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".