Grateful

I'm feeling like I'm in a serious, reflective mood tonight - might be the storms, might be the couple patients of mine that I can't stop thinking about that might not make it to the end of the week.

Life. Fragile. One shot.

So here's what's been on my mind lately.

When I first started nursing, I thought I was going to save the world.

 

CPR. ALS. Codes. Adrenaline.

I slowly become less scared of people who came onto my floor mid-heart attack.

I learned to administer morphine. Adjust IV fluids. Interpret EKGs and telemetry monitors.

How to prep them for stents or open-heart procedures.

I slowly became less scared of codes - especially with my team of awesome nurses back in Mississippi. We worked so well together that we could just look at each other and know what each other was thinking. And the doctors...my first code consisted of our ER doctor telling me, "The only way you're going to learn is to get on up there!" He coached me through the chest compressions with patience and understanding.

I loved it. Loved loved loved my heart patients.

But roughly six months ago I decided to switch specialties.

A specialty that's usually met with a sad face and an "oh, how hard/sad/awful" response.

I'm a Hospice nurse.

I also like to think of it as being a geriatric and end-of-life care specialist.

Not everyone can do it.

Not everyone can face death every day.

Not everyone can come to terms with the fact that death doesn't mean a medical failure.

What do I do as a hospice RN?

• As a Case Manager, I manage medications, diets, wound care, therapy, equipment, appointments, tests, caregivers and CNA's for my patients. I oversee every single aspect of their care. I work closely with our social workers and chaplains. We are a team, and it's a fabulous one.

• I get to be a support to families. I get to watch the weight lift off their shoulders when I explain to them the disease process and what signs and symptoms to watch for - things that people in the hospital were too nervous to talk about.

• I get to assess and care for patients who are critical - without the support of an on-site team. My hospital is in the trunk of my car...that's where I carry all of my supplies, my syringes, my wound care bandages, my catheters, my oxygen tubing. Being a road RN means you better make sure you're assessment skills are 110% - because it's you and you alone making the call on what you see when you walk into that house.

• I have to prove myself as a competent and knowledgeable nurse to our hospice physicians. Like I mentioned above, I have to know my stuff forwards and backwards in order to call the doctors for new orders - whether it be to transfer a patient to the Hospice House for inpatient care, start Crisis Care inside the home, or calculate pill vs. liquid vs. injectable narcotics if my patients can't swallow anymore. If your doctor trusts you, it goes a long way when you call them sixteen times a day on your symptomatic patient.

• Speaking of, just because a patient is on hospice doesn't mean we just sit back and wait for them to die. If they start to have shortness of breath, we're in there with oxygen, nebs, breathing treatments, morphine, etc. so they're not struggling. If their pain is out of control, despite the pain meds their on, we're in there adjusting dosages or adding meds for breakthrough until we can get them comfortable. A lot of my patients come onto our service completely alert and oriented, so many of my visits consist of education and keeping them stable as long as their bodies allow.

• I get to be present with my families in their most raw and emotional moments. I'm the one they rely on to pronounce the time of death of their loved one. I'm the one comforting the family, bathing the body, calling the funeral home, getting all the paperwork done...all the family has to do is, well, whatever they want. One family of mine made calls to other family members to inform them of the death, then they sat back, broke out the photo albums and bottles of wine. They were able to reminisce and talk about their loved one without the stress of having to take care of arrangements and paperwork and waiting for the funeral home to show up - that's what I was there to do.

• People are people. People are not a diagnosis. I refuse to go into someone's house and treat them like a cancer patient. An ALS patient. An Alzheimer's patient. By coming onto hospice, they're telling me they're done with treatments and chemo and millions of pills - they just want to feel like a human again in their own house. So you know what? We do that. We sit and talk and laugh (Yes! We laugh!) and just try to live as normal as the disease process allows. Yes, there are going to be days that aren't as pleasant. There are days you have to have your game face on and get down to business. But you also look your patient in the eyes, don't talk over them, don't talk down to them. You smile, you talk about grandkids and pets and favorite vacation places. It's all about creating relationships and trust.

I love my job. I think the best decision I ever made was getting out of the mad-house hospital and get into Hospice. I grew up around death. I'm comfortable with the subject. I feel like I've found a specialty I'm good at.

Hospice just reminds me that we're all headed somewhere. Life is fragile, and can end in so many different ways. We don't get to choose, but we can decide how we respond to those situations. I've seen every emotion on my patients and families faces - anger, denial, peace, acceptance, rage, combativeness, love, grief. Hospice is definitely emotional - maybe why I've turned to this blog tonight to get out some of my feelings.

Thanks for letting me get it out.

Today I love: Being able to walk. Being able to eat. Being able to hug my husband and pet my dogs. Life. Living. Purpose.

The One with Lots of Updates All At Once

So many, many things have happened in the past couple months, and of course I have done absolutely nothing to keep family and friends updated.

For instance, baseball. I am a Baseball Wife, am I not?

Baseball started in January and goes until the end of April or early May. Coach has been gone pretty much every night during the week, keeping him blissfully happy and coming home smelling like dirt and grass.

The team is 7-7 for the season so far. The hard thing to keep track of is that unlike in Missouri and Mississippi, Varsity and JV do not play on the same night - therefore the reason Coach isn't home four to five nights of the week, and I cannot for the life of me keep track of which team plays which night. 

Spring break just kicked off for Matt this week though, and I think his plans include sleeping, going to the beach, sleeping, sitting by the pool and sleeping. Oh. And sleeping. 

I, on the other hand, have been keeping myself occupied by turning in my resignation at the hospital and going to visit my sister in Georgia.

We never do anything by little steps and measures around here. It's all or nothing, folks.

First: my job. I really, really love working with cardiac patients. I love that I have the knowledge and skill in how to bring down someone's sky-high blood pressure, relieve their pain and teach them how to move while protecting their chest after open heart surgery, and how to administer and monitor critical drips and medications. I love that chest tubes - while they still make me nervous - don't scare the bejeezus out of me anymore.

I love the girls that I worked with. Our floor was so insanely busy and crazy day after day, it was great to work with a team that would pull together and help each other out - some days it was all about survival for us.

However, you all know that I'm a Funeral Home Girl at heart. Growing up in the environment that I did - with the dinner table conversations that I had with my family - I was destined to have a career dealing with end-of-life issues.

Enter: Hospice.

Hospice and oncology is one of the main reasons I went back to school for nursing. I'll be helping someone stay comfortable and live their life to the fullest that they possibly can, while managing their end-stage disease symptoms. Hard, challenging, and one of those career moves that you just know is right. I couldn't pass it up when I was offered the job.

Everyone I'll be working with is so compassionate and caring, with such positive, encouraging attitudes. I'm learning more and more about Hospice and what it does - it's not just giving pain meds and watching someone slip away. I'll be going to patient's homes and doing complete assessments, wound care, medication administration, lab draws, and my big passion - education. Teaching families and their patients about what to expect as the disease enters it's final stages. What happens when the body starts shutting down. How to keep their loved one comfortable and to not hesitate to page the crisis team. You're not only be dealing with the physical, but the emotional and spiritual needs of the patient as well. The Hospice physicians are amazingly kind and helpful, the chaplains and social workers are fabulous resources that work hand-in-hand with the RN.

I'll be working out of the Fort Pierce location, but the Hospice House in Stuart, FL is where I spent the past week in orientation. Policies, procedures, OSHA, HIPAA, etc. My brain was gone as of 2pm Friday. The grounds are beautiful though - lots of landscaping, walkways, paths, fountains...all dedicated in remembrance of patients of TCH.

Ok. Sorry for the RN rambling. Now on to non-job stuff.

My sister!

I spent four days in Georgia visiting Erin, Cole, and Addie.

(Say cheese!!)

Addie got a nurses' kit from Auntie Addie - gotta teach em' young!

She kept going around the house (for hours...days...bedtime...bathtime) saying "Checkup! Checkup!"

She also refers to one of the bearded pirates on her Pirates of the Caribbean placemat as "Jesus," so I'm not really holding out hopes that she'll be a Nurse Practitioner in the next two years or anything.

Erin and Cole are looking forward to the arrival of Liddie in the next couple months - especially since every time I would turn around I would accidentally run into Erin's pregnant tummy. Ooops. My bad. It got to be hilarious after awhile...for me, anyway.

Fun Florida things we've done lately:

Universal Studios, particularly Harry Potter World. We're Potteraholics.

Braves vs. Mets spring training game. We live about 20 minutes from Tradition Field, spring home of the Mets (boooooooo!!!!). Since I'm married to a Braves fan, I humored him and drug myself to a game. Since he's a baseball coach who somehow gets incredible hookups from people he knows, the tickets were front-row and free. I can't really complain.

The only Braves person I cheered for was their first base coach, former St. Louis Cardinals third-baseman Terry Pendleton. I watched him play with Ozzie Smith under Whitey Herzog in the 80's. Actually, I mostly remember Fredbird and eating ice cream out of plastic Cardinals helmets because I was only 10 years old, but still. I remember my parents getting really, really excited about all those good old STL guys and Ozzie's handsprings at shortstop.

So...the best part is...

WE WENT TO A CARDINALS GAME!!

A good friend of ours from our days in Licking came down from Missouri, and we spent the day at Roger Dean Stadium in Jupiter, watching our boys.

I felt so giddy and homesick and wanted to hug every single one of them and say "I know you!! I follow all of you on Twitter!!"

But I decided that that's fairly stalker-ish, so I stayed in my seat and took pictures of the best side of Yadier Molina.

Not ashamed. Not ashamed at all.

Matt just rolled his eyes and pretended he hated being at a Cardinals game. I knew he secretly wanted to cheer for them. You can't run from the red.

And the best part...I got to revive my childhood.

Ice cream helmets! And sunburns!

Great day, despite the loss by one run. I still love you, Redbirds!!

Coming up: I officially joined CrossFit last week. Not sure what it is? Google it. I have no words on how to explain it other than it hurts you and empowers you and makes you want to laugh and cry and scream all at the same time. Fundamentals Day One included roughly five bazillion squats with weights, which meant I couldn't walk upstairs to our bedroom or sit down to use the bathroom for about four days.

Anyway, my sadistic trainer Kristi told me to get all my fun out this weekend, because CF starts for real tomorrow. Meaning clean eating, meaning the complete opposite of the Dixie Cream doughnuts we just had to get for our Missouri guest this morning. (Seriously. Dixie Cream makes Krispy Kreme taste like nastiness. Come to Vero and we'll show you what's what.)

So tomorrow - WOD for real and Paleo/clean eating for real. Matt doesn't think I can stick with it so you know. Now I have to to prove him wrong.

It's on.

On The Move. Again.

Well, it’s here.

It seemed like we were just back in Missouri, all excited about packing up for our new adventure in Mississippi…and here we are again, getting ready to move again, this time to Vero Beach, Florida.

Someone needs to tell my husband that if we move any farther south we’ll end up in Puerto Rico.

This is my last week in H’burg, finishing out my work schedule and making sure the movers get all our stuff.

Matt has already moved. He called yesterday to say he was on the golf course. The day before that he was in Jupiter watching the Card’s minor leaguers…

…while I was getting my oil changed and tires rotated and boxes packed and dogs walked and apartment cleaned.

Something just doesn’t seem right about this situation.

We’re sad to be leaving some great friends, some great co-workers and a great church – the Vero area is lacking a little on the Southern Baptist options and we’re praying we find a great place to get plugged in.

Either that or convert to Catholicism. Not that there’s anything wrong with that.

I went down to FL earlier this past week for a job interview at one of the three local hospitals. This particular facility was recommended to us by Matt’s new principal and the athletic director – I thought it a great sign from people who had been patients there to really talk up the place.

It’s not just a hospital – it’s also connected to a heart institute, which will make several people who read this blog laugh and wonder if I’ve lost my mind.

Bless my heart, y’all.

Back in nursing school at good ‘ole SLU I had regular panic attacks and nervous breakdowns any time I encountered anything that even remotely hinted at cardiac anything.

Before really digging into EKGs, the only heart rhythm I was remotely familiar with was normal sinus, and even then I would second-guess myself at P-wave placement and freak. And cry.

My cousins that I lived with during nursing school got to witness this on a regular basis. Tom, my cousin-who-happens-to-be-a-doctor, patiently sat down with me one afternoon to go over QRST segments and how different rhythms affect different places of the heart. We talked about CHF, mitral valve regurg, aortic stenosis…all the stuff that can come from having a bad ticker.

I still would have my own episodes of RVR (AKA: rapid ventricular rate) when sitting down to a cardiac exam, and I vowed to never have anything to ever do with telemetry or heart stuff. Ever.

Enter Forrest General Hospital here in Hattiesburg.

After working on a surgery floor for six months, our sister floor – a telemetry floor – had an opening. I had floated up there once or twice before, and it literally scared the bejeezus out of me.

Give me a hernia repair or a gallbladder removal or a mastectomy and I can take care of you with my eyes shut. But a patient with chest pain? A patient in AFib?

See that Addie-shaped hole in the wall? Yeah. That’s me running. Screaming. Crying.

But I thought that telemetry  (for those who keep asking, telemetry is simply monitoring the patients via remotes and wires connected to the pt’s chest with sticky pads that show up on the telemetry monitors at the nurse’s station…we can see your heart rate and rhythm all the time. I know when you get up to pee because your heart rate jumps, by the way. Good times.) would be a good challenge, the chance to learn something new.

And what do you know? I fell in love with my heart patients.

Chest pain doesn’t freak me out anymore. Give me some aspirin and morphine and some nitro, and we got this under control, baby!

Heart caths, stress tests and echos are routine to me now. I know! Shocker!

I saw Tom at my uncle’s funeral two weeks ago and he got the biggest kick out of hearing where I was applying in Florida. And of course he had to joke about my panic in nursing school over everything cardiac. Thanks, Doctor. J

So what will I be doing?

Cardiovascular Step-Down.

Very, very excited about this.

I will get to combine my background with post-surgery patients with my ever-increasing knowledge of heart patients. These people will be coming out of the CCU/ICU after having open-heart surgery. We’ll have cath patients, chest pain patients…even overflow during the winter months with all the sweet little retirees that come down from the north.

Speaking of the sweet little retirees…my new uniform colors are WHITE. All white. Why? Because the hospital did a survey and found that those sweet little retirees recognize nurses best in white.

Like in the 1920’s.

But patient satisfaction is important…so I’m off to buy white uniforms and the white underwear it will require.

So as of now, I arrive in Florida on August 15^th, start orientation on August 21, and our furniture is supposed to arrive at our new house August 20. We're very glad we decided to rent in MS - so we don't have to worry about selling a house - but now we're trying to close on a house with me still in Hattiesburg and Matt already down in FL. 

I feel the heart palpitations starting up again. It’s either stress or I’ve had waaaayyyy too many cups of coffee this morning.

Today I love: Extra-wide Rubbermaid tubs for packing and the clean feeling that comes from throwing a way/donating things we really don't use or need. 

Observing Patients, Eleven at a Time

I keep having family and friends ask me what unit I work on at the hospital and what we do. As a brand-new, career-changing nurse, it's been a little hard to explain, even to myself. Now that I'm officially out of orientation and some (just some) of my naivety is gone, I figured I better know where I am and what I'm doing.

I didn't have the slightest clue as to what a hospital observation unit was when FGH hired me. I was just grateful for a job offer in a city that has one major university and several community colleges, all whom had just graduated their own gazillion nursing students who were looking for jobs in the Hattiesburg area at the same time I was. That, and I could finally move out of my parent's guest room and join my husband who had moved down to our new digs several weeks earlier.

No offense to mom and dad. It was a great time having mommy do my laundry again, but this 30-year-old was ready to move out of the proverbial basement and get on with her life.

Honestly, I was so proud of my title as "RN-Medical Oncology" back in Missouri. Caring for cancer patients? Totally worthy occupation. Outpatient Observation? It sounded weak at first, like I would be putting band-aids on boo-boos and sending my patients home with a lollipop.

Some days, I wish that's all I did.

I didn't really know what an observation unit was. I was like, do I just watch the patients and make sure they don't get worse? What are we observing for? Am I going to be bored to tears?

Today's Hospitalist explains observation units like this: "As Emergency Departments are increasingly stretched by capacity constraints and lack of specialist support, hospitals are turning to observation units, also known as clinical decision units, to fill those gaps without taking up inpatient beds. Patients admitted to observation units are expected to be evaluated and treated and rapidly improve within 24 hours."

“The setting is geared toward patients who require more management or attention than can be given in the traditional ED, but do not need the length or level of services provided in the inpatient setting,” says Russell Holman, M.D., senior vice president of Cogent Healthcare, a national hospitalist firm based in Irvine, Calif.

“Placing one patient in the observation unit frees up about three beds in the ED,” says Sandra Sieck, R.N., president of Sieck HealthCare Consulting, Mobile, Ala. "Observation units can help avoid unnecessary and costly inpatient admissions by aggressively diagnosing and treating patients’ symptoms, allowing them to go home in a timely manner."

Our unit works closely with the ER doctors - but when emergency department orders run out after eight hours, care is usually handed over to one of the on-call Hospitalists...which means a whole new set of orders to implement. In the meantime, the physicians and case managers are trying to determine - in less than 23 hours - whether the patient needs to be converted to inpatient status.

So it's very true we move at a rapid pace.

Yesterday alone, between transfers, discharges and admissions, I had 11 patients.

To give you a bigger picture, our unit is only 14 beds. I take seven, the other nurse on shift takes seven.

Seven beds. 11 patients.

Lots of coffee. And aspirin. And charting.

Our floor sees everything from sickle-cell crisis to cellulitis, COPD exacerbations to dehydration. Patients come from outside clinics for blood transfusions. We see a lot of patients with renal failure - I've gotten to know our nephrologists really well. We get a lot of funky wounds, and we also serve as a recovery floor for patients coming out of surgery.

PACU delivers us lap-chole patients, (seems like everyone and their second cousin has had their gallbladder removed lately) hernia repairs, thyroidectomies...just about any same-day surgery where the patient just needs to stay the night and be discharged in the morning. I call those my "eat solid food and drink with out throwing up, pee, walk the halls without passing out and be cleared to go home" patients. We've also had a run of PEG placements lately, and I feel like I can do tube feedings with my eyes closed.

(Which I once said to a co-worker, who told me she would hope I wouldn't. Southern people still don't get that when I say things like that, it's called sarcasm.)

A typical 12-hour patient rotation can look like this: a patient is admitted to the floor from post-surgery around noon, only to be discharged four hours later...who's room was rapidly cleaned and assigned to a new patient who arrives no less than 20 minutes after the previous patient was wheeled out the door.

Or a patient gets to the floor from the ER, and ten minutes later surgery is calling for them (no joke...this happened to me this week). To get a patient to surgery, you have to complete a whole checklist of items, have surgery consents signed - which you can't have the patient sign if they've taken narcotics (morphine, dilauded), which of course the ER gave them just ten minutes earlier - draw labs, make sure the patient has removed dentures/jewelry/glasses/clothes off/gown on, plus call surgery to give report on the patient you're sending them.

Giving report on a patient you've seen for a total of five seconds to the same-day surgery nurse who's been around the block a time or two is nuts. You better have your stuff together. Or at least make it sound like you have your stuff together.

And speaking of drawing labs, PCRMC spoiled me. We had phlebotomists who would come and do a simple stick for an H&H. Not so here. We grab our trays and tubes and trot off down the hall to play vampire.

PS: I love central lines and chest ports. The end.

It can get exhausting. Halfway through orientation I decided I didn't like the floor, it was too fast-paced and that I just couldn't get my day organized with all of the admission orders, discharge orders and general care orders going on in between. One patient coming in while another is going out...I seriously felt I was drowning trying to keep on top of everything. People wanting to be discharged want to go home NOW, not in 30 minutes...at the exact same time the PACU nurses are calling you into the room of the patient they just brought up because they need to hand off the chart and have lifting help from the stretcher to the bed. And then that new patient wants something to drink and their family is hovering and their IV is beeping and....

And people wonder why I'm still broken out in stress-related hives.

(Sarcasm again, my southern friends. But not really.)

Now that I've been on my own for two weeks, I'm realizing that I'm not as incapable as I first felt. I can do this.Yes, it's incredibly stressful. Yes, it's rapid work. But I feel like I know this floor now, I know where things are, and I know who to ask if I don't know something. I'm getting to know the doctors - most of whom are fairly approachable and easy to talk to.

I really like my co-workers and feel that we all work well together. They bring cake to celebrate birthdays, and I like cake.

This floor is growing on me. Once in awhile I still miss my cancer patients and the five-patient, steady, unchanging workload in Missouri, but honestly, this is now starting to feel like home. I don't want to bail ship and leave this unit anymore.

I get it now. I get the point and purpose of observation, and I'm proud to be an RN in the middle of it.

Oh, and my scrubs are cute too.