Reflection

Being a Nurse Practitioner isn't all warm and fuzzy at times... You are faced with decisions that affect not only a patient but their family and future. You give bad news and good news. You are a member of a team that sometimes doesn't always see eye to eye.  You must interact with other disciplines that may not understand your perspective.  You must overcome a Health care system that is is dire straights and have to try to give the best care to someone who can't afford being cared for.

In the past few years I often think why did I do this.   I come home exhausted from the constant days interactions with patients, families, staff and other disciplines.  I lose sight sometimes in my exhaustion of why I decided to be a Nurse Practitioner.  I need to stop sometimes and smell the roses.

In the past couple weeks I have tried hard to think what good things have come to me each day.  Each day I always come back to the same thing.  I touched someone's life today.. Some days I may have touched more than one life.

At the end of the day, I sift through the fury of activities and am able to see what impact I have on my patients' lives.  It gets harder everyday when the challenges of the system you work in overpower the goodness you do.

I am really trying hard to grasp this concept.  The challenges of the health care system has made it difficult for providers to remember why they really are there.  It suffocates you sometimes.  It infuriates you with the mound of charting, communication and justification of why we are there to begin with.

So I come back to the question...why did I become a Nurse Practitioner....to be challenged, to provide good care...to continuously learn and be the provider to I would want for myself.  It is hard to keep this perspective especially when patients don't understand the constraints you are under ...and the system you work in may not truly know what you do on a day to day basis....But the person that it really matters is to me....I know...I put the best foot forward...try to keep perspective...and always remember at the end of the day.....why I became a Nurse Practitioner....was it worth it ....Yes...I am a better person today then I was 18 years ago .... I have grown to learn more than I ever dreamed of....I have become a person that I thought I would never been able to be....I have become someone that someday a patient, a family member, a staff member or a peer will say...She was the best Nurse Practitioner I have ever met.

Challenges of the challenges

No one ever prepares you when you are in school of the challenges you may have ahead of you.  Some of the challenges are unknown.  You are given tools to assess both through questioning and physical exam. The next step you are taught to make differential diagnosis and plan appropriate diagnostics and interventions. Are we ever to prepared to face the  the emotional challenges of patient's ..their demons...their addictions and past emotional problems  that mold them into  persons that they themselves can't face or deal with.


My week was spent working with a patient only experiences through the year could possibly prepare you. I can read about substance abuse, PTSD, anxiety, depression...but when you deal with a patient who has physically caused harm through his own hand of use of IV drugs...you need to dig down deep into the overall experience you have in your possession..rid yourself of making assumptions


IV drug use ..skin popping..do you know they can cause infiltrating infection to you skin...do you know you can potentially cause life threatening infection ...loose you limbs and even death

But you come to me to help you....Time, energy and empathy go into deriding the dead and infected skin from your limbs....time, energy, comfort and empathy go to into providing pain meds and dressing changes to help wound healing after dead and infected skin have been removed surgically

You are given over and above the pain medications that are allowed by CDC requirements and you want more....

You know what the consequences are if you jeopardize your care...but you do  it anyway...Leave the  prior to skin grafting that would protect the exposed muscle and nerves that are left after the infected overlying skin is removed ....saying you are going to another facility who provides conscious sedation during wound care....you leave saying you won't use any drugs until you get to the hospital


I go over and above to seek out a plan that would be amenable to you...go over risks vs benefits of leaving at this point..knowing the lost of your limbs and even death are possible


You....deny drug seeking behavior....you leave ...and don't go straight to a hospital


You are out there with your demons and your addiction.....when do you get it and enough is enough

For all those who work with the patient's who are suffering addiction....you know what I am talking about....you think they get you and  you get them....but some just are ready.


Be patient....and be there when they are ready to make the change

It Has Been A Long Week

Do you ever have those weeks where the days seem to blur together and you find yourself at the end of the week and you don't know how you got there?  Well, if you haven't I can tell you about my week.  It was centered around one patient. How can one patient take up most of your time.  They literally occupy all the energy you have.  They find ways to make them you. I can't go into much detail...but I can tell you ,that as much as you want to help a patient, they may not see your help as beneficial. They may have perception that you are not what they need nor know what you are talking about.  They exert all of their energy into things that are making them sicker and preventing them from getting better. Despite your help and professional expertise and attempting to educate them differently...they are on a  different wave length....This wave length may be attached to deep seeded emotional issues that prevent them from seeing the realism of their real problems.  Their perception  of what will help them is what will hurt them.  Despite your efforts and attempts to see you care...they despise  you and make you the enemy. It saddens me that I can't fix this....It frustrates me I can't help them realize....I will never understand how mental illness can affect an individual to not making the right decisions. Despite their competence, they emotions, personality and behavior supersede their best  judgment and overcome their actions and decisions.
It is frustrating and beyond my understanding how this can be.
Being a Nurse Practitioner sometimes sees those who despite wanting help can't be helped because deep seeded problems that they have yet to face .

It Has Been Too Long

Wow...I have been away for a long time.  I started to read my blog this past week and thought...I really did a great job and I miss this.
Needless to say,  a lot has happened since I last wrote.  In summary, my Dad past away December 16th 2014...He was everyone's rock and hero....I was with him when he passed. He was on hospice on the inpatient unit I had worked....It has been difficult with his passing.. Mostly, my Mom has had a lot of emotional ups and downs.. She also has had some minor physical ailments....We are all trying hard to help in what ways we know.

Work has changed significantly. I am still working at the same place and same unit; however, the patient mix is different. We are now a SNF instead of Short term medical unit. We had to downsize one provider and many nurses and bed count.  It has been a challenge.  I am still not sure administration knows what we are...I try my best to remember my priority is the patient....and stay out of the politics.
VA has finally passed ruling of Full Practice Authority for Advanced Practice Nurses.  Our VA is slow on moving on this..but we will get there.  I am sure there will be challenges on the way.  Most immediate is educating others on what this means...
My Daughter relocated 4 years ago to Indianapolis from Maryland....she finally is back on the East coast living in Baltimore...It is a good feeling to know she is close by. Most importantly, she has achieved a goal she has set out for herself ....So very proud of her.
I am a great aunt x2...Nephew 3 years ago and niece this past January....We also had 2 weddings in our family ( my niece and a nephew 2 years ago). Another wedding for next year (another niece).
My husband and I will be celebrating our 25th Wedding anniversary in November...We have tentative plans to celebrate with a dinner with close friends and family.

I have been precepting a lot of Nurse Practitioner students.  When I first started doing this, I wasn't sure if I liked it or not.   It has been a full filling experience....It is exciting to see how they grow throughout their time with me. The downsize on my unit gets stagnant with patient experience and it may not benefit in the NP students' learning experience in the long run.  I have decided to take a break from this for a semester or two....then we will see where time takes me.

My career is slowly winding down... I do feel burnt out sometimes.  I feel I have lost the effort to learn and be challenged.  I am growing tired of fighting with those who don't understand what I and my fellow peers do on a day to day basis.  I find myself constantly refocusing on what matters...my patients.

I am looking at retiring in the next few years, but I feel I still can share my thoughts and experiences until then.  I really missed this and I hope I you will enjoy my thoughts and experiences through this blog.

Back In the Saddle

I am sorry I haven't written in a while but life got in the way ...Mostly family things. My Dad was really sick last year and was in and out of the hospital. He had problems with CHF and kidney failure. The doctors tried to keep him comfortable on a medication regime as long as possible. However, in September, this was no longer working and he succumbed to dialysis. It was touch in go at first. His body took a while to get use to dialysis. There was even a point where the hospice word came up. It was very difficult being the daughter and keeping the NP role that I possess out of this but I succeeded. He is doing much better now. His quality of life has improved tremendously. He is doing things now that he couldn't do before.

As far as my life as an NP...I keep rolling..today was one of those days that it started before I was ready with a patient in respiratory failure and running a code to get this patient in a better place than where he was....we got him there and his respiratory status improved tremendously....I still have the fire burning despite a lot of days wondering when I can retire...today was a good day.. made me realize I have a lot to offer.....I am going to end with this but before I go...I would love to hear from you all regarding NP's as Independent License Practitioners....what are your thoughts about this???

Let me know.....until the next time...which will be a lot sooner that the last time

The Geek years...

Ok so not only was I a geek to be a volunteen...I became more of a geek in high school...I was determined to do well in school so I could go on to be a nurse...Let me back up a little and tell you about my scholar skills prior to going to high school...As I mentioned before, I was shy and clumsy and some would say not have much common sense...I didn't apply myself in school as much as I should..My school career didn't really get a good jump start...My parents sent me to parochial school...Let me first preface by saying ..parochial schools are very good and one could get a very good education..however, in the 1960's the class size was was over 50 kids in a class. Each class had the kids sit in alphabetical order. There were no teacher aides. Nuns taught the majority of classes and there wasn't any room for individualizing student needs....So my parents sent me from 1st grad to 3rd grade...Oh and did I mention there wasn't any kindergarten when I was little. So...it was up to Mom to teach you what would normally learn in kidergarten...Already that put me at a disadvantage...so needless to say.....my parents finally got the jist that I wasn't really learning well and they decided to put me in public school in 4th grade....I was really behind in math,reading and spelling and struggled to keep up with the rest of my class. I managed to improve in my learning through grade school....middle school got better but still was average...then I had a revelation...I need to be more organized in my studies...I need to study every night...and I need to read and comprehend every assignment..... I was very disciplined in highschool...wanting to keep up with my studies I would study my notes everynight...Read and re read my reading assignment....I would even study on the weekends....I did try to expand beyond my studies and get involved with Marching band in high school...but I pretty much limited my social scene to Marching band in the fall and concentrate on my studies pretty much the rest of them time....well by junior year it paid off...I got inducted into the National Honor Society and was ranked 6th in a class of 400 kids....I was able to take advanced science classes in my junior and senior year to preprare me for my nursing curriculum in college....I will never forget my chemistry teacher..he was the best and I did really well in chemistry.....I got an A ...and when it was time to take college chemistry I...believe it or not it was a review of my high school chemistry class....all the kids in my college chemistry class were struggling and I was brezzing through it....Needless to say my social lfe sucked in high school...I was a geek...everyone knew who I was but didn't want me to be in their "in" group....I didn't go to any proms or dances or wild parties....I couldn't wait to graduate from high school...I did make an impression on the school nurse... She helped my apply for a couple lf scholarships...I did manage to get one for 3 years of college....Oh did I say college...yes .....when I declared to my parents I wanted to go to college and not a 3 year nursing school they looked at me as if I had 3 heads...This was something new...going to college to be a nurse... I think it was as early as 1972 when the first college prepared program was developed. I graduated high school in 1976. My parents didn't know much about the college route...but I made sure they quickly learned... I was accepted to 2 different colleges ( not many were around) and was so excited when I got accepted to West Chester State College.... this was going to be my ticket to being a nurse...Alleluha...

The Revelation

So I am getting a little sentimental in my old age and want to share as much possible with the younger generation to help them put into perspective how things have developed into what they are now. I would like to share my story and my life with all of you. I want start at the very beginning because I still want to keep the Nurse thing in my theme ...So I will start where it all began...when I realized I wanted to be a nurse. I never thought of being anything else but a nurse...I can't remember when or how this thought came into my mind. I can't remember any particular event that made me want to be a nurse...I think I was just born realizing I wanted to be a nurse...No one in my family had any job related to the health care field. As far back as I can think, I always rationalized and did things differently than the rest of my family. I was clumsy, absent minded and shy...Unlike my siblings who were atheletic, percise and spoke their mind. Since I made my mind up about wanting to be a nurse, I thought it would be a good idea to be a candystripper. The hospital where I volunteered called us Volunteens and we didn't wear the pin-stripped uniforms as one would thinks. We wore a yellow apron instead. We would record our volunteer hours and at the end of the year receive awards for the amount of hours we volunteered.. I remember my oldest brother jeering at me says,"why would you want to volunteer instead of working somewhere and making money instead?" I would always brush him off. I knew deep inside that this is what I wanted. Money was not what I was interested in, the exposure was most important. So I would go in every Saturday from 1-3 and do my duty as a Volunteen. I would report to the unit I was assigned to shyly asking the nurses what they would want me to do. They always saved the water pitchers for me. Now, you need to know that the water pitcher were metal. They had a metal tray and the glasses were real glass. So I was incharge of collecting all of the water pitchers,trays and glasses. Then I would take them to the kitchenette and wash them with them with dish soap and water. Refill with water and ice. Then make sure everyone got a clean water pitcher,tray and glass. My next chore was to pass out the mail, water flowers. I would also help make beds every once and awhile. Do you know what was different about making beds back then. They used rubbber pad under the pull sheet. Imagine how hot that was for the patient.
I would volunteer on Saturday afternoons during school year. During the summer, I would volunteer several 1/2 days during the week. The most exciting assignment one summer was volunteering in the Emergency room. My biggist job in the ER was washing and wrapping instruments to be sterilized. Yes, no disposable suture kits, etc. All re useable. Even there syringes were glass. I was also incharge of stipping the liters and washing /clean them down after a patient was discharged from the ER....washing off dried blood from the litter frames were the toughest. The ER doctor would call me in to watch him suture...I was devasted the one time when I almost fainted. The staff took care of me but I was so upset that this meant I would never be able to be a nurse.....the staff assured me that this didn't mean anything and I would certainly be able to pursue my career goals.
The other place I liked to volunteer was Maternity....I loved taking the babies back to the nursery after their Mothers fed them....I never really spent anytime in the labor room...but got really good at making beds in postpartum unit and watching the babies in the nursery.....
I did get a lot of exposure during these years as a volunteen...The experience definitely confirmed my desire to be a nurse......So the journey began .....the next step was to do good in school and take the right classes so I could be accepted in nursing school...

Teaching...helping my mind and soul

So sorry that another month has gone by and not writing...again my personnal life has taken precedent in caring for my parents....My Mom had a small CVA last month and Dad was in the hospital shortly thereafter with CHF ...I believe it isn't going to stop from here on in...the struggles of caring for your parents with declining health ontop on my family and job get a little overwhelming...but I do try to put things into perspective...my husband is the best and helps with house and yard stuff...and usually has a meal ready when I get home...I have my faith that keeps me strong and focus..
My work has also been a saving grace lately...I have a new challenge of precepting an NP student this semester...Usually I find this to be a negative challenge and frustration due to past experiences...but I am enjoying this student. She is mature and experienced and very knowledgeable and willing to learn and help as much as possible...She is even willing to take on complicated patients...wow...So I oblige and set her loose...I think the most memorable experience for her thus far was to watch my interaction and discussion with a patient who was diagnosed with infiltrative hepatic cellular carcinoma...this one day the patient had a rough weekend and was accepting the fact that he wouldn't be able to go home on hospice and would have to be transferred to our inpatient hospice unit...My discussion with him went well and very smoothly...we discussed his wishes of transfer ....At this time I needed to discuss the fact that being a Full Code, as he had currently was designated ,would be futile upon transfer to hospice...he agreed and accepted to be a DNR...I actually looked at this scenerio and wonder how the student took this in ..the conversation that I have had with other patients in the past ...once found it to be a difficult conversation...is now part of my demeanour of being an NP now....This in itself makes me realize how far I have come and able to mentour those who are learing to be an NP preform such and heartful and emotionally discussion such as end of life wishes...
We have had several complicated patients thus far ...it keeps me on my toes and my mind straight and narrow...she has asked some good questions and I have been able to provide her with excellent resources for her upcoming projects and presentations.... I can hosestly say this has been good medicine for my mind and soul...keeps me focused on the days tasks and goals...
I hope I can write in a more timely fashion from here on in..but not promising anything...I do enjoy writing and sharing my experiences....hopefully you are still enjoying as well...thanks for your patience.

Challenges

My personal life has been a little crazy so I haven't been able to keep up with my blog the way I would like to..so sorry for those who are following me...I usually don't like to divulge into my private life but since it has to do with being on the other side of being an NP I am allowing myself this one time to do so....My parents are in their 80's and have been in good health up until a couple of years ago...my Dad was the first to have medical problems...he was diagnosed with CML a few years ago but is in remission now...However, he has other medical problems that have been making his good days of feeling well fewer and fewer...He has an array of heart, lung and renal problems..His has more days of not breathing well than good days...he can't even help my Mom with light housekeeping chores without fatiguing and getting dyspnic.....he has been to more specialist than I can count on my 2 hands and they come up with the same conclusions...Multi factorial causes to his declining quality of life...My Mom has been the rock for him during this time...making sure he takes he medications;getting him to the doctors; and providing love and emotional support....today my Mother ended up in the ER with TIA....I went to visit her at the hospital tonight and she is devastated that she can't be there for my Father and take care of him....she is his rock...with tears in my eyes I told her it will be ok..that is why you have us ...as much as my parents don't want to be a burden and face the reality that the day is here..they need us to help them...it breaks my heart I see this everyday as a Nurse Practitioner caring for my patients...families that are faced with the challenges of elder parents and providing for their elders...I am there I am one of them ...I am wearing the other shoe..I am on the other side of the fence...I am in a fog right now to tell you how I am feeling..reality hasn't set in quite yet..but I know from experience it is creeping up on me...As I sat in the hospital room listening to my Mom telling me how she is so concern for my Dad...I told my self this is my time to be the rock for my parents.....they deserve it...they have given me a good life and lots of love in their own way..right now I just want to be a daughter and not a health care provider....

The TOP memorable patients in my career

Ok I am sure Jay Leno is known to all especially with his Top 10 whatever...so this gave me an idea to post the Top most memorable patients that I have come across thus far in my career:

16 year old female who was raped by her father became pregnant and is raising the child..

20+ year old female who complained have not having her menses for 6months and claimed she never was sexually active in her life....guess what...yep she was 6 months pregnant

26 year old healthy male who came to the office thinking he had a cold...chest xray revealed empyema

80 year old women never wanted a hernia repair ....it literally hung down to her knees

Elderly female who thought she had the virus came in with nausea vomiting back pain...ekg showed inferior MI...to the hospital with you!!!

Amish male came to office with nail from a nail gun through his leg

Schizophrenic young adult male came in for his depokote shot and closed the exam room door and cornered me and was irate...then he runs out of the office building onto a busy highway

Homeless man complaining of foot pain...unwrapped the soil dressing he had covering the painful area to find and foul smelling magot infested wound

so it is only 8 but I am sure I will have many more found memories to be added to this list

Delirium and awful place to be

So I have to say my 2nd week of the year at work proved to be very eventful...The 3.0FTE provider positions are now 2.5. ..myself and attending and 0.5 PA who unfortunately was not on the floor all week because he was covering another PA who is out sick...best laid plans...and the day this went into effect our census jumped from 16 patients up to 26 patients and still going...yep...another best laid plan...so 2 days into this I found myself attempting to convince an 87 year old delirious patient to have his vitals taken and his pulse ox...He refused saying we poisoned him and we aren't doing for him...I pulled him into a very very quite room and tried to reason with him that we were helping him and not hurting him...he started to get a little agitated and I had asked the nurse to give him haldol...despite all efforts we needed to bring in more troops to get this accomplished....at this point his anger became directed at me saying I poisoned him and he didn't want me to take care of him...I also took away his dentures and broke them as well as his hearing aide....he became a little loud and started to take swings at me...we finally calmed him down and gave him his haldol...he slept for a good 1/2 hour...by lunch time he was up and eating his lunch...he was a little more cordial to me but still believed I was no good and against him...my feelings were hurt because he and I were really getting along very well prior to the earlier incident...thankfully the psychiatrist came in to help sort this out for me and we changed some of his medications...this proved to be a positive thing...he finally got a good night sleep( he had his days and nights mixed up) I went in early this morning to find him back to his old self...he was smiling and was very apologetic to me and told me he would never hate me and loved me and my smile...now that was a good moment and one to cherish...

Growing Pains...journey of a career path

I am writing this blog before I title it so hopeful once I am finished I can come up with a suitable title...I am having a writer's block on what to write anymore...this is bad news since I have only had this blog for a couple years...So I was doing some deep soul searching this morning on what I can write about...actually I was in church while I was doing this...call this my morning meditation....as I was thinking an looking around at the people surrounded me I got this overwhelming felling I have really grown into myself...I am saying this not only personnally, spiritually and also professionally....Personally I look who I have become....not the same person I would have pictured in my early 20's ...at that point all I wanted to do was be a med surg nurse, marry young and have a family...not that I didn't do that ...but I took some detours on the way...I did become a nurse(working part time), I did marry...and I did have a family...the glitch and first detour was when I was 25....the happy ever life as I knew it ended...horrified when my husband told me that he didn't want to be married anymore...and leaving me with a brand new house and an 18month old daughter...I had no idea what I was going to do...needless to say...the part time nurse idea was out the door...I had to work full time to support myself and my daughter...hopes of living in the brand new house was also out the door and I was back living in an apartment...my self esteem hit rock bottom...It took several years to pick my ego out of the basement and wipe myself off and realize it was all up to me of how the rest of my life was going to pan out...this is when I did my double challenge take on a new job as a nurse educator and go to school part time for my Masters in Nursing...still a single Mom this was a challenge. By the grace of God and the help of my parents and 5 years later I had a MSN next to my last name and to add to my credentials...during this time I met my best friend and husband...He has proven to be a rock to me ...He made my family true family and we married in 1992...I continued to work in the hospital setting as a nurse educator...but something still didn't seem right to me...I was bored...can you imagine...bored with a family and full time job...plus hospitals were re organizing and the nurse educators were the first on the chopping block...so that is when I decided to go back to school again for my NP and post masters...2 1/2 years of working full time and keeping a house and family I succeded...jobs were not plentiful or were well known at this time for NP's I literally sent out letters with my CV to all the family doctors in the area...I got that one bite and I was on my way to my current career...granted it wasn't all sweet and nice in the beginning...I actually worked a full time job as a Disease Manager in a hospital and part time in the evenings as an NP for the first 6 months...then another family practice approached me to work in their office...so I was able to quit the hospital job and work the two family practices at the same time for a full time job....the first year I worked 60 hour weeks..ugh..and the pay was lousy...after a year I quit the first job I landed and worked the second job ...was lucky to add hours to this job to make it a full time job....During my first 2years as an NP I had a lot of growing pains....fears of not knowing a lot and of possilbly making an error...I wouldn't sleep at night...was constantly reading and looking things up ...I would wake up in the night and think about a case I had during the day doubting myself...it was awful...plus office practice was not the end all and be all for me...the pay was lousy and benfits were nothing...and the docs just didn't get us...that is when I started looking for something different and even 2nd guessing if I made the right choice to be an NP....that is when I ran into a fellow NP collegue at a conference who introduced me to her boss...they were looking for a new NP at the nearby VA....I got an interview the next week and the rest is history...almost 11 years I have been there...they do get it..and I am very happy there...I can honestly say.. I don't feel bored ...I learn something everyday...the docs I work with get me and me them...and I love the patients...working for the VA gives me a sense of security with my practice and with my ohm....I doubt I will ever return to the private sector...the VA has come a long way...it works very hard to provide quality care...it is built in to every providers work day...we are constantly provided tools to provide this for our vets...I can honestly say that I am where I want to be now...I wouldn't even know where else to go nor do I have a desire to go...I do get up everyday and dread getting up only because I can't sleep in but I do look forward to going to work...it is always a new adventure and a great opportunity to help those who otherwise would not be able to get good health care in the private sectore...plus it is my way to give back to those who gave to our country...so now that I wrote this what should I call it?

Happy New Year

Well in looking back to last year I kept my promise to write more...so I am going to try to live up to it again this year...I have already promised myself to organize my closets and kitchen cabinets...done and checked off the list..trying to exercise more...shall be a challenge ..and eat healthier....OK now what should I do for my career...hmmmm...this is always a struggle...I have found myself to be in such a routine anymore...I don't want to go back to school...I have had enough of that...I don't want to change my job...I love what I do...so maybe I can promise myself to read more...educate myself more...maybe I can stick to doing a couple CME's once a week...I think I can do that.....
I always like to self reflect on how my year was in the past with caring for my patients...I have had some real challenging cases in this past year...Some of my challenges were with those patients who lost their battle with life...suffering from chronic diseases, cancer, cirrhosis...Some patients I was able to help and turn their life around...like giving them another chance in life...others remain in the cycle of no return with their poor health and addictions...these are the ones I wish I could make a difference and hope that someday the light will go off and they will get it....Hopefully 2012 will bring more challenges that I can face head on and make a difference in more lives...in a good way...I hope that you too have a very Happy New Year and may it be blessed with good health

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...