AMS.

And, I'm back at the bedside.

First day back, with a patient who suffered from an OD on a variety of his medications. Not much to say about this poor gentleman, except that the MD team was drawing straws as to why his AMS persisted (isn't OD enough of a reason?)...vascillating from neuroleptic syndrome to plain encephalopathy, there wasn't much of a consensus made, and he, young and strong, lay mildly sedated and writhing in bed. I couldn't help thinking of how much of a hell he'd brought himself to, and how long it might persist.

Pretty long, uneventful day, but I won't complain. Slow and steady, right?

I did it!

Sorry so long...the last 6 months have been a blur. Quick update:

1. I passed my CCRN exam! Now, all that stands between me and my eternal certification, is a hundred or so CEUs and a few hundred dollars every 3 years. It feels good to be certified -- I'm proud of myself, and eager to encourage others to take the plunge as well.

2. I moved! New job as Clinical Nurse Advisor for the critical care units at a hospital here in Buffalo. Near family, cheaper living, good food...as soon as the stress of the new job dies down, I think this will be a nice place to be content for awhile...

Life is busy, the work is so so new, but I'm cautiously excited about my new role -- transitioning from a direct nurse, to an indirect educator has been challenging, but I guess I'd be worried if it wasn't, right?

More later on...

Day to day.

I'm procrastinating. In seven days, I'll take the CCRN exam, and test my experience...or should I say, knowledge, about critical care nursing. I feel about 73% ready. I'm shooting for 80%. All I need is 75%.

It's been an interesting experience, studying for this test. I've gone through a few stages. The first, was, like this one, a reluctant stage. I studied in clusters, not really paying attention to any particular area, just looking over things. I took test questions, but found myself stumped - not because the questions were difficult, but because I simply hadn't been exposed to quite a bit of the information. Car accident with left shoulder pain? Hm, sounded like an MI...nope. Clear as crystal: spleen rupture. Never came across that in my little world of MICU. Which vessel was occluded when said leads were changed with ST elevation? Ha! My extent of cardiac nursing goes from looking to enzyme levels and handing the ECG to the resident. Not that we don't deal with these kind of things in our unit, it's just not a regular occurence that I'm expected to know the specific effects of a RCA occlusion. Needless to say, I don't think this stage was my best.

Second stage: reading. A friend loaned me a book, and I read the entire thing. The questions made sense! Of course, I understand now the intriciacies of Guillian Bare syndrom and Acute Lymphocytic Anemia -- the questions aren't very complex, they simply require an ability to recognize familiar facts. This was the most beneficial stage, clinically speaking. I started to recognize things that I hadn't before -- a patient with severe mitral regurge became short of breath when hypertensive -- of course, keeping his blood pressure low helped his breathing! A PE here, a case of liver failure gone bad there...things became clear to me -- from textbook to real life.

Third stage: one week from the test, and I'm just plain unmotivated. There are still things I need to commit to memory -- those walls of MI throw me every time. And balloon pump wave forms, and pacer codes are still vague. Cranial nerves? The worst. I need to just sit down and memorize, but I'm at a loss for motivation.

Either way it goes -- whether I pass or fail -- it has helped me clinically. This wasn't what I expected. When I studied for the NCLEX, everything I knew was book knowledge. Now, it's the opposite. Transforming experience into test questions and answers is difficult...hopefully my thinking cap works next Tuesday.

Two Years.

Well, I've done it. Reached, no, survived another nursing anniversary. Hard to believe I've been at this thing for two whole years. Twenty-four months. Seven hundred and thirty days, give or take a few. It feels longer.

Family members still ask me how old I am. One, a patient, chronically on the ventilator, wrote a note to her husband that said, "That white girl looks like she's sixteen," while I was starting an IV in her tiny arm. It always surprises me to hear myself say, "No, I'm not sixteen, but thanks. I'm twenty five, and I'm going on my third year of nursing."

Just the other day, one of them was surprised, saying she thought I had been a nurse for much longer. That I had a lot of wisdom in my practice, from what she could tell.

Generally, things have slowed for me. Not many cases throw me for a loop anymore, leaving me feeling like I've just been freshly mugged at the end of the day. Shifts are usually filled with the routine of sepsis, neuro emergencies and the occasional person in DT's. I'm starting to think that I'm ready for the next thing.

Today, I looked for jobs in my hometown -- Buffalo. There were only two or three -- in the whole city -- that applied to me, ICU jobs, most of them night shifts. It occurred to me, for the first time, that I might try something new? ER? Psych nursing? Home health care? Daunting, but true, the opportunities are scarily endless. Hell, maybe I'll learn how to deliver babies and realize I've been missing my calling this whole time.

Doubtful, but something to think about. We'll see. For now, I'll keep plugging along with my renal failure-hypertension-rare overdose-ARDS-GI bleed folks. I'm sure they'll keep me on my toes.

48 Years.

"48 years," he said. "We've been married for 48 years." His wife, in the bed, managed a weak smile from under the stiff plastic mask pumping 100% oxygen into her lungs. With the hat on his head declaring service to the U.S. military, and a Bible in his hand, he sat at his wife's bedside - close enough to see her and yet far enough to feel the wall of illness separating them - for almost my entire twelve hour shift.

The day was busy. We floated in and out of the room to and from CT scans and MRIs, each time we left, he made sure to tell her he loved her, and leave a kiss on her forehead. As her results came back, showing a small hemorrhage in her brain, and as the hours past, and I checked her declining neurological status, he sat, calmly talking to family, hardly batting an eyelid at the bad news.

He doesn't understand, I thought. He doesn't realize that his precious wife, who he painstakingly cares for at home, might not see tomorrow.

I approached the resident, telling her of the patient's declining mental status, and high risk for respiratory failure and need for mechanical ventilation. "You need to talk to the husband, give him a heads up," I say, all the while knowing that the words from her would undoubtedly come out wrong; twisted by medical jargon, a foreign upbringing, and lack of experience. But I was busy, I needed to catch up on things from my other patient, she was a second-year, she could handle it.

But, as I suspected, when I returned to him, I could see the confusion in his eyes. "What is this doctor talking about? Intubation? A ventilator? Isn't that mask breathing for her?" Things hadn't gone well. I sat down, and for a good while, explained to him and his son, what the blood in her brain was doing, how, if the bleed grew, it would cramp her brain, drowning it, keeping oxygen out, making it harder and harder for her to stay awake. The ventilator might become necessary to keep her alive, if that happened, and her brain stopped working as well because of the stroke.

Some people stop there. Why continue? You've gone above and beyond to give them fair warning -- why tell them that even thought the venitaltor might save her now, it might prolong suffering that she won't recover from? Her brain might get better, and then we'd all be thankful for the tube, the breathing machine, right? But what if it got worse, and she didn't wake up, and we, as we do so often, find ourselves with little else to do but pull the plug? Would she want to live on life support, in a nursing home for her remaining years, with little to no brain function? Or would it be better to just leave things as they are now, to let her pass quietly in her sleep?

But I had to, and I did. He loved her so much, and the last thing I wanted, was for him to visit tomorrow morening and find her garishly altered, with a tube in her mouth and a machine breathing her -- without having at least a warning. I didn't want him to miss his last conversation with her -- I wanted him to know, and see, just how sick she was.

He and his son talked it over. They said, if she needed the tube and the machine, that they'd want to be called first -- no matter the hour. Hopefully she wouldn't need it, they said. I agreed. It was a wise decision, a good conversation. They understood. He understood. When I left the room, I was glad I had taken the time.

Later, walking past, I caught a glimpse of him. Hat off, crouched in the chair by her side. His eyes looked tiredly at her, I could see his fear. For the first time, he realized her life wasn't as secure as he thought. While I never doubted my decision to inform him of how critical things really were for her, my thoughts haven't left him these past few days. I can only imagine what he feared -- losing her, meant losing his wife, his companion, his friend -- 48 years worth.

My thoughts are to my own life, my own relationships. What decision will I make when it's my time? Will I push hard, asking for everything, knowing that I'm only prolonging the inevitable? But, if I make it to 48 years, will you be able to blame me? 48 years is a long time to love someone.

Should I stay or should I go?

Today, life is demanding answers from me. One, really, in many different areas: do I stay or go? Today, it was in reference to my job.

I just returned home after a meeting with the Shared Governance Research Council, a nursing organization within the Nursing Department of most hospitals, of which I'm a member. Today, instead of just listening to the drivel of information, I presented a proposal for a research study I'd like to and have been working to carry out with two Bioethicists whom I work with.

The meeting went well, and we received approval to move to the next step, but the thing I carried with me was just how much time I'd have to commit. This study would be merely the beginning of an entire research path, a laundry list of studies that would, undoubtedly enhance my resume and experience far beyond my years or education, but will also take...a lot of time.

With tentative goals to move on to another place and type of nursing around this time next year, the meeting, which should have come as good news, turned out a bit unnerving.

I feel like a major review of my priorities is in order. What is most important to me, what will make me stay, what do I really hope to get from this job and place and experience?

But while thinking on it, I started to wonder what makes nurses, in general, stay in one place. Nursing retention rates are extremely low, and although improving in some areas, continue to persistently disappoint. A recent study (perhaps I'll site later, but a tad spent to find it just now) found that nurses who are involved in extracurricular hospital-wide activities, given autonomy and leadership in projects are more apt to stay longer than those who aren't.

While this is true for me -- as far as the unit goes, I've essentially capped my learning there, what's holding me is financial and project-commitments -- it's still difficult for me to pin myself down for sure. Starting a Master's is even a daunting task, simply because it'd tie my here for three years at minimum -- a period of time away from family, which I'm not too thrilled about.

Job, relationships, life in general, it just seems like I have to start figuring out where I want to settle, to stay...to invest. Part of me thinks I'm too young, but with a birthday around the corner, and a two-year-anniversary of nursing a few weeks after that, I'm starting to think I'm getting close to the place where I need to decide.

Nice RN Pick, Obama!

I knew I voted for Obama for a reason.

Although it mildly annoyed me that he mentioned nurse in the same category as janitor and garbage man (two admirable, but unskilled job titles) in two of his debates, I figured he'd be pro-RN by the ANA's endorsement of him, and his campaign's ability to think out of the box (all RN's have that quality).

But today, I found this article confirming Obama's love for nurses.

It's an exciting article proclaiming Obama's selection of Dr. Mary Wakefield, PhD, RN, FAAN to director of the Health Resources and Services Administration.

Finally, a position filled with a worthy candidate, in a job I'd like to have one day.
If only I could get a hold of her resume so I could figure out how she got there...

Needless to say, will be eagerly watching her work in the HRSA, specifically to see if she has the same view as I do, that universal healthcare in the US will never work without first establishing a stronger network of medical homes, in the form of free-low-income clinics. What good is universal healthcare if no MD will accept it?

We'll see. Maybe I could fanangle my way into her office for an interview.