It is a zebra

How many times did they mention the zebra to us in school...basically telling us that this a something rarely seen so keep it way back in the differential ....so you get a patient with pneumonia....treat accordingly...discharge and you are all good...you did the standard of care ...got the xray, cbc chem blood cultures sputum cultures treat with empiric antibiotic for CAP until cultures finalized...and you are good...wrong...the patient is discharged to home on oxygen and never needed it before...first clue...yeah...you send him home on his merry way....in a week...he returns to another facility more dyspnic even with the oxygen...multiple CT's bronchs...antibiotics...he is better good to go ...right...wrong...returns again in respiratory distress...multiple xrays, CT's showing pleural effusions...thoracentecisis after thoracentisis....antibiotics.... without improvement....pull out the big guns...thoracotomy wedge resection....guess what ...he has BOOP....needs steroids over long period of time...in the meantime during this last hooray...he was intubated , vented and trached and lost lots of weight and needed a PEG....wow....so now I get him...wonderful man...ready to jump right back on the horse and get better and go back to work...what an ordeal for this man....okay when in this picture do you think we should of thought of the zebra???BINGO you are right...when someone who didn't need oxygen now needs oxygen...Lesson plan and summary...we are all human God only knows I am not perfect... we get so wrapped up in day to day shmuck in trying to discharge people on a timely basis...we all need to sit back and look at the picture and remember the zebras

What I see during the day

What I see everyday is different from anyone else....working in health care is different from any other career....things I see would not be seen in other peoples' work areas..it may not be accepted or appreciated...My day starts by greeting my first patient sitting outside in his wheelchair catching the rising sun, drinking coffee and smoking a cigarette...they aren't in regular clothes because they may not have any other than the VA pj's we issue everyone when they come in....walking to the elevator I see recovering(substance abuse) vets who are now attempting to be reintroduced into society by working as an escort on my floor...they accompany me on the elevator up to the 2nd floor to start their day of work as well...please note the pay for this job is below minimal wage...but they are thankful they are provided room and board by the VA during this transitional period....I walk to my office an are greeted by the nightshift nurse...always smiling to see me ...accompanied with reports of what happened through the night and a swift good bye so they can leave and attend to their normal lives...once in my office I may occassionally get a knock on my door from an early rising patient who has questions or greets me for the day....once I complete my morning computer run...I walk to morning report to the next building...always greeted by other vets waiting for the DAV van to take them to appointments either to Philly VA or Wilmington VA....once report is completed...I head to my unit again and already have made a mental note of my priorities for the day...walking down the hall I catch a glimpse of many vets lying in bed sombering away....in one room is a wife sitting by her dying husband looking out the window...what is she thinking...does she know that today may be the day her beloved lifelong partner may leave her and this world...further down the hall I see the vet who helps recreational therapy preparing the morning coffee and snacks for the vets on our floor in the day room....I see vets who are bedbound and others who are rehabbing their injuries or recent surgeries...many vets who are on oxygen but don't want to give up cigarettes and turn the oxygen off as they go out and smoke...I see vets who are homeless,disabled and have no money and depend on us to find them a place to go....see vets who have drank themselves from a lively person to decompensated person with no one love ones to help them during their end of life...many come to us with no family support or social support and depend on us to help find them a home or give them a place to die peacefully...I have seen multiple individuals who have been riddened with psychiatric problems with no one to care for them but us...some with multiple medical problems that have no other insurance or finances but the VA to care for their complicated medical course....I have seen loved ones bring their family members to us to find answers for their medical and psychiatric problems...the list goes on...I have found that my day is bombarded with many emotional facets to the gammet of problems and issues that come from all of my patients....my beeper goes off continuously as well as my phone rings without a break..multiple interruptions from families, patients and nurses and other disciplines....but my day ends knowing I have done my best to help these vets...I always walk away knowing I have accomplished a list of tasks, answered questions and held a hand an mostly smiled and consoled my vets and their families...I never walk away dissatisfied with my job...I may be tired and frustrated but I know I have done my best....my day is fulling and I am so grateful I have chose this profession...I look back to my career path..and it only seems right that I have chosen to be an NP...I only wish I decided to do this sooner...but life has a funny way of working its way to what is best for you...this was a perfect match for me ....I cherish my days that I have helped someone being an NP

Full Moon

So I am sure if you work in health care you have heard the term... full moon means a crazy day at work...well that was today..no sooner I walked on the unit...the wolves were howling...Code Blue to start the day on patient that was about to go home...went in to fulminating respiratory distress...ok..get a grip...the day should only get better....although my thoughts were...why me...and how did this happen he was doing so well...wrong to think the day was going to get better....next thing was morning report with nurses when another nurse came in to say another patient was decompensating...uggghhh....thankfully he pulled out of it quickly with quick thinking on the medical teams approach and was stable within minutes...ok..now I can really get to my work...so things went well until mid morning ...attending calls...there maybe an admission with TB...great....but wait until the CT confirms this...so I keep my nose to the grind stone...met with family members on patient #2 that decompensated but now stable...then went on to my daily rounds...wow...things seem to be going better ...hopefully I can eat lunch and take my 30min daily walk...wrong ...phone call from Urgent Care....patient needs blood transfusion...defer to attending to make a decision....wait...does this patient have GI bleed. please check hemeoccult in Urgent Care... in the meantime I eat lunch at desk while working, checking labs and email...call from attending...the patient in urgent care doesn't have a GI bleed can you admit...sure why not...what else am I going to do today....the history and physical wasn't bad but I had to go through multiple records to figure out why this patient has had multiple blood transfusions in her life...nothing really noted in her PCP's notes...(what is a PCP for)....so after multiple phone calls, pages, knocks on my door and 3 hours later I finished the history and physical on this patient.....in the meantime I get a call from radiologist to tell me another patient definitely has osteomyelitis in 4th toe (5th toe was already amputated for this)...had to call podiatry to discuss plan of care then call his wife to give her options on plan of care....then I get a call from a pain doctor who decides to tell me 100 options of pain management on a patient with pancreatic cancer...then another call from a x wife of a patient who decides to run down a list of a 100 questions she wants to answer at 415 pm ...uggghhhh....so the day ended pretty much on time...came home to my hubby who was as tired as me and suggested dinner out...thank God!!!

Daily Activities

Sometimes it is hard to believe I have been in this business for as long as I have...looking back to when I first started as an NP and now have many rewarding memories...Most recently I had the opportunity to help an individual outside of my normal working area....It was last Monday and not so anxious to get the work week started, I was walking to morning report ..I came upon a man wandering in the halls with his coat over his head and face...thinking this was strange, but also realizing Halloween was around the corner...I thought this was an early Halloween performance by one of our outpatients...then I suddenly realized this gentlemen was not celebrating or performing...he was walking into things and stumbling...I ran up to him and took the coat off to see it was one of my patients who I had taken care of many years ago...I see him almost daily at his volunteering post outside of outpatient registration.. He always greets me with "Hi Dr Jayne"...He was glazed over and diaphoretic....He responded to his name...at first I thought he was hypoglycemic...luckily for me the Urgent care was 50 feet away...someone had seen me already and brought a wheelchair to my rescue...we wheeled the patient in and took his sugar to find it was high...he was incoherent would answer questions but not very accurately....I quickly looked through his chart to see if he had any med changes recently ...there were none to be seen...I then asked for him to be further evaluated by the NP who saw Urgent Patients...the remainder of the day I wondered what happened to him..by afternoon he arrived in our Acute Unit...still alert but confused and hypotensive....IV fluid challenge did not rescue his pressure...my attending picked him up and assessed him to find he had a raging cellulitis under his arm...she placed him on IV antibiotics but was concern he was much more then we could handle...he was emergently transferred to a nearby community hospital....I thought of him often as a couple days went by...I then was informed he wasn't doing well and required extensive surgical intervention of the cellulitis...it was so extensive he required transfer to a tertiary hospital....I think to this day....thanks goodness I was in the right place at the right place....thankfully my normal daily routine was helpful to someone else's need...just hope it does well and I can see him again in the hallway back to his old self and hear him say "Hi Dr Jayne".

Nurse Practitioner Web Log: BFF's

Nurse Practitioner Web Log: BFF's

BFF's

well my best friend has ended her battle with a progressive neurologic disease that had left her paralyzed and dependent on bipap. She has left a great void in my life, but at the same time she allowed me to take part in her last few hours. After 17 years of friendship, I watched my friend go from a healthy and active 52 year old Nurse Practitioner, mother, wife,vegan and avid runner to a person who is dependent on everyone to live minute to minute. Her disease started almost a years ago with a limp. Got better. And then with each remission came back with vengence. This last remission left he a flaccid quadraplegic and dependent on bipap for breathing. She could never to continue like this. Despite 2nd and 3rd opinions and best the teaching hospital, she took things into her own matters and demanded to come home and be placed on hospice. She was very percise on how and when she wanted to have her life ended peacefully. She knew what she wanted to wear, what pictures she wanted to have around her and even the music playing in the background...even her water bottle by her side...The last 18 hours I spent by her side and we smiled, talked, joked and laughed...then was the time she had asked me to dress her in her running gear and then say good bye...She was the best friend I ever had...We had similar likes and dislikes. We also saw some things eye to eye and some not..but respected each other for who we were...we shared good times and bad times ..we cried and laughed together throughout the years...you are going to be greatly missed. but I thank you for letting me see you through the end...You were a co worker, preceptor and confidant ...you are my hero

In Memory of Deb Rodzwick Carlis CRNP

Hard Times

I have had some really emotional times in the past couple of weeks..both at work and on the personal front...At work, my co worker has changed 3 times since October...my first co worker, who I wasn't sad to see move on, is now back again..can I tell you I really didn't miss her over the past few month...when she left I worked with 2 other PA's both men...let me tell you ...they did their work and let me a lone and left when the work was completed...they didn't want to talk much ...which was fine by me...this gal is opinionated;critical; talks too much and is driving me nuts... I am really finding it hard to get re acclamated to her again...I have to learn all over again how to ignore her...any tips...all are welcomed
On the personal front...I know I have mentioned my friend with transverse myelitis...well she had been in and out and back in the hospital again...all the mobility and sensation she has gained is gone 100 fold....she was first admitted with hypothermia, hyponatremia, hypotension and bradycardia...she ended up with SIADH...now as a pacer...was discharged and not even home a week and back in with hypernatremia...and now she is completely paralyzed (quad) with dysphagia, inability to speak and respiratory decompensation...what the hell is going on .....why can't anyone help her...she is now going to need a feeding tube because she can't swallow...anyone out there have any thoughts...from what I know her neurologist is going to try some type of chemo(cytoxin?) agent to boost her immune system however one of the side effects is leukopenia which she already has...I feel so helpless...know all that I know and I can't even help her...I think of her day and night...I wake up and she is my first thought...if anyone has experience with any patient that has had similar symptoms...please email me....would love to hear how it all worked out for them...in the meantime...prayers...

Life Goes On

I am back..not writing as much as I would like to this year...but trying to do my best...Have been thinking a lot about the next phase of my life...retirement...what would I do...when can I retire...I am 52...I am already thinking of this. A lot of this is due to jealousy of my spouse who is 10 years older than I and has already retired...he was fortunate to do this at 59....some of it had to do with health issues and just plan old being the oldest dog in the rat race where he worked....he is probably the most happiest I have ever seen him in the 24 years we have been together....he still works 2 half days a week at a hardware store....and has a very small business..( this is really just a hobby with tax right off benefits)...but he gets up everyday and just does what he wants to do...mostly his day starts as going to visit a group of men his age who hang out at a pool supply store...he stays there til lunch...eats lunch there (usually chinese order out) then comes home...takes a nap then gets into stuff around the house.
So I think what would I do if I retire....well first off I have to get there...I am thinking another 6-10 years...if I wait til 62...I am going to hang up my stethoscope collect my pension and ssi and just relax...if retire earlier ...will have to work part time...
But then I think...I really love what I do...I know there are days I am totally drained and just had enough...but I come home...have a relaxing night..go to sleep and back to work the next day ready for more...I have come to realize that what I am doing now is what I was made to do...I have come such a long way in my personnel and professional life that in hindsight...this is it...I really struggled in the past to become an NP ...but once I made the decision to go back to school I was really dedicated to get through....this was another story I will tell next time..the hardship I faced personally when I was going to school...even when I first started practicing I faced some challenges...first I could not find a full time job...so I had to work 2 part time jobs to make a full time job..then I was so unsure of myself in what I was doing...it took me at least 2 years to fell comfortable in a family practice...then I decide to really switch things up and work in a VA with elderly complex medical patients....I have been through many challenges and learning curves...I fell very good of where I am now in my life and profession...granted I still need to read and educate myself ...but I really feel good...retirement is a goal ....they say you will know when you are ready...I am not ready yet... but dreaming doesn't hurt....

Friends through thick and thin

I am currently saddend by a friend who is strickened with transverse myelitis....first of all I have known her for 18 years...we have been through a lot...first met at a job that was new to both of us...we were both clinical nurse specialist. I was a Med surg clin spec and she oncology clin spec...I looked up to her beacuse she was in the role a lot longer than I was...she taught me a lot...we faced many challenges together at the hospital we worked for ...however we and the other clin specs raised the bar of nursing practices as well...this was done with many challenging forces both staff nurse and administration...in the long run...the challenges got us all ..and more or less chased us out of the institution...we all went back to school to become Nurse Practitioners..I was the last. My friend was one of the first...again she helped me with this new role being my preceptor and a great supporter in my new role...our lives have changed million times and we both had face personnel challenges throughout the years, along with this and our professional challenges, we always managed to stay in touch..instead we grew closer and closer together...this new challenge for my friend has given us another challenge to face....not with our friendship..but how to help her make her better and get back into the mainstream of her life and career...currently she is paralyzed from the waist down..she has faced many relapses and has tried to stay positive ..but this isn't always easy...she is now on the other side and is the patient...facing the many challenges of knowing what is right and not right when it comes to providing the better of health care...I think this is the most frustrating thing for her....she has seen good and bad care and becomes very discouraged..but yet has enough will in her to know what she wants and verbalizes that as well....she has been in rehab for over a month...faced with a relapse during this time and has said enough is enough....she is going home and doing it her way...she has been stricken with over 3 UTI's during her rehab stay (needing to be straight cathed) and know that at home she won't be exposed to the multiple care providers and potential for bacteria with cathing...she is going home and paying out of pocket for her own rehab therapist....I am going to do my best to help with her wishes and see she gets better and back to walking again...if you are reading this and have any faith in God...please pray for her...thank you.

Friends

I am currently saddend by a friend who is strickened with transverse myelitis....first of all I have known her for 18 years...we have been through a lot...first met at a job that was new to both of us...we were both clinical nurse specialist. I was a Med surg clin spec and she oncology clin spec...I looked up to her beacuse she was in the role a lot longer than I was...she taught me a lot...we faced many challenges together at the hospital we worked for ...however we and the other clin specs raised the bar of nursing practices as well...this was done with many challenging forces both staff nurse and administration...in the long run...the challenges got us all ..and more or less chased us out of the institution...we all went back to be Nurse Practitioners..I was the last. My friend was one of the first...again she helped me with this new role as acting as a preceptor and a great supporter in my new role...our lives have changed an million times and our personnel challenges, along with our professional challenges never broke us apart..instead we grew closer and closer together...this new challenge for my friend has give us another challenge to face....not with our friendship..but how to help her make her better and get back into the mainstream of her life and career...currently she is paralyzed from the waist down..she has faced many of relapses and has tried to stay positive ..but this isn't always easy...she is now on the other size and is the patient...facing the many challenges of knowing what it is right and not right when it comes to providing the better of health care...I think this is the most frustrating thing for her....she has seen good and bad care and becomes very discouraged..but yet has enough will in her to know what she wants and verbalizes that as well....she has been in rehab for over a month...faced with a relapse during this time and has said enough is enough....she is going home and doing it her way...she has been stricken with over 3 UTI's during her rehab stay (needing to be straight cathed) and know that at home she won't be exposed to the multiple care providers and potential for bacteria with cathing...she is going home and paying out of pocket for her own rehab therapist....I am going to do my best to help with her wishes and see she gets better and back to walking again...if you are reading this and have any faith in God...please pray for her...thank you.

It always happens in 3's

How is it in the medical profession everything happens in threes....someone dies...it is in 3s...someone codes...it is in 3's..someone falls ...it is in 3's....well this week we had 3 codes in a matter of 48 hours on our floor.....is it the change of season..the lunar force...time change...don't know if anyone out there has an answer let me know....another thing is Full moons..if you are working in a hospital, you don't want to work during a full moon...crazy things happen...for us ...people fall, leave ama or do crazy things...like being admitted for alcohol detox and leave the unit to go to the downtown bar...again..lunar forces????
The codes on our floor were from a man being unresponsive, a staff nurse suffering a panic attack (aka chest pain) and a patient who decided to not breathe very well because of his moprhine for pain medication.....of course they all happened when I was there..and 2 out of the 3 happened right before I was ready to leave work....so much for getting out of work on time..and the last one happened on a Friday afternoon..not very good timing...but codes never are...but I do have to commend the nursing staff, respiratory, ems, and my attending for always doing a great job and acting smartly and quickly in providing great emergency care....until next time...watch out for the full moons...and remember it always happens in 3's

DNR

The worst part of my job is discussing DNR status with a patient or their family. I find people are not well educated as to what really happens when a patient is found without a pulse or breathing...people only know what they see on TV which really doesn't protray the reality and success rate of CPR....the drama of doctors and nurses beating on someone's chest and putting pattles on someone and then showing the EKG monitor going from aystole to NSR is not what really happens. I had the opportunity to really explain the success rate of CPR to a family member the other day...I have to say this is probably the 100th time a provider has explain this him during his brothers longterm stay and he always says "I want to do to my brother the same thing I want for me"....well the reality is that the healthiest person will only have a 20% survival if CPR is preformed on them....if the person, like this patient, has any other health problems(emphysema, ascvd and heart disease) that 20% significantly drops...then I get the question...what would you do if it is one of your family members...I don't even want to go there...why does hearing what I would do help you decide what you are going to do...just know the fact plus look at the quality of life...this particular patient has already has a poor quality of life...has dementia,fed by tube feed is dependent in his care, is immobile, needs a lift to get him in and out of bed...I just don't understand how his family sees that doing CPR will make this man's life any better.....I am all for doing the best for our patients and do no harm but really what is truly the best for this patient...I just hope after my lengthy conversation with this patient's brother, that he really makes a sound and educated decision....I know thats what I would want for my family members...

Work Doldrums

Well, I am trying to keep my promise to write more this year and here I am again...I am sure many of you feel when does the work day end and when can I go home and soak my self in calgon to get me away from it all... typicallly I don't feel this way. I have learned to handle the stress of my job creatively and productively...I come home kiss my husband and sit down and relax to a good home cook meal..maybe accompanied by a glass of wine,...then prop my feet up and do some mindless reading or knitting in the winter or gardening in the summer...for the most part I look forward to work..but this week was not so...first of all I am really hating winter...Southeast PA has had its share of weekly snow or ice storms; secondly (as I mentioned before) running solo at work without help on these snow days hasn't helped my morale...then I was sick last weekend into the beginning of the week...I hate being sick... no kidding...my job is taking care of sick people all day...why do I want to feel the way they do...not...so I was really feeling low and under...to the point I told my husband ...not sure how much longer I can do this....so, I thought, what are my options...Well I can retire in 3 more years...but I still have to work...and if I still have to work what would I do...I know nothing but health care. If I retire and have to work...I want nothing to do with health care...and if I work I want to work part time like 2-3 days a week from 10am to 2pm....I did toss around going for my certification in laser hair removal...but do I really want to go back to school again and learn something else...not...do I sound like I am winning because I am....What other options do I have....well when I came to this point ..the weather finally turned around and we had a 60 degree day and a 70 degree day...all of a sudden I wasn't thinking of options anymore but back to lovin my work...there is one thing I have learned when I do get down and out at work not to take it out on my patients or their families...this does take a lot of patience and indurance...I want the best for my patients and I don't want them into my mind where they feel they are making me this way....after 12 + years of being an NP this has taking sometime and self training to do...so come on warm weather...I nee a healthty dose of Vit d to help my happy thoughts to keep me in the work mode for a longtime...at least another 6 years!!!

Winter Coldness andLoses

Well, we are certainly in the midst of weather in southwest Pennsylvania. Thankfully, Phil predicted an early spring. My winter has been very busy at work. Not because the weather has been bad or the flu season is here. I have been working solo on the worst snow days... My co worker has decided not to come in on snow day because of the distance to work which leaves me holding the fort....Actually it has been ok....thankfully I enjoy my work...despite the busy unit I work on I have found solitude and enjoyment in my patient load. I do have one patient I would like to share of my experience during these months. He was a very challenging patient when he first came to me in September. He literally damaged his mind and body from cocaine. He drained all of his finances and laid in his bed agitated confused and angered. He required 1:1 nursing 24 hours for almost 2 months. Psychiatry saw his patient everyday..The nurses did not fear this man but worked hard to bring him to the point that he would recognize us and cooperate with us. He learned to communicate effectively. Sometimes with choice words and foul language ...but by the time Christmas came around he would wheel himself in his wheelchair and sing Christmas songs with the visiting musicians. He was more social and would even have an attention span long enough to play tic tac toe with one of our nurses....We grew very fond of him but his time was growing short with us and was medically stable to move to a longterm care unit.... that day came he we said our good byes...I knew deep down inside he would soon return....for one thing that I have learned in my years as a nurse and nurse practitioner ...this type of patient can easily become sick and not get better....one month after we transferred him he returned...sick and more demented...I knew as much as I tried to help him he would never be the way I remembered him singing the Christmas songs...I worked closely with his family and many discussion occurred and the family decided to make him hospice...he died within a week of going to hospice unit...Although I was sad to hear this, I knew he lived his last months in a sheltered environment, comforted, in no pain, and around people and family that loved him and cared for him...His family and children are beautiful people and have grown up to love him very much...I did tell him that before he went to hospice..he looked at me and I knew he appreciated me telling him this. The day he died his family came to thank me for all I did.....I was only doing my job and I knew if this was my loved one, I would want the same thing for them that I gave to this patient.