner. most past experiences of learning a new job or role have been pretty independent – i’ve gotten used to just being dropped off into whatever situation, and i manage to catch on. and in the meantime, whatever supervision i have tends to be fairly far removed, so the process turns out the be largely self-regulating.

this time around, i’ve had the constant presence and support of my preceptor, but also have been under constant scrutiny. i’ve appreciated the attention and input, but have found myself responding in surprising ways… and not particularly helpful ones. i don’t tend to think of myself as an overly anxious person, but that side has really come out over the past few weeks – somehow i’ve gotten myself into a cycle of constant self-critique, which takes me from recognizing that i’m making mistakes to feeling worried about making mistakes to making even more (and ever stupider) mistakes. sometimes i have a hard time zeroing (that word just doesn’t look right…) in on the most important thing and end up spending my time and energy doing things that shouldn’t be the top priority for the given person/situation. which, obviously, is the exact opposite of what i need to be doing.

so … time to take  a big breath and try to regroup. had a talk with my manager and preceptor this morning – they were both understanding and supportive. we’ve made some scheduling changes so i’ll be at work more frequently but for shorter periods of time, and i’m going to get a couple of extra weeks in orientation. i’m going to do a little studying to catch up on some medication info that i’m not quite on top of yet…. and try to relax. hm… that sort of sounds like a mandate for a massage…

another first

{ April 10, 2009 @ 10:36 am } · { Uncategorized }
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back to work yesterday. kept  busy with a couple of emergent patients. one, an older man who came by ambulance from a nursing home with respiratory distress, turned around nicely – was opening his eyes and looking much more comfortable (according to his family much more like his norm) by the time we sent him to a regular medical floor. it’s kind of amazing to see that process when it happens – when someone comes in really sick and gets better by the time he leaves. the other one was a middle aged man who was sent by a clinic where he was having an outpatient treatment. he’d had a sudden change in his mental status. he was pretty out of it by the time he got to us, and deteriorated over the several hours that i was taking care of him. i watched his neurological status change almost before my eyes – from being confused and disoriented to being very lethargic and only responding to pain/discomfort. i found myself feeling worried and helpless as i watched him decline, even while the diagnostic process was going on – CT scan, blood work, etc. – just wondering what it actually was that he needed and whether we would be able to get it done in time to help him.

initially he was quite aggressive, probably because of the fact that he wasn’t understanding what was going on, and because what was going on was decidedly uncomfortable. his condition was such that we needed to do a number of invasive procedures over the course of the time he was there – from taking a rectal temperature to putting in a foley catheter and a nasogastric tube. we started with the IV – one of the techs had to hold him down while i put it in and drew blood. then – i don’t even remember what it was that we were doing, maybe something as benign as repositioning him, but all of a sudden, he lurched up in bed and landed a heavy punch to my chest. i wouldn’t have liked to have been on the receiving end of his full force had he been less debilitated.

i’ve often had to fend off swats and scratches and general resistance, but never something as direct (or as powerful). the funny thing was that although i was surprised, i almost didn’t register it – i remember thinking, am i hurt? i don’t think so. and then just going back to whatever it was we were trying to do. the resident next to me asked if i was ok and i said yes and that was it. i was almost surprised that she asked somehow.

except for fights with my siblings when we were kids, and the odd spanking from my parents, i’ve never been hit. i know that nurses (along with other health workers) frequently face violence in the clinical setting (some of which is not a byproduct of confusing/mental changes) and i don’t think it’s particularly uncommon in the ED. it’s something i haven’t spent much time thinking about. do i feel vulnerable? not really. but i think that’s because my tendency is to assume that people are not going to attack me, not necessarily because that’s an accurate assumption. perhaps i need to tune up my alertness to danger. not what i expected to get out of this new undertaking! but not a bad thing.

busy busy busy

{ April 6, 2009 @ 1:20 pm } · { Uncategorized }
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worked all weekend… spent my time back and forth from work to home, with barely enough time to sleep and eat. it was good to be there for three days in a row, though. i have the next 3 days off, which is great on the one hand, because i have a big exam to study for (it is of the employment-contingent-upon variety!) but on the other hand, i felt like i learned so much over the past 3 days and i’m afraid of getting behind by the time i go back on thursday. had my first evaluation with my manager and preceptor – they thought i was doing fine in terms of my knowledge base, which was one of the things i was most concerned about in this transition. the main thing they think i’m behind on is speed and time management, which was something i didn’t expect to have so much of a problem with. ultimately, i still don’t think i’ll have a problem with it – i’m sure i have the capacity for it – but i can see that i’m definitely not there yet. sometimes things feel like they’re going along smoothly, and sometimes i feel like i’ve been turned into the dumbest person on the planet when i forget or miss something that should be really obvious. and time flies so quickly once we start getting busy, and then all of a sudden i find myself behind and catching up for hours.

but i like being there, and i want to succeed…. it’s just a matter of working through the process. i don’t mind putting myself in unfamiliar situations, but i also feel a lot of discomfort in that pre-competence space…. which i think is part of why i tend to learn quickly, so i can get out of it!! i’m trying to figure out how to get up to speed, and also how to take advantage of the opportunity to work with my preceptor during orientation and learn from her. she is just so knowledgeable and great at what she does.

the truth about the ER is that there’s no rhyme or reason to the pace of things – you can have one patient at the beginning of the shift and then have 5 more walk in during the next hour and be completely swamped. i notice patients’ reactions too – those who come in with less acute problems, if they happen to be there while there’s nothing more acute going on, may end up being very happy with the care and attention they receive. but if that person with the scraped knee walks in, and ten minutes later we all get called into the trauma room, we may not be back for an hour, and even when we are out, there is probably someone else waiting with something more important that needs to be addressed first. so, while we’re trying to keep someone from dying right that minute, someone who has a minor problem that may not even actually need medical care is stewing about how terrible all the nurses and doctors are and how he is not getting the attention he deserves. almost every day i have a patient tell me i am a good nurse and almost every day someone else tells me how bad a nurse i am. (right now, to be honest, i am a lot more concerned about what my manager and preceptor think!! although obviously, i try to take the best care possible of everyone.) and almost every day someone complains about how long the treatment is taking, even if it’s not being abnormally delayed, and someone wants us to hurry up because of needing to get to another appointment or take care of some commitment. i think a lot of it goes back to the acuity of patients’ medical problems and how that compares to what else is going on at the same time. but i also think that somehow the idea of the emergency room connotes instant gratification – which is far from reality!! some people think we’re mcdonald’s, where they can ask for exactly what they want and get it right away – cheap/easy/tasty – but in reality we are a lot more like a soup kitchen, where they get whatever we have available, with extreme variation in speed and quantity. and then we ask them for their co-pay.

season change

{ March 31, 2009 @ 9:53 am } · { Uncategorized }
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well… it looks like i still have a few readers left, even after neglecting my little blog for a few weeks. i don’t know what exactly i have been doing that’s been keeping me away. i have yet to feel that i have a routine, and actually am not overly concerned about developing one because in a couple of months i’ll be switching to nights (7pm to 7am), at which i will have  a much more intensive restructuring of my time! that’s right, by june i should be on my own… kicked out of the orientation nest and hopefully flying! i’ve been away from the unit for over a week thanks to several class days last week… i am finding that when i go back after several days off it’s hard to get back up to speed or kind of hit the rhythm of what needs to happen with everyone. but now that classtime is mostly done, i’ll have a chance to really dig in and hopefully start hitting my stride.

spring is finally putting in its appearance… much too late, by my estimation… every year i turn into more of a shivery snowbird. all winter long all i think about is how to escape it and how soon it will be over! an old roommate of mine is moving to san diego this summer, and i must admit that although i have no sense of whether i’d actually like the city itself, i do think of those moderate climes with longing! but for now, we’ve got plenty of sun and it’s slowly warming up. just what we all needed!!

iso… ?

{ March 8, 2009 @ 8:58 pm } · { Uncategorized }
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a while back, i decided to make my blog searchable on google… no particular reason i guess, just thought i would experiment. i have a handy little page called ‘blog stats’ that only i can see, which tells me how people come to the site. so if someone puts a link to me on a blog, and someone else clicks it, i see that it came through that particular site. and now, i can see if someone visits me via a link that pops up in a google search. here are a few search terms that brought people to me:

betel leaves

madurai

flowers stall

madurai meenakshi temple photo

shiva madurai temple

view through a window

swallowflight.files

sri meenakshi temple, madurai

betel leave

demolished building

shri meenakshi

backpack india pics

most seem to be explicable through the tags on my posts or something in the text – the only ones i really can’t figure out are “view through a window” and “demolished building.” go figure…

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