As fate would have it

So we have been busy trying to clean out the trauma service since Thanksgiving and things were slowly but surely getting back to a good looking census. So when the cheif resident asked if I'd be okay with the intern having the weekend off I thought it might be okay. I figured better for him to get his days off now than over New Years, right? Well, I guess I still think that (because, really, how is New Years weekend going to be anything but complete craziness???) but I would feel better about it if we didn't have to get slammed this weekend. Ugh! Things weren't too bad on Saturday during the day, but then I came in on Sun and see my list 3 times as long. What the heck, people?

So there was good news and bad news in that. The good news was that most of them were "trauma specials." That means they'll get to go home. But also, therein lies the problem. Technically someone staying in the hospital is less work than dc'ing someone. So I had over 15 c-spines to clear, and of course you wait, wait, wait for final CT c-spine reads to come back...and then they all come in at once. And of course everybody wants the collar off since the second it was put on them (now probably 24 hrs later). But obviously I can't see all 15+ people at the same time, so people toward the back of the clearing list are even more cranky than they already were. Anyways, going around to a dozen different floors to get collars off is only half the battle. There's of course the infamous "paperwork" to actually dc them. No small feat there. Plus the pager going off non-stop about other issues, like true medical problems. So as you see, it turned out to be quite the day. But I'm sure I'll be happy when I have an intern to help see people come New Years. Lord knows I'll need it more then than I did this crazy weekend.

Foreign objects

The other day I was discussing with my colleagues the topic of foreign bodies. What have we seen over the years? Probably my most memorable foreign body was finding a koosh ball on a pelvic exam. And let me just say, it'd been there a while. Interesting, but I don't think I took the cake. My colleague had a patient that was "cooking naked" and fell on a can on cooking spray. Don't you hate it when that happens, especially when you relax your sphincters when falling? Fortunately the lid was conveniently duct taped on. Sadly, this is actually not the first time I have heard of a large can being found in lower GI tract. Really, you'd think that would be a unique find, but surprisingly no so unique.

A perfectly round object was seen on AP and lateral views of a pelvic x-ray of another patient. When questioned the patient casually replied, "Oh, my golf ball?" Oh, of course! Now why didn't I think of that? Just where I keep my golf balls. Apparently the patient was annoyed by diarrhea and felt a golf ball was a better choice than, perhaps, Imodium.


I have to say, I learned something in this conversation. I learned a new term "fisting." I'm not sure if I'm better or worse for knowing this information, but maybe somewhat enlightened on an apparently common [sexual] practice. Call me boring, but fists don't sound like a good time. Each to their own I suppose, but clearly even the name could suggest the potential for injury. The "foreign object" was of course not present on admission, but the fist had perforated the bowel.

Well, although some of these stories can be funny and strangely fascinating, they generally aren't so funny in the moment. They actually can be quite serious (like perforated bowel!) and often require surgery for removal or repair. And of course in the category of foreign bodies, often comes impalement. Hum, perhaps I should save impalement for another day.

Acute Care

I just got back from a meeting for Acute Care NPs at the American Nurses Credentialing Center to discuss boards. The meeting reminded me of certain nuances about being a trauma sub-specialty within the umbrella of Acute Care. I'll admit that there were times in grad school when I questioned if Acute Care was the right specialty. Being around a lot of people who love cardiology or neuro or some other system made me feel a little isolated when my thing was injuries. Sure, trauma affects systems, often multi-system, but it is very different then discussing heart failure. But what other specialty would a trauma person be, right?

As I might have mentioned before, I used to work in the ER prior to becoming an NP. For anyone who has worked in the ER before, or really even just in a hospital, you know the ER is a bit of its own entity. It's like being part of the hospital, but not quite. And the Trauma Center I work for now has the Trauma bay separate from the ER. Trauma resus patients come directly to the 2nd floor to the trauma bay, which is next to the OR suites, just in case. So I have nothing to do with even the patients in the ER in my current hospital.

Despite feeling a greatly outnumbered in school, and working in areas of the hospital that can feel a little removed, I do ultimately think Acute Care was the right specialty. It seems perfect now. But being at this recent meeting reminded me that even though we are all ACNPs, we all do very different things and like different areas within our specialty. I do feel like trauma is a somewhat underrepresented, so it was nice to have the opportunity to bring the trauma perspective to the meeting.

Tis the season... for ATV crashes

I see it has turned into ATV season again. We are seeing more ATV crash injuries coming into the hospital now that the weather has cooled off in the desert. Half of the trauma service is now ATV crashes. And as if riding an ATV weren't dangerous enough, people seem to invariably come in with an alcohol level and/or positive toxicology.

I suppose I can understand 20 or 30-somethings riding ATVs (sober, of course), but 80 year olds? Really? What's with the elderly riding ATVs? We even had a 92 year old. They seem to say, "Well, I've been riding ATVs for years. This has never happened." I'm all for being active in your old age, but I at some point you might need to re-evaluate your "activities."

I see ATV crashes commonly result in spine fractures. Head injuries are seen as well. And that is in younger folks. All of elderly that have come in lately did have spine fractures and and one with significant pelvic fractures also.

The hard part about elderly being injured with pelvic or back fractures is the toll immobility takes. When younger people are laying flat in bed for days waiting for a back brace and/or surgery, they can recover physical strength faster. Elderly lose their strength quickly and get it back slowly. This often results in a discharge to a skilled nursing facility, which doesn't always have the best rehab outcomes.

Personally, I've seen far too many devastating injuries from ATVs and would recommend just staying away from them. Since I know not everyone will, I then recommend being smart about it:

1. Don't drink or do drugs (ever, really, but in this case when planning on riding an ATV)
2. If you are over 55 years of age really consider it a sport not for you anymore (or maybe over 60 if you are really fit and super cautious)
3. Wear a helmet
4. Don't ride around like a maniac- use common sense.

I suppose if you stick to those recommendations you should fair much better than the people I see in the hospital.

NPs in ED

I just read a journal article that came out recently on patients' thoughts about being treated by an NP in the ED. They surveyed 190 patients being seen in the fast track area of the ED asking about 8 questions, with the crux of the questionnaire essentially being "Would you be willing to be treated by a nurse practitioner today?" I found the results interesting. Albeit the majority, 65% said yes (17% were unsure and 17% said no). To me, this is lower than I would like to see it and I think it stresses the fact that people need further education on the NP role.

Also, 56% stated they had previously been treated by an NP (with 22% saying no and 21% unsure). I would venture to say some of the patients that fell into the "no" or "unsure" category have actually been seen by an NP before. Quite often I am referred to as "doctor" even after I've introduced myself as a nurse practitioner. I can continue to repeat myself, and some folks will still stick with "doctor." Eventually I give up because ultimately it doesn't really matter; care and treatment will proceed the same regardless.

Perhaps I used to also be guilty of no delineation. Back when I worked in the ER as an RN I used to say, "...blah, blah, blah...the doctor will be in to see you." We had physicians, PAs, and NPs working in that ED so it really could be any one of them, but I generally didn't know which one would get that patient. So unless stated by the provider, it is largely assumed to be a physician.

I think this study really pointed out some things most of us already notice in practice. Since I noticed this knowledge gap, I have made great efforts in educating my patients, and others in general, about NPs and the role. Hence, the development of the www.worldofnursepractitioners.com website. The observation was actually the impetus behind that website, but of course it still takes many, many more health care workers educating patients/public.

By the way, the article is "A Patient Survey on Emergency Department Use of Nurse Practitioners" in Advanced Emergency Nursing Journal.

PhD

Oh dear, I've let time pass again. My apologies. I had been consumed by yet another standardized test in my life. But it is now behind me and I can move forward again.

As you might remember, I mentioned my debate about returning to school for a PhD. Well, the process is in full swing now. And through the process I have decided to open the application process to several schools, not just my alma mater. I think this is a wise decision. But, of course, for every school added, I see the amount of work to do multiply exponentially. I still think it's smart to cast a broader net, at least for comparison.

Part of the process is deciding what I really want to study for the next 4+ years. Trauma, of course, no doubt about that part. But I love so many things about trauma it's about committing to one aspect of trauma that I will want to research until I'm blue in the face. It appears things are settling down to two main camps: trauma in the elderly vs. violence (esp. intimate partner). My particular interest is in prevention and I am on the hunt for the right faculty to work with.

Right now each school is on it's own pace. While I am just starting to communicate with some schools, others are approaching their deadline as I type. The first application is due at the end of this month. I actually find this an exciting time. I will be sure to add updates about my progress intermingled in my blogs.

Pen in the eye

There are certain things you like and certain things not so much. I dig just about anything trauma related. But eye trauma is one of those things that I just find sort of creepy. Well, in a recent trauma lecture we had a great Head & Neck surgeon come and talk about facial trauma...which of course included eyes. It was great to learn the nitty gritty of Le Forte fractures, which we see quite often in facial fractures, but the orbital trauma makes me want to squirm.

Apparently jail inmates place an empty pen shell over a real pen. So what this means is when they stab someone, they pull the pen out and everyone thinks that what went in came out, but really the pen shell got pulled off and left behind. This matters anywhere a person is stabbed, really. But we saw video of a this being next to the eye. A patient stabbed to the eye complained of pain to the eye and initial providers sewed the lac without further imaging. There was some mild edema near the medial canthus, however no overt signs of a large foreign body. Yet once transferred, further imaging revealed a large portion of a pen, which was subsequently removed surgically.

It was quite interesting seeing howing eye trauma, and facial fractures, are repaired. An incision is made on the inside of the lower lid until the bone underneath is accessed. And then that opens a whole eyeball world. The topic was interesting and enlightening, although it still makes me squirm.

Pilon Fractures

It seems we've had a rash of pilon fractures come through lately and it prompted me to share here. Really this is something the ortho guys love, but as well all know ortho and trauma work pretty closely together. So first off, what's a pilon fracture? It's a comminuted fracture of the distal tibia that usually occurs from vertical/axial loading which drives the talus into the distal tibia. It generally seems that the axial loading mechanism we see is a jump from a height. There are probably a multitude of ways to break your distal tibia other than a jump. A motor vehicle crash is another frequent method.

The picture above is lateral x-ray of a pilon fracture and the picture to below is an A/P (anterior/posterior) view. Treatment can be either non-op or operative repair, and I generally see the Ortho guys go for operative fixation. This, of course, depends on age, comorbidities, and all the other factors that go into deciding if a patient is a surgical candidate. Nonetheless, they are practically always splinted and made non-weight bearing. Bone union usually occurs in 2-3 months. Apparently it's reported that those without surgical complications can expect about a 75% chance of a good outcome, yet I think clinically I see it higher than 75%.


When the mechanism is a low-energy impaction, it's not uncommon to find this as an isolated injury, or at least limited to the ipsilateral extremity. This tends to be the case for the jumps I mentioned, but those can also include bilateral extremity injuries and back injuries if it was from a descent height. A motor vehicle crash would be a high-velocity impaction and then you can certainly have a whole host of other problems. This could be to the extent that the pilon fracture is now small potatoes compared to the chest, abdomen, or head injuries that are immediately life-threatening. But it's always good to give a shout out to the bones too.

Can I get a drink?

It is not uncommon to see chronic drinkers end up on the trauma service. When it comes to trauma, it seems just about anything goes. "Fall" or "found down" are common catch-all types of trauma we see, when in fact there may be no trauma. My favorite was "found down in bed." Hum...most of us are. At least I am; every morning in fact. Anyways, the fall or found down group will often bring in a drunk. And generally, if they do have a "traumatic injury," it tends to be abrasions, lacerations, contusions, and hematomas/cephalohematomas. Not all, of course, but more often than not. So clearly the plan would be to clear their cervical spine, i.e. get the neck collar off of them once the radiology read is back and negative, and then discharge home, or street.

That plan can be delayed if they are still drunk because they can't answer your questions, because they can't walk straight yet, or because they just won't wake up enough to leave. But then, if they drink a lot, you only have a window to get them out once coherent enough to talk, walk, and eat. If they actually had injuries, you tend you run into problems. This is because caring for the injury tends to take longer than that special coherent window. Even if caring for their injuries was essentially consulting another service (say Plastic surgery for a nasal fracture), and they say the patient is non-op and ok to dc, but it took until the following day to get that answer, then you may have missed the window. Then ensues the withdrawal, and what would have been a short hospitalization turns out to be longer than a week, sometimes requiring them to go to the ICU for management of severe withdrawal.

One thing we do at our hospital that some people seem surprised by is that we give chronic drinkers beers with meals in the hospital. This is with the thought they can be discharged soon and they will go back out to drink again. In order to stave off the DTs, and in turn avoid a long hospitalization, we give them beer. Ativan is always made available prn, too. If they have significant injuries and will be in the hospital a while, that tends to change management. Generally then the choice is to go with a Librium taper. But we rarely start a Librium taper on an overnight drunk with minor abrasions. I do think it is a bit sad that they don't get intervention. It is, however, true that most of them go straight from the hospital to go look for a drink. They'll even tell you that's their plan. So in those cases I suppose beers with meals is a proper plan. But I think it would be nice if we also had a routine of offering our drunks the option of a Librium taper prescription if they'd like to kick the habit. But now you know, some hospitals do indeed give patients alcohol.

A super union

I've been excited reading about the creation of what's been touted as the "RN Super Union." And then I read that 1 week ago, on Oct 1, that Massachusetts has joined the team. Now leaders of 3 major nursing organizations have formed the National Nurses United (NNU). It is now the largest union for registered nurses with 150,000 members. It is the United American Nurses, Massachusetts Nurses Association, and California Nurses Association/National Nurses Organizing Committee that have come together to form this professional association aimed at improving patient care conditions, protecting RNs, and expanding patients' rights and RN practice.

I think this a great move. I am in complete support of this union formation and think it will only help nurses gain a national voice. As part of the California Nurses Association, I see the benefits that a union can provide at the state level. And it was this voice in CA that helped establish the successful RN-to-patient ratios for safe staffing law. Taking a union to the national level can only help raise awareness of issues that nurses face every day, enhance our advocacy for patients, and collectively join on common goals and issues no matter your state.

NP-MD model

Well, I've returned and thought I'd share a bit about my trip to another trauma job. I think it is always interesting to see how other hospitals run their business compared to what you're used to. I know my hospital has been interested in the idea of an NP-MD practice model, but not sure how to approach it. I can see why. When you sit in your own bubble, used to the problems and bureaucracy of your institution, it's hard to envision it different. But when you visit another place, you see what they've tried. The difficulty in going to an NP-MD model is what happens to the residents? Obviously they need to train and need to be there. But then how can you run a service with only the NPs and an attending physician?

So what I saw at this other hospital was that they separate the residents from the NPs right out of the gate. They have an entirely different set-up, where the trauma patients are on one floor and that floor is covered by the NPs. Somewhere else the residents are off managing other patients, trauma patients I assume that didn't get a bed on the trauma floor. The way I'm used to is I meet up with the resident/intern every morning and we divide all of the trauma patients, no matter what floor they are on. I see and interact with the residents all day. By all appearances, the NPs at the other hospital never see the resident, except for sign out at night to the on-call resident. There the NPs completely manage the floor almost entirely alone and round only with the attending, and there are no layers of residents. It's a more autonomous situation I think for those NPs. But every method has ups and downs. Just as they are downsides of less autonomy where I am, there are upsides of consulting the chief resident on specific issues and the opportunity to do more teaching.

So what's my take on the whole experience? I think it's a great job....but I'm not sure if I'm willing to leave what I have for it. Maybe had I actually been looking for a job, I'd be inclined to make all the sacrifices to go for it. But like I said, I already love my job and why leave it for an unknown? It may have worked well with school, but I'll just have to sort out that situation later if school opens up.

Job out of the sky

Ok, so I've been a little delayed between entries lately. I have been mulling over 2 big decisions, which sort of go together. So I'd been considering going back for a PhD, but I've thought about this for years. But now I was thinking it might actually be about time to move forward on this idea. And then I got an email from my previous program director from my NP program about a job opening at that university's hospital in trauma. And the hours looks like a perfect fit for school. Holy moly! Could it get better? Well except for the fact it's like 9 months too early! So now I'm officially going to apply for the PhD it seems. But what about the job? I reply saying it looks good, tell me more. Next thing is, "Can you send a copy of your resume?" I figure, sure, what do I have to lose? But the whole thing spirals into a snowball with an interview and then another big ol' interview coming up. So now I'm thinking, "If this happens, I'd have to sell my house and move 3000 miles away." Ugh. Which, admittedly I'd have to do next summer, but that gives me time to sort things out. This would mean I have to get a move on things right away. So I meet with 3 realtors who give me bad news: either I can't sell my house, or I can't sell it remotely for what it's worth in this current market! AH! Now what? Rent it out? (Which then means I have to rent over there?) Gosh, I don't know. So that's the step I'm looking at. I've got 2 meetings set up with property management companies when I fly back from the interviews to see what they are all about. And what about my current job? I don't know about that either. I love the people I work with, I love where I live, I love what I do. How do I leave? Once again, assuming school does work out, I'd have to leave anyway. But sooner than I planned or wanted. On the other hand, a job like this is unlikely to present itself when I need it to, and for it be at that same hospital is even more unlikely. As you can see, I'm in a conundrum and have some serious thinking to do. I'm first waiting to see how the job really sounds and get the nitty-gritty when I'm there. I have a lot of details to work out if I decide I'm on board for the change. I'll keep you posted!

MetiMan

We have all probably had some experience with simulator models but I realized yesterday that simulators have come a long way since I last saw or worked with one. In nursing school, I remember SimMan. He was pretty neat, where you could hear abnormal breath sounds, different heart beats and rhythms and maybe a few other things. But that's about all he did. At an all day trauma lecture/conference yesterday, I met MetiMan. He's probably a relative, but was far more advanced. I was shocked and impressed by these advances. His eyes open/blinks (with a click), has reactive pupils, can get diaphoretic, cyanotic, has pulses (and apparently can tell if you've assessed his pulses correctly), can bleed out (seriously, like 4 liters), has bowel sounds, can talk, can have tongue swelling, and still has the breath sounds and heart sounds that his relative did. You can practice IV starts on him, chest needle decompression, suctioning (he can make mucus), chest tube placement, and probably more. Pretty amazing to see how technology advances. I think this is a great tool to practice on if you get the chance. However, he apparently costs around $70,000 so he may not be everywhere. I thought I'd share this in case you haven't had the chance to meet the new and improved version of simulators. (I have no affiliation with or endorsement by MetiMan. This is merely for information.)

Ah, the Foley

Yesterday I got into a discussion with one of our residents about Foleys. As she talked about her experience as a med student learning to put a Foley in, it made me think back to when I learned. I remember in nursing school practicing on the rubber crotch and thinking, "Will I really have to do this?" My friends and I joked about it, and of course there was no missing the right spot on the rubber model. And then when it came to attempting on a real patient, I realized this was no rubber model with "X marks the spot." While trying to still get the hang of sterile technique, I fumbled around there for a while trying to get that catheter in. Eventually, I did, but it was no simple feat. The resident related that she's only put in less than a handful and commented about it being harder in larger women. That's the truth. When I worked in the ER, I put Foleys in many times a day. Far from the days of figuring out where to aim, I put so many in it became like old hat. But I had a very large lady one day, and I absolutely couldn't see anything down there. Ultimately it required two people holding each leg and person with a flashlight behind me. It was still a blind shot. I don't remember if I actually got it in or not, I think eventually I did after multiple attempts. But really that isn't what mattered. The memorable part was that to date that was the most difficult Foley placement (barring traumatic cases).

You'll find through your career, that certain things start out hard to do but eventually become easy, or easy enough. Really that's the case with starting anything new and you just don't exactly know what to do. But with time, you learn how to do it better, you gain more experience from your attempts, even if they are initially failed attempts, until you feel you might have a handle on it. But then there will still be those cases that are out of the ordinary, that challenge your skills. And it will be those that you remember.

That's a good question

Pimping is a strange term really. And for those not in health care at all, it probably sounds all wrong. What it is, essentially, is publicly grilling someone on medical facts/procedures/expected outcomes or the such.

In nursing school, there was some pimping from your instructors, but it wasn't that painful. Most memorable was getting asked about all the meds you had to give your patient in their AM meds, which needed to include indications, at least 5 adverse effects, contraindications, special instructions if any (like take with food or avoid leafy greens), and mechanism of action. When you could answer all those questions, the instructor would give you the medication. (I can understand why she did this, boy what a bottle-neck that made for all us students waiting in line for our meds!) But really, pimping wasn't extreme.

Even when I worked as a nurse, I don't really remember getting pimped. Some nurses were definitely not nice to newbies (and I completely then understood the statement nurses eat their young), but pimping wasn't really involved in that.

But then came grad school. Really, I still felt sort of exempt from pimping. I felt like that was more for the docs or med students. And I'm in nursing, so I don't have to go through that. But on one of my rotations I got pimped just like the rest of them. And it was painful. Every time I turned around, I was being asked a question that for the most part was way over my head. Sometimes I had no clue; didn't even know what the question was about! One physician in particular would just work his way around the group grilling people. If one person didn't know the answer, he would keep asking people the same question until either someone got it right or he ran out of people to pick on. Then it would be a new question. On-and-on all day, everyday, for that rotation. And for one of these questions, I simply answered, "That's a good question." I really had no other answer. I couldn't even try to answer it. But for the rest of the day, every time he pimped me, he'd say, "Are you going to say that's a good question?" Painful.

Now anytime I ever say something is a good question, now matter the topic, I have flashbacks to that physician. I purposely try to avoid it, in fact, if I can. So beware, nursing professionals can get pimped just as hard as the medical students and residents. Personally, I'd recommend avoid saying something is a good question though. I have to say, though, pimping will certainly make you learn the questions you missed in front of a crowd of people. And I'm sure this is why they do it. Public humiliation is a great way to learn fast!

Rocks

Something I learned when I came to this trauma job is that there are some patients that are really difficult to discharge. Those patients that stay in the hospital week after week, and then month after month, are called rocks. And at given times, the trauma service can have multiple rocks, or a rock garden as we say.

This notion of rocks was new to me. In the ER, patients came and went. And I suppose in training I wasn't in any given rotation long enough to learn about rocks. But when I became an NP and followed the same patients throughout their hospital course I met the rocks. We've had patients stay on the trauma service for over a year. That's quite a while for a trauma team, which is generally notoriously known for the "young and healthy" hospitalizations. Clearly after that long they have healed their acute injuries, often able to walk independently again, yet usually remain in the hospital due to their social circumstances.

These long lasting patients tend to be homeless, undocumented, or have family unwilling or unable to care for them with no money/insurance to pay for long-term care. Usually the most limiting injury is a traumatic brain injury. Even if all their broken bones are healed, wounds closed, organ injuries resolved, the head injury is frequently what prevents them from other discharge options. This may leave them with limited mental capacity and poor judgement and reasoning that prevents them from caring for themselves; however, they may be able to walk, talk, eat, and otherwise function. Other patients are more severely head injured such that they are not able to follow commands, or track with their eyes, or feed themselves or walk. These folks clearly need placement, and if they have a trach and PEG will need a subacute facility. This can be quite difficult without funding, and sometimes not even knowing the patient's real name for a long time (which delays even applying for funding on their behalf).

It's really quite sad. I didn't truly know this problem existed until I worked directly with it. I imagine there are rocks on many trauma services all across the country. It seems to me there should be a better way to help these patients but right now the system doesn't seem to work in that favor. Maybe someday someone with the power to make a change will see using acute care hospital beds on patients that no longer need that high level of care anymore wastes money and resources when other new patients really do need those beds. Maybe then the rocks could get the more appropriate level of care sooner, free beds in crowded hospitals for those who need acute care services, and actually save money by spending it appropriately. I realize it's probably a pipe dream to think a big system change like that could happen in my lifetime but I'll hold out hope for the sake of all the rocks, and all the new patients that need the rocks' beds.

Do no harm

Someone recently asked me how hard it was to learn nursing. I think it was hard for the mere fact that you had to learn to do things that most professions never ask you to do. And in many cases, some of the things you have to do just don't seem natural. I went into nursing to help people. I remember having to learn to place an IV and thinking, "But I don't want to hurt them." Of course there's no other way to get an IV in. It's going to hurt- it's a needle. Initially that was a barrier because I felt like I wanted to soothe people and thought I was in the business to make people feel better...not hurt.

Then I one day came to the realization that there are things that are necessary to make them better and to feel better, and sometimes this will incur pain to get there. I learned that in order to treat your patient well and appropriately, you will have to do certain tasks that make them hurt or uncomfortable. Sometimes a proper assessment can cause discomfort (assessing a wound, checking for rebound tenderness, CVA tenderness, etc.) but to NOT do it is remiss. To not properly assess the patient, or not place the IV, is not taking care of the patient, even if it avoided hurting them for the moment. Once I came to this realization, I found doing what I had to do easier. And educating your patients is where you can really shine!

Providing your patients with the information as to why you're doing something is crucial. So often they are whisked here and there, told to do this or that, with little information or explanation. Telling your patient why your placing the IV, why it is important for them, and how it will help them is really what they want. Most patients, when they know why, are agreeable. It makes for happier patients, and your job easier. And I'm sure some of you say, "There's no time." I'm not saying to have a full blown discussion of the pathophysiology of it all. Just fill the dead air time with education. There's never a need for awkward silence with your patient because they always want to hear what information you can provide about their current condition, disease, the plan, what to expect, etc. As you pull the IV out of wrappers, or as you look at the wound, or whatever the case may be, talk as you do it. And I think it helps to know that to be a good nurse, you have to sometimes cause some pain. You don't help the patient by not doing the right thing for them.

AANP Conference

I went to the American Academy of Nurse Practitioners conference in June this year for my first time. It was a neat experience and great to be around so many NPs. The one thing I noticed though, was just how many NPs worked in primary care. I knew from reading, many NPs go into in primary care settings, but I suppose not working in primary care myself I never really see it first hand. In grad school I pretty much spent all my time with the Acute Care specialty folks and never really knew what Family or Adult were up to. And since I've always worked in a hospital, I still spend all my time with other ACNPs. Many AANP meetings were on primary care topics, many folks I met were in a primary-care specialty, and I was feeling a little left out being in Acute Care. It got me wondering just what were the specialty demographics at the conference. Well, I don't know about the conference directly, but I learned that the AANP membership consists of 62% Family NPs, 22.5% Adult NPs. ACNPs were only 6.5%. No wonder I felt out of place. I was particularly excited when there was an acute care topic and I could bond with others that worked in the hospital setting.

But overall, being at the conference was a great feeling, because in the end we are all NPs. There are times at your hospital job you feel out numbered and aren't sure where your big support group is. In some cases, you may be the only NP on your team, or even in the hospital. That was the case in my previous job. But I never felt like that when I worked as an RN. Then I had a bunch of other nurses around me, and a whole chain of nursing command that I knew was there to go to if needed. Don't get me wrong. I absolutely love the surgeons I work with, and feel truly part of the team. But I'm not a surgeon, nor do I care to be one. There are a couple of other NPs I work with, so I am not literally the only NP around. That helps. But when I went to the conference, the best thing was we were all NPs! That alone made us connected. And then to top it off, it was also the largest NP gathering to date. Now that's neat!

What's the difference

I am often asked when I say I work as a nurse practitioner, "What's a nurse practitioner?" I'll also get, "Oh, is that like an LVN?" or "Oh, my friend's a nurse and...". I have learned that many people don't know what an NP is. So how is my job different than an RN? Well, I am an RN too, but I no longer work at the bedside. The easiest way to describe the difference is to say how my job changed from when I worked as a nurse to what I do now. As a nurse, I carried out all the orders the physician, nurse practitioner, or physician assistant wrote. (As a point of reference, I worked in the ER). I did functions such as placing IVs, drawing blood, placing Foley catheters, placing NGTs, performing EKGs. Those were fun things, but there were a lot of not-so-fun things. For me, that was namely cleaning up after bowel movements. Now, I was in the ER, so fortunately that wasn't nearly as often as nurses who work the floors/ICUs have to deal with. But for me, the bigger downside was not having more control over the patient's management. It was one thing to have to "anticipate the doctor's needs" but it's another to actually make those orders.

Now as nurse practitioner, I manage my patient's care. I write orders for tests or labs they need, interpret the results, write prescriptions for meds they need both inpatient and at discharge, discharge patients from the hospital, work with the interdisciplinary team to prepare for discharge (like needing a wheelchair or placing in nursing facility). Some other functions include pulling chest tubes, downsizing or discontinuing trachs, and doing VAC changes. During grad school I learned how to place chest tubes and central lines, but the job I took doesn't have the NPs do this- in part because I work at a teaching hospital where all the residents are dying to do them and need to learn as part of their residency. What procedures you do will vary according to the job, and according to your state's reguations.

For me, moving from the bedside to have more autonomy was the right choice. I know many nurses though that have no desire to have authority to manage the patient's care. And this is certainly not because they are not capable of the work. But realistically with the autonomy comes more responsibility that some nurses just don't want. Not to mention the sacrafices of going back to school after you already have a great job, and potentially worse work hours than you had. Some NPs take call- I fortunately don't. All-in-all, I think going back to become an NP was a great decision and I would support anyone considering the idea of working as an advanced practice nurse!

Trauma by region

I was reminded yesterday, as I cared for a patient hit by a surfboard, that you don't see this kind of trauma everywhere. Beach trauma is only relevant to certain regions. Although obvious, I guess most of us don't really think about the regional trauma you'll get when picking a trauma job. Going into trauma I expected car crashes, gunshots, assaults (which of course I do see plenty of), but living on the coast brings an additional group that I realize not every trauma center will see. On the other hand, my friend's sister works in trauma in a rural region, and sees things I never would: animal attacks, snowmobile crashes, and even falls in wells. Other locations can see farming accidents and bull riding accidents and south sees border-related trauma (often injuries from jumping the border). I love working in trauma and personally I think the beach-related injuries are an interesting change. But I think it is interesting that a group of people all trained and ready to go out into the trauma world may end up really seeing some different cases depending on where they decided to work. I did all my training in ER/Trauma at a school not near a beach so getting a surfing accident was new when I moved. But does that matter? No. Ultimately trauma is trauma, and really regardless of mechanism, you approach it in the same fashion and with the same protocols. But for those of you new to trauma, or considering entering trauma, this may be an aspect you haven't really thought about- just as I hadn't. Realistically, I think just about any trauma center you go to will have motor vehicle crashes (and motorcycles) and falls, and sadly I bet assaults. But there will also be traumas that are unique to your location, which may actually be the ones that you find extraordinary and make you truly connected to your community.

Welcome to Nurse Central!

Hello blogger community and readers!

Welcome to Nurse Central, a place to discuss all things nurse-related. Nursing is a great career path and I'm here to support any potential newcomers to the profession, as well as connect with fellow nurses of all levels, specialties, and locations. Health care professionals, and nurses in particular, are a unique group of people that are bonded together by experiences very few other professions are exposed to. We have to see, do, and deal with things on daily basis that bond us together in a special way. And sometimes you want to talk about these experiences with others that can understand where you are coming from, but perhaps don't want to share it will all of your co-workers.

I am a Nurse Practitioner and have already created an informational website for NPs (http://www.worldofnursepractitioners.com/). But that site is primary only devoted to nurse practitioners and so far doesn't offer the opportunity for anecdotal discussions. I believe informal discussions or narratives of the job are sometimes just as important as the formal academic information. For those considering entering nursing, it just may be this information that gives you the the full insight into the career to make a decision. And Nurse Central is for all nurses, or soon-to-be nurses, or even those just curious about nursing.

I will share my thoughts, experiences, advice or tips, and I look forward to reading any comments or questions as we go along. Welcome!