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Monthly Archives: July 2010

Inglorious Bast-turds

Turd is a 4-letter word that I much prefer over test. I promise, I am not talking about wiping bums today, but I do not feel ashamed in at least mentioning it. I would far prefer to clean up after someone who passed their bowels than take a pharmacology/physiology/issues of nursing test…ANY DAY.

I am a bit worn out on exam-taking today. This week. This month.

If there was a pie chart of my life, studying for exams would be disproportionately representative. I know that I need to learn this material in order to be a safe and effective nurse, but this method of tricky multiple choice testing day-in-and-day-out really takes a toll. That’s why going to the hospital this week was such welcome relief. Patience may be a virtue, but I am sadly lacking it when it comes to waiting for competence in nursing practice. Yesterday, however, reminded me why it is worth working for.

Our preceptor placed us with telemetry/cardiac monitor patients this week. In the RICU, this may seem like a step down in terms of hands-on learning since our patients weren’t dealing with tracheostomies and ventilators, but in terms of gleaning knowledge from our patients about their present illness, it was profoundly educational and emotional. This was my first patient that could actually speak to me!  More than speaking to me, she entertained me to no end.* Breathing was difficult, her energy was low, but her wit abounded. She was a total trip. She told a doctor that she was going to kick, ahem, his little “behind” if he didn’t get her off the drug that was causing her anxiety. While she was consulting with a palliative care doctor about possible treatments, her son was telling me all about her career working for the police department and before that, traveling with the army for close to 20 years. In a break from talking with the physician, her son asked, “Hey mom, what’s your favorite gun?” Without missing a beat (quite a feat on a 50%-O2 saturation partial face mask) she responded, “M-16 and M-19,” then she turned back to the doctor and continued conversing about her treatment. I was momentarily shocked that this little tiny lady had not only handled a gun, but that the names of her personal “favorites” had tumbled from her lips as easy as 1,2,3. Previously, we had spoken about salsa dancing and I had pegged her as a dancer in her former life, but that clearly wasn’t all… She is quite a character. Unfortunately, her condition doesn’t promise a quick recovery: sigmoid colon cancer, pancreatic cancer that quickly metastasized to the liver, bones and lungs. For this reason, my day with her was quite bittersweet. I was able to talk to her about her life and illness, take my time in giving a bed bath which she and I both thoroughly enjoyed, and also meet one of her incredible children who moved here from different state barely a week ago to be with her in the hospital. I was able to understand her condition (an achievement in itself) but this also opened my eyes to the possibility (or reality) that she will most likely not be leaving the hospital with her son. This is a hard pill to swallow.

When I left the hospital yesterday, though, I wasn’t sad. Maybe my residents helped me understand death and dying a little better. There was a part of me that was sad for her and her family. But I was able to compartmentalize that sentiment and also recognize another emotion: elation. At 6am that morning, I left the house as a Negative Nelly, feeling down-in-the-dumps over another upcoming test, compounded by a serious sleep deficit. But at 3:30pm, as I left the hospital even more weary, I had a completely different outlook. Again, my patient reminded me why I am here. It made me so excited to learn more, even if it means test-anxiety, some more sleepless nights, and even the monotony of studying on a Friday night. It’s only a few more weeks until August, and then it’s three weeks OFF!

In honor of my impending cooking-fest, I will post a recipe that I found the time to make the other day and ADORED.

Eggs Nesting In Tomatoes On Toast

Adapted slightly from A Cozy Kitchen

Serves 4 (maybe…)

  • 4-5 eggs (separated, reserving 2 of the whites for another use)
  • 1/8-1/4 cup extra virgin olive oil
  • 2 cloves of garlic (minced)
  • ½-1 tsp red pepper flakes
  • 1/2 tsp of dried oregano
  • 1 24-oz can of whole tomatoes (San Marzano highly recommended)
  • 1/2 tsp of salt
  • 2 Tbsp of chopped fresh basil (I’m growing mine on my fire escape!)
  • 4 slices bread–whatever you have on hand, toasted

In a cold medium skillet, combine the oil, garlic, red pepper flakes, and oregano.  Turn on the heat and warm over medium heat until the garlic begins to become fragrant (without browning), about 2 minutes.

Raise the heat to high, then use your hands to “crush” each tomato into the pan. (I used a fork/finger to pierce them because the squirt-factor was out of control. Beware of your cute t-shirt, it is in danger!) Season with salt and pepper.  Fry the tomatoes, continuing to break them up with a fork. Cook until they concentrate and no longer look watery (5-7 minutes).

Lower the heat to medium and stir in the egg whites.  Cook until the whites become opaque and firm, thickening the tomato sauce, about 1 minute.

Turn off the heat. Using the back of a spoon, make 4 indentations in the sauce, allowing a few inches around each.  Nestle an egg yolk into each indent.  Pull the sauce in from the edges of the pan so that it cradles each of the yolks.  Cover the skillet and leave it on the stove, heat off, until the yolks are just warmed through and beginning to set, about 3 minutes for runny yolks.

Gently spoon some sauce and a yolk onto each piece of toast and serve immediately. Use a large spoon, perhaps lightly oiled, to pick up a nestled yolk without breaking it. Enjoy for breakfast, lunch, snack, or dinner. Or another special occasion time (plucking your eyebrows??)

*information changed & withheld to protect patient identity

 

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Inserted Co-rectally

A friend's picture: The view from our school

 

The other day, I found myself at the butt of the joke but in a great way. I felt closer to my residents, all the way back home in Seattle. Why? Because I was dealing with feces and bowel movements again! Funny that this can make me feel all warm and fuzzy now. I guess I am a bit kooky. When people curiously inquired about my work as a CNA, they always wrinkled their noses in disgust when we get to the part about helping people pass their bowels. They say they “admire me” for my ability to deal with it without disgust. But really, admire me for wiping poopy butts?? I mean, come on, we all wipe our own don’t we? Nobody has a robot in their bathrooms? Is it really such a stretch to think about helping out someone else who is wiping-impaired? Please, choose something else to admire me for! Listen, I know I write about poo a little more than the average person in this blog, but who doesn’t at least think about poop once every day? At the very least. It’s only natural, folks.   

Which is why what I did the other day really wasn’t such a big deal. Certainly not compared to the catheter insertion last week which felt much more foreign, to say the least. Let’s start by saying that I am amazed that I am where I am. In a hospital, providing care to patients in acute respiratory conditions. Turning a patient over is difficult not because of their weight (usually) but rather because of the sheer number of peripheral and central lines and catheters coming out of every imaginable orifice. Yet, I am not “grossed out.” I am not freaked out. I am learning what each line goes to and I am fascinated by its purpose. My thirst for this knowledge is insatiable because I want to be the most adept at helping my patient. I stare at the medication list (which looks like a grocery list in some alien language) and I feel overwhelmed by my ignorance but willing to look them all up. Mechanism of action, pharmacokinetics and pharmacodynamics…these were all foreign terms to me even 1 month ago and yet I already know the drug indications/interactions/mechanisms for at least 30 classes of drugs. In the hospital now, I am not afraid of my patients, I am afraid of not knowing enough. It’s exciting to be learning so much every day. Every patient confirms or illuminates something I read in a textbook or was told by a instructor. Our patients’ pathologies and co-morbidities helped me understand the renal system, the circulatory system, cardiovascular disease, neurological impairment and so much more. Even about poop! I never knew that nearly everyone in the hospital is on some kind of bowel regimen. But it makes sense: less movement may mean less peristalsis, pooping is never easy lying flat and there are so many medications that have constipation (or diarrhea) as one of their drug interactions. The patient I worked with yesterday had at least 17 meds and I counted at least 5 of them that consisted of her bowel regimen (aka: Poop Plan). Yesterday we found out that our poor lady hadn’t passed her bowels in four days! Talk about discomfort, not to even mention other implications. After providing morning care, I had really grown fond of our patient. She was the sweetest yet most stoic patient I have met so far. She caressed our hands even as we caused her discomfort here and there. Her eyes didn’t show any sign of reproach as we fumbled through only our 2nd bed bath with a patient who has so many indwelling lines and a ventilator.   

After the bed bath, our preceptor enter with a nurse practitioner and announced that we were going to be able to watch and learn from a manual probe to look for fecal impaction, which would then be manually removed if encountered. I looked forward to observing. Then my preceptor quickly changed her mind and said to the NP, “Actually, would you mind if we do it so that I can teach my students?” The NP readily agreed and walked out to help another patient. I happened to end up on the same side of the bed as my preceptor, at the patient’s backside.   

Without missing a beat, my preceptor said, “Okay, Rachel, now I’m not going to do it. You are. We are going to take a rectal temperature, perform the manual rectal exam, remove any impaction and then take two swabs for a culture.” And, to give myself due credit, I also said, without missing a beat, “Okay, sounds good. Should we start with the rectal temperature?”   

Without going into the nitty gritty details, I performed all three tasks with ease. The exam produced no sign of fecal impaction, so we decided to insert a rectal suppository, hopefully to induce a bowel movement. It all went so much more smoothly than the catheter insertion! I thank my residents for the familiarity and comfort I feel at the helm of the behind. Not even an hour later, our resident had her first BM in 4 days. She didn’t say as much (again, the ventilator) but I interpreted her silence as relief. I know I would feel relief. It feels so good to be helping. 

 
 

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Donning Gloves and Gown, Entering Hospital Town

Ten years ago, I squirmed when I saw blood and guts. My best friend loved gory plastic surgery TV shows, but I couldn’t handle them. If someone had told the childhood version of me that I would be a nurse one day,  I would have told them that they had the wrong Rachel. An author, sure. An artist, why not? A TV news anchor, yes for a short time, I’ll admit it. But never, not ever, would I have guessed a nurse. All those personality tests we had to take in high school (Meyers Briggs, career assessments…) none of them correctly predicted my future path. Granted, if they had come back with “Nurse Rachel,” I would have rolled my eyes even longer than your typical high schooler, but little did I know…

In our accelerated summer program, we only have one day/week of clinical time. It is welcome relief from sitting in the lecture hall for hours on end with our bums molded to the weirdly shaped red chairs, hunched over our computers and notebooks, furiously scribbling/typing away. 8-12 hours of classroom time every day is enough to make anyone grateful for an intravenous catheter insertion demonstration (or in my case, hands-on experience). I ended up at a well-known hospital for my first clinical site. Not only did I get lucky with the location, but I was placed on a RICU floor (respiratory ICU) which is like jumping into a freezing lake: much better just to throw yourself in without knowing the temperature of the water. Our patients have acute medical conditions, and the majority are in respiratory failure. The first clinical day, we spent most of the time in the patient lounge with our preceptor teaching us about the floor; essentially a crash course in Respiration & Ventilation 101. We were overwhelmed. At the end of the day, we went in, as a group, to visit one patient. Our preceptor was going to demonstrate how to dress wounds, specifically a pressure ulcer, but it turned out that this woman, Senora Vasquez* had more pressing concerns. She does not have a tracheal intubation (rare for the floor) and just receives oxygen from a nasal cannula. She was able to tell us more about her own disease process that the chart could tell us (with occasional reminders from the preceptor). I noticed that her bed was wet and wondered if he urinary catheter bag was leaking. Our preceptor noticed as well, and quickly determined that no, the bag wasn’t leaking, the catheter itself was leaking and “we” would change it. She asked which of us wanted to do it. Without thinking, I asked in alarm, “Wait, we can do that? We haven’t learned that yet!” She glared at me and said, “Well, I certainly hope you can do it Rachel! You better be able to do that.” I fell silent. She asked again, who wanted to do it. Suddenly, without my permission, a spirit possessed me and I somehow volunteered myself to change the catheter. Who me?? Yes, me. In a dream state, I listened to her instructions and prepared the sterile field. With 10 pairs of eyes (or 11 pairs, counting our patient) watching my every move, I tried to remain calm. I don’t remember much about the process, except that I went through 2 catheters instead of one because my preceptor forgot to tell me when to apply the Betadine the first time, but other than that, it went without a hitch. Luckily for me, this lady was no stranger to catheters and her urethra make an easy target. I was in shock at the end of this, “Oh…wow, that was me! I did that!” But the best part was realizing that in many ways, this wasn’t so different from working in assisted living. I helped someone. As (student) nurses, we made her day better. She had been lying in her own urine, and now she was clean and dry with a new catheter and a freshly dressed pressure sore. I may have felt a little too much sympathy for her condition, but I was also able to walk away feeling like we made a difference. So, that was two weeks ago.

This past week, we were paired in smaller groups with patients. Our patient was an older, emaciated woman, with a trach. When I first saw her, all I could focus on was the plethora of tubes and indwelling lines coming out of her body. Her face was caked with residual sleep, and her mouth needing to be swabbed badly. She looked uncomfortable. I cannot imagine being unable to get out of bed in the morning, stretch deeply, and relieve myself…perhaps splashing water on my face as well. Yet here she was, waiting for the assistance of someone else before she could “do” any of those things. Making matters worse, she didn’t understand that she couldn’t get up and go to bathroom, despite us explaining it to her multiple times. (What do you say? “I am sorry, but here’s a lovely bed pan for you to use instead? Yes, I know you feel like you have energy to walk to the bathroom, but you see, there are all these tubes you are attached to, and they are breathing for you…”) She tried to communicate via lip-reading, but really, she was much better at reading our lips than we were at reading hers. Understandably, this frustrated her immensely. Not knowing what else to do, another student and I started the bed bath. Washing her face, I watched a completely different emotion take over. From consternation and vulnerability her expression melted into total peace and relaxation. Her eyes closed, and her lips spread into a serene smile. It was amazing to watch, and my own body relaxed as well. I swabbed her lips, and suctioned her mouth. We worked our way slowly down her body, warming the water periodically, assessing her skin all the way down. It was a lovely experience, knowing that we were providing palliative care when there really wasn’t much else we could do. The day was draining. Our patient didn’t receive visitors and it was hard to see her all alone, knowing that no one came to see her. Her condition was acute, but not without a fighting chance of survival. Yet, I couldn’t help but wonder to myself whether she felt like she had much to live for. A week later, I was still pondering this conundrum until I realized something quite simple. It is not my place to wonder for her, or to make that decision. My role is to make her day, the moments that I am with her, a little better. I am there to ease her discomfort, ensure that she is not in pain, and fulfill her basic needs. I am there for comfort and healing, which is why I went into this profession. Remembering this, I leave the hospital feeling tired but satiated, as if I have just eaten a big bowl of steaming soup.

*Name changed.

 
 

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