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.