Real Nurse!

I passed my boards this morning.

The exam was nothing like I expected it to be-- full of questions about disease processes, procedures, and drugs that I've never even heard of. Most of the questions were 100% guesses-- by the 60th question, I was going with whatever sounded good.

It shut off at 75; apparently I'm a good guesser.

I feel like in preparing for the boards, I was inundated with advice, statistics, strategies. Kaplan is the only good class. You only have to get a 51%. 86% of people who take it, pass. Just do 5,000 review questions. Don't bother with review questions, just study the facts. If you don't take a review class, you'll fail.

Really, all I needed was a good knowledge base and a little confidence. It helps that I did well in school-- I know myself to have a good test-taking track record. To be honest, those statistics helped me some too-- I have never received a 50% on an exam-- why would I start now? And do I really think I'm in the bottom 14% of new grads? No.

So all in all, it's a weight off of my shoulders, and I'm excited that I can finally really start my career. I'm excited to get to focus on knowing the important things that will serve me well-- instead of trying to absorb as much pointless, inapplicable information as possible.

But for tonight, I'm most excited to read the trashy fiction I picked up at Borders today--instead of my nclex review books!

It begins...

So I started my new job on Monday. Haven't taken my boards, haven't been hired onto a unit, but I started my new job at a children's hospital at a big university in the south. I was hired as a Nurse Resident... basically, a new grad. As a pediatric critical care nurse resident, I spend the next 7 weeks rotating through PICU, Peds ED, NICU, Peds Cardiac, Hematology/Oncology, and step down surgery/trauma.

So far, everyone seems great. The first day was a lot of stupid hospital orientation, sitting in an auditorium listening to person after person talk about benefits and payroll, the credo and mission of the university, etc. Most of the people in the group seem to be really great, smart, people. They told us that they received over 500 applications, interviewed almost 300, and hired a total of 90. 65 in the adult tracks, 25 in peds. Today we had more orientation talks and then took a tour.

I was really looking forward to this part. Finally, getting into the hospital and seeing what each of the units were really about. We started on the PICU and upon entering the unit, I just got a sort of sinking feeling. I felt overwhelmed and nervous-- not anything I'm used to lately and certainly not anything I expected to feel. I'm so disappointed that we're only spending one or two shifts in each area. I had hoped to actually get a taste of the dynamic on each unit; one shift is certainly not going to allow me to do that. Then we went to the NICU, which was not much better...I think the NICU is at the bottom of my list right now. The population is so narrow, with only micropremies and neonates. The unit is very secluded and separated into 6 bed pods, so interaction among nurses is limited. The 7th floor was next, peds surgery/trauma. Nothing special. The last stop was the Peds ED. This is where it all started to feel ok, like I was actually meant to be there. A lot of the chatter among nurses was things that I had heard a lot of in my last job ("I'm gonna go give this bolus"; "When was his last dose of Tylenol?") and that made me feel really comfortable. This is my first unit-- I go next weekend, probably for swing shift on Friday and Saturday. I'm really looking forward to it. So based on first impressions, Peds ED, PICU, NICU.

I really want to try to keep a good log of what's happening and how I'm feeling about things. We'll see how it goes!

NSICU begins...

I remember the first day that I spent on the neuroscience intensive care unit last term. The nurse that I was working with had just received a call from the ER announcing that she would be getting a trauma patient. From the brief report, we learned that he was a 28-year-old with a GCS of 4 and a self-inflicted gunshot wound to the head.

Moments later, I was pulling on gloves and helping to transfer this young man from the stretcher to the bed. Mr. W had three or four tattoos and a goatee; he looked healthy and normal, vaguely like a guy I could have dated in college, though this thought didn’t occur to me until later. He was intubated, wore an Aspen collar, and had large bore IVs in both arms. He also had a hole on the right side of his head, just behind his ear, where brain matter was oozing out onto the crisp white sheet.

We set up his blood pressure cuff and the nurse handed me a butterfly, which I pressed gently into his antecubital vein. We did constant neuro exams, monitoring his pupils, his cough and gag reflexes, his response to painful stimuli. While initially his pupils were fixed but not dilated and he had a cough reflex and showed decerebrate posturing, he had no Babinski sign and within the hour lost his cough reflex and stopped responding to pain. The CT scan showed that the bullet had crossed midline, and, as one of the neurosurgeons explained crassly, “bounced around,” though there was no exit wound. It was becoming readily clear that this young man had an unsurvivable brain injury. LifeNet had been triggered upon his arrival to the ER, and the goal was now to keep the chemicals in his body within the limits for organ donation. He had been given Mannitol, so we monitored his urine output and gave him fluids as appropriate. His vital signs were, for the moment, stable, and we drew blood gases and worked with the respiratory therapist to adjust the ventilator settings as needed.

His family had arrived and wanted to see him. His older brother, “J” came back first, with his girlfriend. I remember him wiping tears from behind his glasses, waiting for us to leave the room before he broke down. I closed the curtain and stood outside the room while he sobbed, telling his brother how much he loved him. “You don’t even know,” he yelled. “You don’t even know how much I love you.”

His mother and aunt came back to see him, crying quietly and staying only for a moment. His mom pulled the sheet up to his chest, worrying that he must be cold. J told us a little about his brother’s social history, explaining that this was not the first suicide attempt, that his brother was a heavy drug user and, on certain drugs, got very depressed. He told us that years ago they had been very close, but one night several years before, they had been arrested together. J straightened up and started his life over and his brother did not. When we explained the gravity of his brother’s situation, he asked us if you could donate organs if you had hepatitis C. Then he asked if there was a bar within walking distance; he needed a drink.

While his family was gone, his nurse and I began preparations for brain death testing. Mr. W initially failed the apnea test, as he was breathing over the vent which was set at a rate of 8 to level out his blood gases. This meant that he was not brain dead, so all further testing stopped. 30 minutes later, I stood holding his had while his brain herniated. His pupils were fixed and dilated, his blood pressure rose rapidly, and his heart rhythm was wide and bizarre. He had no cough, gag, corneal, pain, or Babinski reflex, no dolls eyes. He was no longer breathing over the ventilator. I remember that standing there watching it happen and not doing anything to stop it or fix him was extremely hard.

I went home that night and thought about what had happened and about how disconnected I felt from the whole experience. I thought about what we hadn’t done for him, if that was the right thing. I thought about movies and TV shows and how gunshots are portrayed and how different it was to be a part of it. I thought about what could hurt so terribly that you would rather put a gun to your head and pull the trigger. I didn’t cry that night, and I felt guilty about it. A few days later, after talking on the phone with one of my sisters, I cried hard for him and for his brother and his family and the pain that they had all felt and would feel for a long time. I thought about my own family, about my sisters, my parents, my friends.

I learned later that his brother had returned from the bar drunk and unwilling to discuss organ donation. Care was withdrawn the next morning.

Last week on peds

This week, my last on the peds floor for my clinical, was one that got me thinking. My patient was a 17 year old girl who had been diagnosed with a medulloblastoma (brain tumor) almost a year ago. What gets me most with these cancer kids, I think, is how they initially present. Bruised shins, headaches, nausea and vomiting-- things that kids just get, except this time, they ended up with cancer, too.

I've chosen mostly heme/onc (hematology/oncology) kids for my patients, and I've seen them all at different stages of the disease and treatment process. My first week on the unit, my patient was in the middle of her third round of chemo for ALL (acute lymphoblastic leukemia). A few weeks later, my patient, who's squamous cell carcinoma had been complicated by several intense cases of pneumonia and metastases to lung, liver, and bone, had just become a DNR/DNI (do not resuscitate/do not intubate) status, and was at the end of a very long battle. His dad was at the bedside, waiting for the snow to stop so that he could take his son home to die. A few weeks later, my patient was a toddler who had, that day, been diagnosed with neuroblastoma, and had a tumor the size of a football in his belly. This past week, I finally got to witness a little bit of success.

This adolescent girl had presented a year and a half ago to her primary care physician initially because of some vision changes. After being lost to follow up for nearly 6 months, she came back because one side of her face had started to droop, and she had headaches. After MRI showed a mass in her left parietal lobe, this young woman underwent surgical resection (yeah, we're talking brain surgery) and radiation, and then chemo. This week, she was hospitalized for her final round (of 6) of chemo. With her Mom at the bedside, she was hopeful and optimistic; this 17 year old was the friendliest patient I'd had all term, even being pumped full of poison. She was doing really well-- clear lungs, 0/10 pain all day, eating well, ready to go home and get back to school.

When a mishap with the shower (she somehow leaned on the curtain and knocked the pole--and the surrounding tile-- off of the wall) forced her to move rooms, she randomly ended up in the same room where her chemotherapy had first begun. As her nurse and I hooked her IVs back up and got her settled, her Mom stood at the window with tears streaming down her face. She remembered months before, watching snowflakes circle to the ground, wondering if her daughter would survive to see her 18th birthday.

She had come full circle. And for my very last day as a pediatric acute care nursing student, I couldn't have asked for anything better.

a little history

History is an integral part of any thorough exam, right? We need to know where our patients have been in order to have an idea of where they might be going.

So, in an attempt to get us all on the same page, I thought it might be helpful to let you in on my history. I grew up in Southern California, and my parents divorced when I was young. Dinner table conversations consisted of my father's comments about the "VSD that we couldn't get off bypass," the "20-gauge scalp line in the premie," and the "FLK's circ done under general". I remember wishing that I understood what he was talking about...I wanted so badly for him to share with me, but how does one explain these things to an 8-year-old?

In high school, I decided that I wanted to save the world. Not with nursing, no, that came later-- I wanted to be an environmental scientist, and I wanted to specialize in the destruction of the world's oceans. I got SCUBA certified and started college at an extraordinarily granola university, and the further that I got in the program, the less convinced I was. I considered law school, but my oldest sister's less than exuberant anecdotes about life as a 1L really didn't suit me.

I bounced around a little bit and finally, in the fall of my junior year, narrowed the field down to 'something medical'. I studied human physiology, struggled through anatomy (I was somehow unaware that my first anatomy lab was with cadavers), and hit my stride. I graduated and moved to the big city. I was hired out of, I'm sure, good faith alone, as an inpatient phlebotomist.

Make no mistake, phlebotomy is much more than just a skill. Running from room to room at 3:30 in the morning; waking people from a dead sleep; narrowly escaping vomit, spit, urine, and fists; attempting to maintain control, speed, grace, and accuracy-- all while keeping in mind the looming bloodborne pathogen risk. Perhaps this sounds simple to you, but for me (as unexperienced as I was), it was a challenge to say the least.

I heard from both the sweetest and the most hateful of patients in my year of drawing blood. I gained a sense of humility that many of my coworkers had either lost through time or never had to begin with. Yes, I learned to draw blood. But I also learned that I like the way it feels to walk out of work and struggle to get up the stairs of the parking lot, but do it anyway. I learned that even after 10,000 successful draws, I will still miss from time to time. I learned that, despite all the swearing I do in traffic, I actually do care about my fellow human being. And today, in the third of five terms in nursing school, I use what I've learned.

FIRST BLOG!!

New nurse, new project. Well, let's not get too far ahead of ourselves, shall we?

I'm still in school. But everyday brings me a little bit closer to graduation (this December), and as I'm well aware of the masses of 20-somethings (and 30, 40, and 50-somethings) starting out in Accelerated Second Degree programs for Nursing, I thought I might have a market here. If not? Well, that's fine too. I want to remember for myself what these days were like.

I want to share my day-to-day life in (and outside of!) nursing school, dispel rumors and myths about the rigors that this type of education brings, and talk about the real stuff. I want to address issues that I've had and am having (like why, despite my previous experience as a phlebotomist, glowing recommendations from clinical instructors, high GPA, and all around good nature, I can't get a job taking vital signs and giving baths).

I've recently really gotten into reading other people's blogs-- from codeblog to CF stories, this type of expressive informational medium left me interested and envious. I want to share my stories too! With a little nudging from my BFF back home, this blog was born.