Nursing Instinct

It started with a feeling. You know, that gut feeling that nurses get when something is about to go wrong. They call it “nursing instinct”, but no matter the name, it’s never wrong.

My first assessment was nothing out of the ordinary. My patient was on the ventilator for recurrent sepsis, and looking to improve. She responded to my questions appropriately, nodding her head yes when I asked if she felt warm, which correlated to her above 100 degree F temperature. I offered her a cool, wet washcloth for her forehead and a fan, for which she smiled. I asked if she had pain, to which she shook her head no. I continued on, listening to her chest and abdomen, checking her pulses, looking over her IVs, and finished by asking her if she was okay, to which she nodded yes. I informed her I would be right outside her room and would be in periodically to check on her. She smiled, but something still did not feel right.

I sat in an alcove between her room and another patient’s, which allowed me to both see my patient, as well as her monitor. In report I had asked about the patient’s ongoing sinus tachycardia, to which the off-going nurse replied, “The doctors know about it. They’re not concerned, and just want us to keep an eye on it.” How many have heard the “keep an eye on it” warning? That set off an internal alarm, when I continued to watch her heart clipping along in the 130’s. Had it been that high all day? As I looked back in the telemetry monitor records, it seemed it had. I knew her heart could not stand much more after all she had been through.

But I was optimistic. Here she was, on the ventilator, no sedation, no pain, completely appropriate with talks of weaning in the morning. But then, her fever went up. It went up a whole degree in the course of an hour. I went back in to check on her, offered her some Tylenol, to which she eagerly nodded, and administered it via her OG tube. I thought, that the fever could be part of her tachycardia, that hopefully the Tylenol would help, which in turn would help decrease her heart rate. I wanted to believe that things were going okay for my patient, but that internal nudge would not stop telling me the contrary.

I went back to my alcove to start charting around 2100. I felt good about that at least. I had already assessed both of my patients and had given nighttime medications. Did I mention this was my 3^rd shift on the floor as a new travel nurse, and my 1^st shift on my own? The charting system was new to me, so I was glad I had a chunk of time to devote to navigating the charting system.

As I was in the midst of checking boxes and tabbing along, the alarm went off for my patient’s arterial line for a low reading. I looked at the tracing and wondered why it had dampened, when it was brand new that day. My patient still had an EKG tracing, but I went in to check on her to make sure she was okay.

I should also note that my patient was in droplet isolation. I gowned up, put on my gloves and mask and started in to see that my patient was not the responsive, bright eyed, smiling patient that I had come into that shift. I tried to rouse her several times, and then proceeded to check a pulse and did not find one. I called out to my (new) coworkers to call a Code Blue. She had pulseless electrical activity (PEA), which progressed to asystole. I started compressions almost immediately, her frail body surrendering to my hands pumping her chest. I could feel her ribs buckling beneath me. Must. Pump. Hard. It’s an indescribable sensation to feel someone’s ribs moving under your hands, as you try to do the work the heart cannot do itself. My coworkers ran to assist me, the Code team arrived, someone else took over compressions, someone else gave ACLS medications, and there I was watching (and also providing what I could remember about the patient’s condition and history).

They let her go with just enough effort and called the code at 2133, which was about 15 minutes after I discovered the change. Coming from an open-heart surgery background, I was astonished by the short duration of the code, but also felt at peace with it. I have watched a code go on for over an hour, thinking, when are we just going to give up? There are only so many medications you can give before the body rebels. I’m sure many of you have had this same thought, just know you are not alone.

What I have taken away from this experience:

That it can happen to anyone, anywhere.

That nurses are great team players when there is a code (despite non-code conduct).

That my nursing skills transmit to a variety of environments.

And that my gut is never wrong.

If you get the feeling that something is not quite right with your patient, but you can’t put your finger on it, you’re probably right.

A Young Snow Bird

...is something I haven't ever thought to describe myself. But here I am, in Arizona, during the winter months, away from all that cold white stuff I have previously surrounded myself with for 29 winters. Why didn't I do this sooner? :)

I spent August through the end of October in Monterey, California at a 200 bed hospital in their ICU. Monterey is beautiful to visit, which is what everyone says when I tell them where I spent my first assignment. Try: foggy almost everyday and in the 60-degree range. Not my idea of summer, when back home (in Michigan) everyone was talking about 80 degree days and I was missing my lake. But this was my first assignment, which took all of about four months to come by. I will talk about the frustrations of landing my first assignment in another post, but needless to say, fate had her part and I am thankful to have had the opportunity.

Tucson, Arizona is the second stop on this travel nursing venture. It was all about timing (again), and my newest recruiter, Nina Velasco from Onward Healthcare, heard about this job only A DAY before my other recruiters, and that was all it took. Well, that, and my sweet phone interviewing skills.

The hospital is a 60-bed heart and vascular center, which is 14 ICU beds, and the rest telemetry. I've worked both, and honestly do not have a preference one way or another. I guess I get that from my Munson roots, where I worked in an acuity adaptable open heart unit. One day I could have a fresh heart from OR, the next could be 3 step down patients. I love nursing, and especially open heart nursing, or I should say I love taking care of the open heart surgery patient, no matter where he/she is in his/her recovery. This does not make me a *good* ICU nurse because I actually LIKE talking to my patients and their families.

Unfortunately, travel nursing and open heart nursing don't exactly go hand in hand. This is mostly unfortunate for me, because this is where I feel most at home. Open heart surgeons tend to be a little, how shall I say this...picky. They like to know the nurse recovering their patient is going to do a good job. Seeing as I'm the new kid on the block, the surgeon doesn't know me from Jack, and probably doesn't feel comfortable letting me watch over their baby for the night. Oh, and the part where I never took care of an IABP patient because we didn't have them very often, and when we did, they went to more "seasoned" nurses. Yeah, this part sucks.

But I am learning a lot, despite not being able to take care of hearts. First, I am learning to be very flexible. I think I knew this about myself before, but traveling actually made it come into practice. Each hospital has new rules, policies, procedures, charting, and PEOPLE, and you are just expected to fit in and get the job done. Sounds pretty easy, right? Well, luckily I'm a pretty nice person, smart, and learn quickly. It also doesn't hurt that I offer to help you bathe your patient, or help with a turn, does it?

Second, I miss having friends at work. I did not realize how much I would miss this (and all of my Munson peeps), until I actually left. I even miss the finicky CT surgeons I worked with! I am very fortunate to be traveling with the love of my life, but it is good to have friends at work too. Making friends while traveling is hard to do because of the usually short (3 months) duration of a contract, and the older I get, I find, the harder it is to make friends. This is not always the case, as I am lucky to have met another traveler here in Tucson. She's such a sweetheart, but unfortunately has not liked traveling due to a number of things including a car accident, a crappy travel company & contract, and a relationship not working out. I think I'm helping her keep her sanity while she finishes up her contract here.

Third, I still love nursing. This is not completely surprising to me, or those who know me, but just validates that I made a really great career choice. I am fully invested in nursing, nursing education, and continuing my own education so that I can help others achieve what it is I love so much.

So, I plan to be a snow bird this winter. It will be nice while it lasts, but eventually I have to go back to school.

Exciting life ahead...

This May, I will finally graduate, again. I say again because this will be my second degree. The prospect of putting additional letters behind my name, well it isn't all that exciting to me. It seems that other people are more excited about my graduation than I am, but that's no reason to not have a party :)
But what to do after this built up graduation? There has been something that I keep coming back to, and that is my love for traveling. It is quite convenient that I have a job that allows me to travel and work, all while getting paid more than I would if I just settled down somewhere and got a regular hospital job. Where do I sign up?
While it sounds like a dream, there are quite a few questions to be asked, and things to be secured before one ventures out across the country. First, is to find a reputable company. This is where I'm starting. Ask your fellow nurses if they know someone who has traveled, and get in contact with them. Find out which companies they have worked for, and which ones they would work for again. Repeat business is a sign of a good company. Actual or past travelers are going to give you honest information, while the recruiters are going to give you sweet talk to get you on board.
You also must decide where you want to go. Someone who only wants to go to Hawaii and work day shift will have a much harder time finding an assignment than someone who specifies "somewhere warm". Be flexible, it will only open more doors.
Other important information to find out: benefits, housing, and of course, pay. Benefits can make or break a deal for some people, but if they aren't so important to you, you can get that extra money in your paycheck. Housing is usually provided, and some companies even offer a stipend if you want to secure your own housing, or perhaps stay with someone you know (that can equal more cash in your pocket). Pay is generally something that draws nurses to traveling. I've seen upwards of $50/hour plus completion bonuses. Now what you have to do for that $50, I can't say, but I assume that you will be working hard for the money. There are also referral bonuses that come in handy when you know people that want to break into the travel nursing scene.
Keep in mind, that each state you travel to requires that state's license, unless of course you are luck enough to live in (and have residency in) one of the NLC states (see https://www.ncsbn.org/nlc.htm). Don't freak out here, YOU DO NOT NEED TO TAKE THE BOARDS AGAIN! Getting another state's nursing license is a fairly easy process. They call it endorsement. This endorsement comes with a fee, but does not incur the headache that taking a national board licensure examination does. The travel company may or may not reimburse for this fee, so find that out beforehand. There are also usually fingerprinting fees, drug testing fees, and other "fees".
Not to mention, how the heck are you getting to where you need to go?! Some people find a road trip fun and exciting, while others like to jet set across the nation. Things to keep in mind include: how long you are planning to stay, how many items of clothing and shoes you can fit in your luggage, and if you can really bear to part with you collection of unicorns.
If you are considering travel nursing, remember, this is just a brief synopsis of preliminary considerations before joining the world of travel nursing. It can be a very rewarding career choice.
Just remember, travel nurses must learn to pack lightly, and be flexible.

Scrubs

Scrubs are the everyday wear of most hospital personnel, and this site has a great selection:

www.mynursinguniforms.com

Tasks and Trash...

Sometimes I wonder what it is I actually do in a day. I think about the individually packaged pills I have to open, and think, I probably opened 100 little packages today, not counting the individually wrapped syringes and needless luer-lock attachments. Yes, it might be safer when each pill has a printed barcode on the wrapper, but the pill packager has gone on the fritz putting pills in the wrong packages before.

Then there are the innumerable tasks. I often feel like a glorified waitress, fetching water and juice, then IV morphine. (My days at Chili's during college DID pay off!) Dressing changes, assistance to the bathroon, ordering, then taking the meal trays away, patient and family education, comforting a nauseated patient, and throwing away used tissues are just SOME of the tasks I complete in a typical day. I like when my job is a little bit more than task oriented, when I can sit and talk with a patient about her pet Pomeranian, or about how she used to travel. Those are good days.

Today, for example, I had to change IV tubing. This is something that must be done at least every 72 hours, of which we keep track of with little colored sticker "flags" that attach around the plastic tubing, indicating "Change Monday" (or whatever day comes 72 hours from now). I had to change tubing today because the patient went from "critical care" to "step down" and when that happens, the IV pump themselves are switched out, requiring a new set of IV tubing.

This is just one example of how trash is created. I think to myself, how wasteful my profession is, how much trash we produce, and that none of it matters because it's all about cost, and not about the environment. If I saved all of my throwaways, not counting sharps, I'm sure I would have a brown paper grocery bag full, and that's just one nurse. On my unit today, there were 12 nurses scheduled, and that was one nurse short. And that's just one unit in hospital with 350+ beds. Point is, it's a lot of trash.

I don't think things will change, at least not soon, but it's something I think about from time to time. Maybe you do too.

Thank you is not enough...

Yesterday was one of my normally scheduled 12-hour work days. I punched in at 6:58am, with a whole 2 minutes to spare. I say this because I walk a couple of blocks to work with my travel mug of coffee, a lunch bag, and lately an umbrella because the fall so far in Northern Michigan has been quite wet.
I go to get report, and find out I'm to take care of this patient who has been in the hospital for 40-some days post-surgery. Needless to say, he's had some complications. Because of the nature of HIPPA, I can't go into much detail about him, but the more interesting component is his very involved wife. Maybe involved isn't the right word, but I'm sure many of the other nurses out there have encountered some overbearing family member who thinks they are trying to help, but really makes you want to strangle them. While helping this patient in the bathroom, requiring myself, one of my coworkers, a walker, a gait belt, and strength beyond what we possessed, helped the patient stand. While doing what we do in the bathroom, the Mrs. said, "How about a courtesy flush?" So my coworker stopped what she was doing, to flush the toilet, and then return her focus to the patient struggling to stand. What was she doing in the bathroom with the 3 of us anyway? She felt the need to supervise us because we weren't competent to wipe an ass? Anyway, this is just ONE example of the directions I received during my 12-hour shift, not to mention, I had another patient.
Don't get me wrong, I do love my job. I love being able to make a difference, bond with patients, help them recover from a very intense, life-saving surgery, but sometimes it is mentally exhausting. Sure there might be a "Thank you" here and there for returning with a fresh ice water or warm blanket, but there's never a thank you for wiping an ass or dealing with an overbearing family member. I know that it's the nature of the work, that nurses often share a feeling of underappreciation, but it doesn't mean that we don't want to feel appreciated from time to time.

Teaching Clinical Students...

I have been teaching clinicals for over 2 years, which is roughly half of the time I have been a real nurse. I started clinical teaching because of a deal I couldn't pass up...free tuition for an MSN class, paid teaching, plus a stipend (and $ for mileage because I commuted over an hour!)....and it turned out to be a great experience.
Truth is, I've always loved teaching. Back when I worked at a large chain grocery store, I was a "store trainer", and then when I waited tables at a popular restaurant, I was also a "server trainer". All of which may have prepared me to train people. Teaching nursing isn't all that different, however the outcomes are a little more serious than a steak coming out a little too rare.
I like the daily, hands-on experience, and the opportunity to see things from a student's perspective again. They get so excited to do something I now see as routine or simple, such as dc'ing a foley. They doubt themselves, or maybe I should say they don't give themselves credit because they know SO MUCH. They just need help realizing it, and that's why I'm there.