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...