The One Year Nurse, a UCSF MEPN student's journey

Insomniac Ramblings

2010-02-21T00:34:00.000-08:00

12:35am might not the best time to get restarting into my blog. Its two hours after my sleeping pill clearly didn't help me with just that, and I'm left , like Romeo, "so unsatisfied"--somewhere between lucid thought, the daze of the work day, psychadelic dreams, my personal studies and good old fashioned sleep. I sure would like to buy me some of that good sleep. For a quarter!

My wife is studying for the BAR coming up this week and vibrating on her own frequency of atomic collision while I continue on my pin-ballesqe jostle-tostle through and at the laughing hand of God. And it is laughing and it is God's hand my friends. This makes perfect sense to me, so I should probably stop. I have insight enough that this sounds like ramblings to someone else, but my expressive brain that shares some of the questionably bundled neurons stuffed to the back (the funny looking ones that occasionally squawk or fizzle) can't resist conducting a tangential tryst with such enticing impulses. Feel me? Pop....

Not a failure if it weren't such an effort. So I leave you with a prayer from the righteous words of Jerry Springer, "Until next time, take care of yourselves and each other". Schmuck.

My Little Brother

2009-06-09T15:01:00.000-07:00

My little brother, Elliott, was born at eight and a half months with a clubfoot. That was an outstanding outcome given the complicated nature of the pregnancy. Under doctor’s orders, my Mom had been bed-bound for the last three months of her pregnancy after her amniotic sac prematurely broke, induced labor but then miraculously resealed itself. Bottom line: today Elliott is healthy and my hero. He's 22 now and going to nursing school.
Elliott’s actual birth followed the pregnancy’s theme of dramatic and unexpected events. Already on edge due to the previous complications, when my Mom’s water broke for the second time at 5:30 am on November 19, 1986, my Dad drove us to Kaiser Sacramento at over 100 miles per hour. I was nine years old. When we arrived, all the doors of the hospital were locked due to an ongoing nursing strike. We pounded on the doors for what seem like hours. My Dad had me run up and down the hospital looking for open doors. As I ran, I can distinctly remember watching nurses picketing while my Mom lie panicked on the sidewalk. I did not understand why they wouldn’t help us. I still don’t. My Mom suddenly screamed in panic because she knew Elliott was well on his way. This was her third child. My Dad, always heeding the call of an emergency, grabbed the locked steal and glass sliding door, and with the superhuman strength that you read about, unhinged the door and moved it to the side. An alarm went off that triggered the attention of an irritated, all too casual nurse to walk down an extremely long hallway and yell at us, “What the hell is your problem?” My Dad ignored her, carried my Mom passed her and to the nursing station of the birthing center, and got the help of a more interested staff member. Almost fully dialated, she went straight to the birthing room. While on the gurney, my Mom howled just like a wolf and could be heard throughout the hospital.
In the shuffle, I was left with the nurse we had first met. She put me in a little square room and said, “That your Mom?” I nodded, she snorted, told me to stay put, and closed the door. I REALLY didn’t like her. Following my Dad’s example, I ignored her and left the little square room and followed the still audible howls. In my mind, the hospital staff was suspect and I wanted to make sure my Mom was okay.
I followed my Mom’s howls through a labyrinth of hallways and doors. I found her. The birthing room had a large window and I had arrived just in time to see my Dad cutting Elliott’s umbilical cord. Elliott was born at 7:00 am. Another nurse came up to me and told me I wasn’t supposed to be there. I just looked up at her and pointed through the glass and said, “That’s my brother.”

UCSF MEPN interview

2009-01-07T11:05:00.000-08:00

Two years ago, I went through the UCSF MEPN interview. It scared me silly and so I prepared for it in a variety of ways. Here are some ideas; my "brain storm", or more appropriately stated: "brain fart".

My understanding is that this year in the UCSF MEPN interview, y'all are doing a panel interview with a couple of interviewers. One will represent your specialty and will have a slightly more academic/administrative slant to their perspective. The other interviewer will be a clinical nurse and, logically, will be more concerned with clinical/bedside nursing than the advanced practice degree specialty. The panel interview differs than in years past, when we interviewed with the same people, but in two separate interviews. In any any event, these are, by and large, the questions you will be asked. My answers are there too, but clearly you shouldn't copy those.

INTERVIEW PREPARATION

Questions
• Why do you want to be a nurse?
• Why do you want to do critical care/trauma?
• How will you handle the stress?
• What do you think will be the most difficult thing about being a nurse?
• How do you intend on using your specialty in 5 & 10 years?
• Why not medical school?
• How will you prioritize your day?
• How will you know when you are being a good nurse?
• Give an example of a difficult/high stakes decision you’ve had to make and describe the thought process you went through
• Describe an ethical conflict that you’ve gone through
• Describe a frustrating experience at work and how you dealt with it
• Why no pediatric nursing?
• Describe your strengths and weaknesses.

Answers
-Q: Why do you want to be a nurse?
-A: Fundamentally I want to be able to help people—that’s a part of who I am. I’ve always worked with at risk or marginalized youth in a variety of settings because I feel it is the most necessary and practical work that can be done. In the same vein, I feel that in helping people, it is important to know how to treat the physical as well as the psychological, especially since the two are extensions of the same being. In my obsession with practical care, I realized that it was important for me to know how to care for the whole person, not just the mental aspects of care.

Furthermore, I have always worked in and around youth that are in crisis. The students at ___ and residents at _______were extremely violent and verbally abusive because of their past histories and troubles with their families. I thought it was extremely necessary to work with type of person because they absolutely needed some outside help to resolve some of their psychological issues. Sometimes that was as simple as having their meals prepared for them in a consistent manner. Often it involved de-escalating a child that was highly emotionally reactive.

Often, an emergency would take place where someone was injured and I wouldn’t have the knowledge to care for the people. That bothered me: not being of direct use in an emergency situation. So I started volunteering a year ago at _______ Emergency Department in order to see if the crisis management skills were at all applicable to working in the ED. I found that they were. Youth going through emotional crises are fundamentally similar to people going through a physical crisis—they just need several types of care within both the psychological and physical realms. I have been assigned to act as an information liaison in the ED at ______ where I announce my presence at the beginning of every shift to the patients and families that are waiting in the ED to see if I can be of use to them. Many patients will have been there for 3+ hours, so waiting time is often a concern and many people will be quite reactive to not having been taken care of within the time frame that they see fit. Maintaining a calm, consistent, and honest presence is of the essence in dealing with these situations. Occasionally I can use humor, but not until I have established professional rapport with the people in the ED.

Beyond the desire to help folks when they need it most, I also really enjoy the technical knowledge of nursing. I love to think systemically about patients and what is ailing them while I work in the ED. Using my basic knowledge of Anatomy, Physiology, and Chemistry I steal glances at charts, EKGs, x-rays, blood pressure readings, lab reports and CT scans and try to think critically about all the elements that are contributing to a persons illness. I like to ask a ton of questions to the RNs and MDs—especially about pharmacology, which I find fascinating.

Nurses in the ED have so much autonomy to care for the patients and they are always thinking on their feet and problem solving at all hours of the night. I like the challenge—the constant challenge of thinking about things that will help someone heal.

I also love the way nurses learn: it’s like an apprenticeship where clinical experience trumps all academic experience. Often times nursing is super physical and mechanical and demands refined expertise.

-Q: How will you handle the stress?
-A: I will handle it in that I am actively involved with how I experience stress. Some people appear to be impermeable to stressful situations. I don’t believe I am one of them. I get tired, irritable and my decision-making skills can become compromised unless I take consistent inventory of how I am experiencing stress. During a stressful situation I am usually so ensconced in working the problem that I am hardly aware of how I am physically feeling. Then, once home the fatigue and irritability sets in.

Techniques that I’ve learned to handle stress are
(1) Go running everyday
(2) Ask for help: Recognize that I am not the only person in the situation and that I can rely on others. I am extremely independent so this is often difficult for me.
(3) Take a break
(4) Eat all the time. I am somewhat hypoglycemic, so being aware of that is helpful.
(5) Breathe
(6) Honest with myself and others. Being clear and straightforward lets people know what expectations are and therefore doesn’t allow for unrealistic expectations to put added pressure on me.

-Q: What do you think the most difficult thing about being a nurse will be?
-A: I feel that the most difficult thing about being a nurse will be overcoming the inevitable process of habituation to the routine—and the “hardened” perspective that goes along with habituation. In working at the school for severely emotionally disturbed youth, I found that after about a year, I started to become too accustomed to being there and would, on occasion, let the routine take over rather than being actively involved with my students. This occurrence would make me a less aware/less perceptive/less skilled teacher. I think the same thing could happen in working with patients—I might become accustomed to being there and therefore less sympathetic and less aware of their plight. I think it is incredibly important to keep your assessment abilities sharp and acute no matter how long one has been there.

-Q: How will you know when you are being a good nurse?
-A: I’m pretty realistic about people’s behavior. I learned to have realistic expectations from working with SED youth. Frequently, I would be celebrating Ds and Cs and the fact that a student wouldn’t hit someone that week. It’s not that I’ve lowered my expectations—I want for them to be really successful and get As and be all that they can be. It’s just that I have realized that it is important to have realistic expectations. Being what they have gone through, it’s sometimes a miracle that they wanted to wake up. I have realistic expectations for patients that are in crisis and people in general. More often than not, people let you know when they are unhappy but will not let you know when they are content. Thus, if all of my patients are being quiet, it’s most likely that I am doing a good job. I’ll still be doing my rounds if they are quiet though.

-Q: Describe a frustrating experience at work and how you dealt with it
-A: Too personal, can you believe it???

-Q: How do you intend on using your specialty in 5 & 10 years?
-A: Upon graduating from UCSF with an advanced practice degree in nursing, my immediate plan is to gain outstanding clinical experience—humbling myself to the people that have knowledge and experience within the field and carry themselves with professionalism and a well-adjusted attitude. I plan on letting my clinical experiences be my guide as far as specialization in treatment. I am particularly interested in diagnosing internal injuries with non-specific symptoms, myocardial infarction, and severe wound management. Once I can gain enough expertise in an area of special interest, I would like to be a consultant in an ED/ICU for other nurses. Once I have tried my hand at teaching other nurses in a clinical setting, I would like to seriously consider getting my PhD in nursing and teaching clinical rotations within a nursing school such as UCSF. I could also very well wee myself working as a consultant in order to write legislation that would effect bills that would change health care. It’s up in the air in many respects, but my dedication and focus and quest for answers is second to none.

-Q: Give an example of a difficult/high stakes decision you’ve had to make and describe the thought process you went through
-A: There are two types of high stakes decisions: (1) those that require “from the gut” type decisions because there is some sort of emergency, or (2) those that give you a little leeway in terms of time.

If a decision requires an immediate response, I am not someone who sits back and does nothing. That’s part of the reason that I want to learn critical care/trauma nursing so that I can be of use in an emergency. An example of a time when I had to make a quick, high stakes decision is when: AC caught on fire, I heard it, nobody responded so I evacuated the house.

When a high stakes, life changing decision allows for a little time, I do research and talk to members of my “team”: my wife, my brother, my Mom & Dad, my friends, and my co-workers. Two high stakes decisions that I’ve had to make are (1) getting married, and (2) deciding to become a nurse. In deciding to become a nurse, I wanted to be sure that I knew what I was getting myself into, so I started voluntering weekly at ________ from 9-midnight so I could look before I leapt. There I observed, investigated, and absorbed as much as possible. I also spoke with my wife, to see if she would support the decision. Being that she is in law school and I was the primary earner in the household

Questions for her:
How did you get into nursing? Why? What is your specialization?
Do you do more administrative work than clinical work? Do you miss clinical work?

Strengths
-Moral: I believe in making the right decisions
-Honest:
-Work Ethic: second to none.
-caring & dutiful: I feel it is important to take care of people and feel that it is my duty to do so.
-perceptive: I enjoy observing situations and seeing nuances of behavior that give me insight as to how to deal with people.
-always willing to challenge myself: I like running up hills.
-independent: always thinking for myself and not within groupthink—allows me to be more objective.

Weaknesses
-rigid: Somewhat rigid when setting goals and pursuing them: difficult time shifting gears—result of me being a perfectionist.
-judgmental: used to making a lot of quick, split decision judgments in order to take care of people—this can affect how I treat people.
-too independent—sometimes have a hard time working with others.
-too dutiful: sometimes don’t take time for myself.

New Nurse Insanity

2008-11-06T04:20:00.000-08:00

REFLECING ON: Why working as a new RN is nuts on my floor. I can't believe a year ago I was a student.

I've been remiss in writing because, well, I've been absolutely going bonkers (in a good way) since getting hired as a new nurse on a cardiothoracic floor/telemetry unity. What's that mean? It means I get patients that are so sick that we monitor their heart and oxygenation 24/7. It means that our patients are WICKED unstable: recent/ongoing heart attacks/unstable angina, unstable heart rhythms (including V-Tach/Rapid uncontrolled A-Fib, heart block, and pacemakers), heart transplants, lung transplants, double heart/lung transplants, profound vascular disease requiring amputation, and a general hodge podge of rare diseases that academic hospitals get sent because nobody else has the resources to treat them. People code on my floor. We send a lot of folks to the ICU. We get a lot of folks from the ICU. I work 3 12-hour shifts a week, which I realize initially sounds pretty cush, but when you see the actual schedule and do the actual work, it's more like a 16-hour day of non-stop running. Here's my day:

*0400:
-Wake up and stumble to coffee maker.
*0430:
-Become conscious, realize have clothes on; don't remember dressing. "Neat", I think, "I'm efficient even when I'm semi-conscious." Double check that I have stethoscope, ID, PALM, a couple of power bars. Double check that I actually have pants on. Kiss wife. She murmurs through morning breath that she loves me. I tuck her in again and make sure her alarm is set for 0500. She will get up as I leave to study for the BAR. I want a day off. "It's okay", I remind myself, "I love my job."
*0430-0500:
-Review lab values/pharm/diseases that I've never heard before but nonetheless will be required to manage and speak intelligently on to patients, their families, fellow nurses, MDs (R1-R3, and maybe an attending), RTs, OTs, PTs, PCAs, PSAs, radiologists, and of course, my boss and nursing students. I drink a Liter of protein-shake straight from the blender while doing this.
*0500-0545 :
-Drive to SF, find parking in one of the neighborhoods around the hospital that ISN'T 2-hour, so that I can save $20. Remind myself that the 15 minute walk to the hospital is worth it. I may be finally making a paycheck, but I also remind myself that I'm still $75,000 in school debt.
*0545-0600:
-Walk to hospital, listen to iPod, consider second cup of coffee and perhaps going to Mexico where ephedrine is still legal (kidding). Try to breathe. Get semi-religious and pray a bit. The prayer is always the same: "Please Gods (I pray to all of them to cover my bases), give me the strength to act in the best interests of my patients. Allow me to act decisively when I know and ALWAYS seek help when I don't. Keep me and my team safe. Thank you. Word. One love. Amen." I breathe in fresh air one last time before entering into the hospital. It is usually smoky because the entrance is next to the smoking shelter.
*0600:
-Arrive on hospital unit and sympathize with my night shift homies. They all are bug-eyed and slightly delirious. They openly wonder why the hell I'm there so early. They then get scared and start doing what they need to do before end of the shift. They don't understand why I am so early. I've been an hour early every shift since Janurary when I was a student on this floor. I am still early after working for 3 months. I don't intend on changing. This is my way. Don't knock it.
"No, but seriously, Nat, why?", they ask.
"This is what I do, don't worry about it and dismiss me as nuts", I say.
-I need to catch up on my patients and read new admission histories. I get to the computer and start reading about my assignment. (I am going to write the hospital jargon abbreviations next to the common ones so you can learn to interpret medical-ease) I review the assignment. It's heavy. I look at other folks assignments. They're all heavy. Okay, here we go:
-Patient (Pt.) #1: 47 year old (yo) female, status post (s/p) lung transplant (lung tx) 2/2 pulmonary fibrosis (PF) presenting with (p/w) shortness of breath (SOB)/wheezing/Chest Pain (CP) secondary to (2/2) Cytomegalovirus (CMV) infection. Right upper lobe (RUL) has SERIOUS wheezing. Pt. refuses oxygenation because prior to her tx, she was on a high flow mask that covered her face for 6 months while she was waiting for the lungs. @ 0900 she will be receiving a $35,000/dose immunoglobulin (Ig) that I will eventually have to do battle with pharmacy to get in on time, and then figure out how to administer because even veteran RNs have only given it once in their careers. I pray I don't drop the bottle. Later, after successfully administering it, I kid the patient and tell her that she is $35,000 richer. She laughs and thanks god for health insurance. I think of folks that don't have it. I then call pharmacist and kid that I dropped the bottle. Pharmacist takes me seriously. I let moments of awkward tense silence pass on the phone, and then admit I am joking. "That was REALLY not funny", she groans. On paper this is my least stable patient, but in reality, is my most stable patient because she knows SO much about her own treatment. I listen to her and try to coordinate appointments and medication administration around her work, which she still manages to do from her hospital room. She had had 7 hospitalization in the last 11 months, some lasting more than 2 months.
-Patient #2: 80 y.o. male s/p right lower lobe lobectomy (RLL lobectomy) 2/2 adenocarcinoma metastasis. Right Chest Tube (CT) in place draining 10 mL of serosanguinous (SS) fluid/12 hours. She's post-operation day (POD) #3. CT will probably be pulled today. Pt. also has history of (h/0) going into rapid uncontrolled atrial-fibrilation (A-FIB) (HR 180s) and becoming hemodynamically unstable (BPs: 70s-140s/40s-100s). This is in the context of NO prior cardiac history. Apparently when you mess with the bull (lungs) you get the horns (heart). The heart does not like major surgery anywhere near it. According to the literature, the heart will sometimes become irritated in 30% of thoracic surgery patients and convert from Normal sinus Rhythm (NSR) to A-Fib. Basically the heart decides to suddenly do the mambo and not pump blood so efficiently. Pain management and oxygenation are MAJOR issues with this patient because she's never NOT in pain. Epidural (pain medication that infuses directly into space around spine) has just been stopped. Nervous family watching my EVERY move. I learn to earn their trust by effectively managing her hemodynamic instability with fluid boluses and IV metoprolol. I learned that from my preceptor, Bill. He is not there today, but I remember hanging on his every word through the 10 weeks of orientation. I quietly think to myself, "I wish I still had a preceptor." Nope. Time to "nurse" up.
-Patient #3: 27 y.o. male p/w elevated troponins (heart muscle fibers) that indicate he's had a myocardial infarction (MI) 2/2 methamphetamine use. Pt. p/w CP and assaultive/aggresive behavior that requires restraints in the Emergency Department (ED). Pt. also in complete congestive heart failure (CHF) 2/2 profound substance abuse (SU). Pt. continues to be actively psychotic and later, we learn, has escaped from a lock-down psych facility after being brought in on 5150 hold for assaulting folks in the streets. Pt. complains of (c/0) dragons outside room. Pt. will eventually take off his cardiac monitor, insist we are sucking his soul away through the wires and inform me that despite the fact that I am good, that I am "dying" in my eyes. I must look tired. Good rapport established, he begins to trust me but will eventually rip out his own IV, shoot blood all over the floor, and begin sucking his own blood out. Before the day is through, he will also assault a secure officer with an ice-cream sandwich, try to escape multiple times, and require an amazing amount of anti-psychotic medication (seroquel, thorazine, ativan) before taking a nap. Because the patient trusts me, he takes medication by mouth (PO) but refuses another IV, which he also told me was sucking away his soul. I will have to monitor for extrapyramidal side effects (EPS--abnormal motor/neurological movement), neuroleptic malignant syndrome (NMS-sudden reaction/fever to some psych meds), and oversedation AND be extremely concerned about the condition of his heart. Pt. will eventually be restrained for assaulting another security guard. This time with his dinner tray.
-Patient #4. 56 yo male p/w increasing SOB and CP 2/2 CHF 2/2 genetic dilated cardiomyopathy (DCM). He will be initiated on a dobutamine drip that will keep his heart pumping until he can get a transplant. Dobutamine is calculated to the microgram and requires some serious attention when you've never managed before. I've only studied about it for the NCLEX and in my patho class with Pam ("let's get it started"), my favorite nurisng professor. I'm glad I studied so hard for the NCLEX. I'm even "gladder" I have time to read about how to administer this drug before giving it, monitor for side effects, and initiate proper hospital monitoring policy/protocol for this patient. This amounts to HELLA paperwork. Glad I arrived an hour early.
*0700-0730:
-Take report from night shift. Quietly wonder if this is manageable. Update resource nurse about my patients and who will be "heavy". I kind of think they're all heavy.
*0730-1900
-Run my ASS off managing everything from hypochondrical family members to a patient crashing and almost needing to go to ICU. Frequent re-assessment for patients 1-4 because, well, they are not all that stable. Throw in a smattering of moody sleep-deprived residents and helpful residents. Everything is a blur and every monitor is beeping, calling my name for attention and assessment. My work cell-phone rings off the hook. I wash my hands at least 200 times. I try to be calm when 25% of my medications aren't available because pharmacy is backed up. I make friends with the pharmacist so that I can get things on-time for the rest of the day. I remind myself not to give patient #3 any more ice-cream sandwiches. I occasionally wonder how I am managing to not go insane as this actively psychotic patient. I call in support from veteran nurses but frequently realize that I need to act decisively and independently so as not to burden them from taking care of their own patients. Then the $35,000 medication comes and I need to administer it immediately. That's when Pt.#2 almost crashes. I am suddenly and inexplicably less overwhelmed right now because I know the crashing patient takes priority. I am now doing one thing and not a million things. I hand the $35,000 medication to the resource nurse and ask her, "Can you find out how to give this? I'll be right back (white lie), I need to call rapid response (team of nurses that respond to REALLY unstable patients)". Pt.#2 become stable after an hour of work. I am now REALLY behind. I become overwhelmed at one point because 2 pages of orders suddenly appeared in the chart that weren't there a minute ago. The orders were back-timed by a sneaky MD to read as if they were written @ 0800 and it is currently 1000 so I look like I neglected to execute important orders. Talk to resident about not doing that again. A different, helpful resident (R3 no less) gets excited about doing a Guiac Test on pt. #1 that now has been diagnosed with a upper gastrointestinal UGI bleed. I am happy to delegate a poop test to an excited doctor. I kind of love him for that. Now reader, I urge you, to never breathe deeply while handling melena (look it up and you will know it's definition: black, bloody, tarry poo. Smell it once and you will never be the same).
-At one point I will have to change my scrubs because, while helping a colleague, explosive diarrhea covers my scrubs, and I need to change. There's no washing this out. We call it a "code brown". After disgusting some folks on the elevator, and getting a new pair of scrubs from the basement, I take this opportunity to eat a power bar. After changing of course. And washing my hands for the 300th time. I get back to the patients and more of the same onslaught ensues. Constant reorganization and re-prioritization. Somehow it's all getting done. Thank GOD for the team. Blur. Blur. Triple Blur. I look up and it's almost time to go. I should probably chart more than vitals. Damn. I've got a half hour.
*1930
-Give report to newly refreshed night nurses. It is then that I remember that I didn't eat anything but the power bar or pee the whole day. After report, I then have the most satisfying pee of my whole life. It lasts an abnormally long time. I wonder if I've given myself prostitis or a UTI. Will find out next week.
*2000
-Leave hospital after tying up loose ends.
*2015
-Arrive @ car and assess whether I will fall asleep on way home. No.
*2045
-Arrive home and take a LONG shower.
*2115
-Wife now accepts kiss because she now is no longer concerned about poo/blood on me.
*2130-2200
-Catch up with wife while eating Cheerios.
*2201
-CRASH.
*0400
-Time to do it again.

Chadwick, RN

2008-08-02T20:53:00.000-07:00

Yup. I passed the NCLEX! I am happy. Really happy. I feel quite accomplished. I over studied, but that also saved me from feeling the anxiety of seeing something on the test that I'd never heard of. And now, 3 days of 12 hour shifts and 1 four-hour class each week sounds like a real vacation. My off time will be mine. No looming deadlines. No papers. No tests that will determine the course of my life. Just good old-fashioned work.

I've been working on the cardiothoracic floor for 4 weeks now. I'm all thumbs but I love it. The struggle is so much more tolerable when it's not in a book of theory and out in "the real". I can see that my efforts are directly benefiting the patients that I work with. It's awesome.

And for now, it's time to relax a bit.

Murals @ UCSF

2008-07-18T09:55:00.001-07:00

Uploaded - Jul 16, 2008-8
Originally uploaded by nat_chadwick

I've recently purchased an iPhone and am having mad fun taking pictures and uploading them to my flickr account. I can even post them from the phone onto my blog. Wild. Technology is something. Anyway,they have these medical murals all around the UCSF campus. Some of them are really bizarre, especially when you get into detail. Click on the photo to see more iPhone photos and bizarre mural photos.

M.I.A.

2008-07-13T16:39:00.001-07:00

So, sadly I haven't been writing much. I've been MIA from most of my life these daze. I miss writing, but I've been a little preoccupied with studying for the NCLEX and starting the new job. Unfortunately, I still haven't taken it because the date I originally wanted to take it was not available due to scheduling issues with my new job. I am so incredibly happy and feel so lucky to have gotten a job on the floor where I work. It happens to be the same floor where I did my Med-Surg rotation. I'm seeing new MEPNs all around me as I attempt to learn the ropes. I loved this last year, but I would not try to do it again. It was an intellectual-spiritual-physical-addyourown-ical challenge. I do hope they enjoyed it like I did. It was a hell of a year. At this point, I will be taking the NCLEX on the 30th. I cannot wait to have that monkey off my back. Wish me luck.

Psych Moments

2008-05-20T17:34:00.000-07:00

So I've just recently started my psych rotation on a floor that specializes in patients with schizophrenia, bipolar disorder and shizoaffective disorder. I've been out of psych for long enough that I miss it. Random moments and exchanges with patients that you won't ever experience anywhere else happen on these floors. Here are a couple:

First day getting adjusted--I am suddenly distracted from a conversation with a biploar patient due to a loud noise. I ask the patient to repeat what she just said. She responds, "Look, I know I have a short attention span, but I'm bipolar. What's your excuse?"

Second day, talking to a patient with schizoaffective disorder. I attempt to assess his ability at abstract thinking by asking him to interpret the saying 'A rolling stone gathers no moss'. Our exchange:
Patient: Stones don't gather moths. Besides moths couldn't lift stones either.
Me: No, moss.
Patient: Oh, that changes everything. That rock is a loser. The moss is the winner.
Me: Why is that?
Patient: The rock couldn't gather any moss so the moss must have gathered all the stones!
[I still don't know how to interpret that one]

Third day, walking up to patient who is rolling their eyes in every direction, " I can't even see my eyes!"

Another patient, when asked if she was Catholic, said, "I'm on the cusp."

A HIV+, 60 year old man diagnosed with shizoaffective disorder that was coming down off a recent crack binge was asked about his goals, "I'm just trying to get a grip on what little years I got left."

“There’s a boy in here”

2008-05-01T17:49:00.001-07:00

This is me venturing out of my personal narratives and into an op-ed style...

While doing an observation at a pre-school for my Pediatric Nursing course, a four-year-old girl entered the classroom and, curious to identify the strangers in her classroom, asked her teacher, “Who are the new people?” Her teacher responded plainly by stating that we were nursing students. The little girl’s face quickly changed from an innocent and curious expression to being conflicted and confused. She took a long pause and then looked up at her teacher and said, “But there’s a boy in here.”

Indeed there is a boy in here—right smack-dab in the middle of many people’s privately held stereotype of what a nurse looks like. The little girl, of course, is certainly not without adult company. On more than one occasion I have been asked, “So you’re going to be a male nurse?” as if I was still in the process of choosing my sex as well as my profession.

Yes indeed! I’m a “murse”. Or, more accurately, a “mursing” student. And to be perfectly honest, I’m never offended by people’s surprise at a man becoming a nurse; not only do I revel in throwing people for a loop, I understand that some part of their stereotype is not without basis. According to the 2002 U.S. Department of Health and Human Services’ National Sample Survey of Registered Nurses, only 5.4 percent of RNs in the United States are men. Given the fact that registered nurses constitute the largest health care occupation, with 2.5 million jobs, the chances of interacting with a female nurse are pretty likely.

What does trouble me, however, is the all-too-frequent follow up question, “Why didn’t you go to medical school?” Given that 72.2 percent of physicians are male, I suppose I should probably expect this question, too. And yet, I am simultaneously fascinated and deeply concerned by how infrequently the flip side of this question, “Why didn’t you go to nursing school?” isn’t being asked of medical students. Clearly, nursing is not on equal footing with medicine.

I believe that the reason that this question isn’t asked points to a different, very misguided part of the nursing stereotype that is seldom discussed openly: that nursing is some sort of a lesser, sloppy-second alternative to medicine—particularly for a boy. I take serious issue with this aspect of the stereotype not only because is it categorically untrue, but also because this belief is extremely dangerous due to its roots in the long-standing power struggle between men and women. Historically, women have been professionally subjugated to men due to the inaccurate and sexist perception that men are smarter than women.

The reason that this hushed stereotype still exists is rooted in socially constructed and learned behavior. As exemplified by the four year-old at the pre-school, from a very young age we learn gender rules on a variety of subjects that range from toys and clothes to behavior and jobs. Consequently, I believe that the average Joe and Josephine on the street quietly subscribes to the idea that nursing, being female dominated, is also associated with the female personality attributes of caring and empathy while medicine, being male-dominated, is associated with the male personality attribute of scientific objectivity. Or, put more simply, RNs are sensitive girls and doctors are scientific boys. Furthermore, this translates to why Joe and Josephine view medical science, being more quantifiable than the ever-ambiguous emotion, as being equated with intelligence, while they view nursing as less intelligent.

It is absolutely time to smash these perceptions. Easy. Although it is true that nursing fosters a slightly more nurturing perspective than medicine, nursing is an incredibly dynamic field that includes nursing research on subjects not traditionally associated with nurses. For example, a colleague of mine, Monica R. McLemore, a Ph.D. Candidate and American Cancer Society Fellow at the University of California, San Francisco School of Nursing, recently described her research to me, “Simply put, I study the isoforms of CA125, which is a tumor marker of ovarian cancer. I also attempt to correlate these isoforms (using kilodalton size as a proxy for the true amino acid sequence, since I'm not THAT well funded) to serum concentration.” How about them apples?

As a man within a traditionally female-dominated profession, I am acutely aware of the fact that my presence in this profession is still perceived with some discomfort due to the fact that the socially constructed stereotypes of yesteryear still govern many people’s perception of the field. My message to you is this: let’s evolve people. It is absolutely time that we embrace a more enlightened perspective in order to truly understand the incredibly dynamic and diverse field of nursing.

I got a job!

2008-04-11T21:39:00.000-07:00

I got the phone call today that I got a job on the cardiothoraic floor where I did my Med-Surg rotation. Wow! I feel so incredibly fortunate to have found a job so early in the year that is so in line with what I want to do. I accepted and then called my wife and then my parents. I will bask in the glory of this moment today, but tomorrow, I move on to the next thing to worry about...the NCLEX!
Countdown To NCLEX

Nurses As Scientists

2008-04-07T10:03:00.000-07:00

A classmate and colleague of mine, Elizabeth Goldstein, recently created and published a self-made podcast that explores the notion of "Nurses as Scientists". She is interested in demonstrating how nurses use science in our everyday actions, though it might not always appear so...take a listen.

How job interview anxiety and this program has caused me to talk to myself...

2008-03-09T08:32:00.000-07:00

Reflecting on: Job search anxiety that manifested itself as apocalyptic self-doubt...

I am a little tired. Okay. A lot tired and want a break. My anxiety has been getting the best of me lately. I re-rehearse things that I certainly already know for tests, and for interviews. Thank god spring break is almost here. I have pushed myself and learned an amazing amount in one year. I have sufficiently squished and jammed my brain so full of knowledge that occasionally I don’t remember what’s going on around me. My brain aches like it does after a really hard test. All the time.

I’m complaining but am not going to change because this kind of ache is hugely beneficial to me. Knowledge allows me to better understand my patients and facilitate desired outcomes for them. From time to time, however, I need my rug pulled out from underneath me. I also need a little balance; a few purposeless conversations that aren’t always guided by overarching school goals might do me some good.

The long and the short of it is that I'm starting to talk to myself (loudly) in public. Most concerning...

Tomorrow I have a job/scholarship interview on the cardiovascular-thoracic floor at the hospital where I have been doing my clinical rotations. That is certainly freaking me out. No doubt. I made the plunge a year ago and was committed to an academic and profession. But this is the job. This isn’t school. This is the work! This is the work that I want to do. These patients—this is why I am in this program. Holy. Freaking. Cow.

The advanced practice degree, though meaningful and eventually useful, is not exactly my focus right now. Understanding the exactness of nursing procedure and working with patients is. Each patient is a lesson. There is no way of knowing what might happen in a day, except to monitor them and pay attention through assessments.

So I am committed to this work—as I am committed to working on this floor. Initially, I was concerned that working on a cardiac floor was not necessarily consistent with my career goals because it is not strictly a critical care environment such as the emergency department or ICU. When I really examine what I have learned this year and what I want to learn, I realize that working on this floor is perfect for me. My primary goal is to help patients that are critically ill and better understand them. While the ED certainly provides this opportunity, I do not believe that the patient care perspective that I will develop in the ED will be as complete as I need. Having volunteered in the ED for almost two years, I realize that nurses mostly get little snap-shots of different patients before stabilizing them and then discharging or admitting them.

While I feel that I am capable of doing these important tasks and still want to work in the ED, the cardiovascular-thoracic floor affords me the opportunity to cast my net a little wider, and better understand the history of the disease/illness that has brought the individual to the hospital. Thus, when eventually I decide to work in the ED, I will have insight into the exact "snap-shot" that I am seeing. Given the fact that heart disease kills more Americans than any other disease, the skills that I will learn on the cardiac floor are particularly relevant to emergency and intensive care nursing. Furthermore, the variety of patients and pathologies is particularly appealing to me, not to mention the fact there are codes almost weekly on this floor, thereby allowing me to be surrounded by and participate in critical care as well as acute and even preventative care.

God I hope I get this job.

Heart Attack and Angioplasty...

2008-02-24T18:27:00.000-08:00

The heart is becoming my favorite nursing preoccupation. I could write pages about the pathophysiology of a heart attack (myocardial infarction/MI), or you could just watch this really good video. In a heart attack, the heart essentially essentially chokes itself to death.

To correct for the "choking", the coronary arteries must be widened, which can be done by placing a Stent, or artificial tube, in the coronary arteries to widen it. An excellent explanation:

Here is the actual video of someone's angiogram where they are injecting the dye in order to see various parts of this guy's vasculature.

Stress and Tachycardic, Psychedelic Dreams

2008-02-06T17:44:00.000-08:00

Reflecting on: Nursing, stress, and psychedelic dreams…

Lately, I’ve come to the conclusion that MEPN, for me, is like running a race where the finish line is gradually being pulled further away from me. Sometimes I feel like I’m gaining ground—most of the time, really—but then there are the times where my legs are cycling in a sick, nightmarish pantomime that approximates running, but gets me exactly nowhere—as if I’m stuck on a quicksandish treadmill and the finish line disappears into the horizon.

I’ve actually had this dream before and it sucks every time.

The key to overcoming such nightmares, I’ve found out, is to become self-aware while still in the dream. It doesn’t happen as much as I would like.

In the nightmare, I spin my legs so fast and become so agitated and over-rot with emotion that I actually wake myself up—heart beating as though I actually were running an endless mile. I can hear the blood pounding in my ears…I take a moment to soak up the relief that I am not actually stuck—that I am in my bed with my ridiculous cat and beautiful wife and that everything will be alright. My wife snorts and shifts her pillow. The cat rouses and looks at me as if I were crazy. Possibly. But not so far gone that I’m afraid to go back to sleep. I look around and slow my breathing. I close my eyes…

…I fall back asleep and drift off into the same dream.

Given a second chance, I become self-aware—“lucid dreaming” I think professionals call it. The sensation of lucid dreaming is akin to the same relief that I had when I woke, but quickly transitions into being exceedingly tickled that I can laugh at the ground I was once stuck on. Chuckling to myself, solid matter blurs into sky and I fly off through clouds and over towns I vaguely I recognize. Total exhilaration of the dream fuzz flies past my face. I feel victorious that I have overcome physical boundaries. But then, while flying, I sometimes am bothered by the notion that “this isn’t real” and will falter—even fall. Gravity regains its hold on me and I plummet. As I rush towards the earth, I am reminded that I am still dreaming, and go into my best dive formation. Hurdling towards the ground, there is no impact because I dive into the earth’s crust and through the center of the earth. I am now in an entirely new dimension.

I want to do it again. And again…

Sometimes my dreams mean something and sometimes they don’t.
Sometimes I don’t wanna know (seriously).

This one, however, has some pretty obvious symbols.

Clearly, I’m racing my ass off to be the best damn nurse I can be in one year. It’s kind of ridiculous when I say it out loud, but since that is what I am, in fact, doing, it’s better to be clear about my intentions. The overall experience is a lovely mélange of being completely overwhelmed but, now faced with a challenge, exhilarated that I am alive and in the middle of something meaningful and stimulating.

Baptism by fire.

The finish line is nonsense though; it is nothing more than a self-imposed limit that I created because this accelerated RN experience is done in one year. Time to laugh and become self-aware: I am built for this. I love doing this. So why would I ever stop? Why would I even want a finish line? I think I’d rather keep on running, jump in a limo, get out, and, I don’t know, do the freaking running man or something. I mean, let’s evolve, right?

Right.

The endless, never ending run that doesn’t allow me to move anywhere: that’s my battle with perfectionism—a huge limitation. I am operating under the incredibly unrealistic notion that I have to be perfect in 6 weeks. Ridiculous. More ridiculous than my cat. So what do I do? Let’s challenge those expectations…let’s laugh at them—or rather, laugh with them! Maybe I’ll fly. Maybe I’ll forget…more than likely I’ll do both…but whatever…let’s breakdown and build up and get back to basics. Let’s evolve. I said that already. How about relative perfectionism instead? How about I be as good as I can be in 6 weeks without losing my mind and making my quicksand treadmill a reality? How about a little reminder that I can continue to reform and dive into the challenges that present themselves to me…

It’s a beautiful thing to be stressed and overworked and running with your pants around your ankles because although it makes me crazy, it forces me to think and learn: it is here that I am reminded that I can fly and that I will fly again.

Just one non-nursey thing...

2008-01-31T21:45:00.000-08:00

Pretty much the most calming song and video I've ever seen. I'm trying to remember to take it easy--this seems to do the trick somehow.

One!

Laparoscopic Nephrectomies for dummies...

2008-01-22T22:25:00.001-08:00

Today I got observe a laparoscopic nephrectomy (kidney removal). Just amazing. Very similar to this one, except it wasn't "hand"-assisted; laparoscopic clamps were used instead @ much smaller ports, thereby reducing the size of the incisions and scaring of the patient. It took me a while to get my bearings, because although I know my anatomy pretty well, knowing it inside-out and backwards takes some doing. I got the hang of it by the second operation.

It did confirm one thing though: I don't have much of an interest in working in the OR as a nurse due to the lack of face-time with the patient (unless of course one counts time watching the vital signs of someone who is under general anesthesia). OR nursing is valuable, no doubt, but I just don't think it would be the right fit.

Check out a nephrectomy (pretty bizarre that a nephrectomy is on youtube). Simple as 1-2-3:

1. Dissect away the connective tissue from the bowels and kidney.
2. Clamp of the major arteries/veins feeding/running off the kidney.
3. Cut out the kidney with a cauterizing clamp.

Check it out:

Feathers, Harpoons, Livers, & Transplants

2008-01-05T14:19:00.002-08:00

REFLECTING ON: Ethical issues of transplanting a new liver into a "recovered" alcoholic. Martha's name is real and written with her permission.

In post-conference on Friday, a fellow MEPN ruffled my feathers. You see, in our clinical rotations, we were discussing the hospital policy to transplant new livers into “recovered” alcoholics and the ethical issues contained therein. When somebody informed me that the hospital's policy required a transplantee to be sober for a mere 3 months, I stated aloud, “That just doesn’t sit right with me.” There were some murmurings of agreement and some quiet dissent.

The feather ruffler, Martha, then coolly dealt her reply, “Oh those alcoholics, they don’t deserve livers, do they?”

Ire now raised, I took the bait, “That’s exactly what I’m saying.”

With what I perceived to be silent judgment, Martha looked me coolly, and said, “I know.”

Discussion ensued amongst the other students, but my mind was fixated on Martha’s words; they had jarred me. I was mad at the implication that my judgment of alcoholics was inappropriate or unfounded. I remained silent though. You see, one of the few things that I’ve learned in my thirty years is that when I am full of emotion, I try to keep my cards to myself for fear of revealing a bad hand. I don’t enjoy becoming overheated; it’s a sure-fire recipe for saying ridiculous things and becoming illogical.

As the discussion continued, Martha solidified her seat in court, “And those queers, should we give them livers too?”

Fine Martha. I see your point. Where do we draw the ethical line regarding who is eligible for a transplant and who is not? A fair point: we need to maintain objectivity or else slip down that slope of judgment that can ultimately lead to prejudice and discrimination. And although I concede this point, it was presented with the delicacy of a harpoon thrower. Of course, perhaps I need a harpoon now and then so that I can re-examine issues like these. So, in all honesty, thank you for the harpoon, and for the record, I do believe that gay people do deserve livers.

Alcoholics though? I just don’t know.

Where I take issue with most alcoholics is theirs is an affliction of the mind. While the non-addicted brain maintains its status as an efficient conductor of the organ systems that supply and maintain life, the addict’s mind will gladly sell the piano that it feebly pounds out chopsticks on in order to continue its own selfish, self-annihilation. Replacing the liver is a like putting a tiny band-aid on a huge gash that will continue to expand, ooze, and bleed until the actual cause is effectively managed and treated. The perpetrator of this deep cut is not the liver; it is the mind, and all of the complex and ever evolving layers and patterns that it alternates influencing and being influenced by. I maintain, as in triage, the most serious and life-threatening problems should be treated first. Since the origins of an alcoholic’s liver failure are routed in their addiction, a mental illness, the mind should therefore be prioritized for treatment. And although I am open to it, I have never witnessed a recovery from addiction in just 3 short months.

I ask, what is the point of extending a person’s life that is hell-bent on drinking him or herself to death? Unless that individual shows sincere and real progress towards treating their addiction, their true disease, fixing a diseased liver merely buys them time in the off-chance that they have an epiphany—and what is the likelihood that a person will suddenly shift to a pattern of making healthy decisions after a lifetime of making it’s bad ones? It’s like waiting for lightening to strike.

And in the meantime, while we’re waiting for lightening to strike, what do we actually witness? In my experience working at a group home for emotionally disturbed boys, most of whom were the products of parents that were abusive addicts, I watched how alcoholism continually disappoints, hurts, and self-destructs. One child, Steven, comes to mind. At 14, Steven appeared as if he was in early grade school. His physical and mental stature had been severely retarded by his mother’s drinking. His face and head revealed all the classic physical manifestations of Fetal Alcohol Syndrome: small head, low, misshapen ears, an unnaturally flat face, almost no jaw, thin lips, and incredibly small eyes. Steven read at maybe a 2nd grade level on a good day but cursed like a sailor when he was angry, which was almost all the time. When he got mad, he would often run away in a manner that resembled what a second grader would do: run three or four blocks, and then return home. Until he began to express suicidal ideation, the staff at the facility where I worked would let him run, knowing full well that he would soon return. One day, after Brent Steven expressed committing suicide, I was chasing him during one of his efforts at going AWOL. When I caught up with him, I just stood beside him. I had learned early on that grabbing someone that wants to leave is a sure way of making them dislike you. So I just stood, and then walked beside him, away from the group home. Steven was clearly frustrated—his brow was furrowed and he walked with fists at his sides. Then he stopped and looked up at me. I looked down and asked the kind of question that you only ask after you’ve chased a kid a hundred times, “Why don’t you ever just go for it? Why do you always stop?” Steven turned around and began returning home. We walked side-by-side. He walked silently for a bit, and then answered my question, “If I only just had a piece of paper, that I could draw a map on, then maybe I could draw a map and figure out how to get out of here.”

Now Steven had been in cars and even hikes that lead him off the facility’s premises a thousand times. It was only in that moment that I became acutely aware of how damaging the alcohol had been to his brain: he couldn’t keep his surrounding or even where he was in his mind for long enough to leave. He wanted to draw a map, one that he could keep in his mind, so that he could escape. In his distorted thinking, he hadn’t thought to consult an already existing map.

So there it is: why I resent and am so unforgiving of alcoholics. How can 3 months of drying out correct for Steven's lifetime of depression and frustration? It can’t. And it’s not fair. It’s not fair to Steven and it’s not fair to someone on the transplant list who, in all honesty, shows a hell of a lot more promise than a 3-month “recovered” alcoholic. Does Steven's mother deserve a new liver? I think not. And though it may sound harsh, I’m fine with that. Why? Because both within my personal and professional life, I’ve seen and felt the wake of mayhem and hurt left behind by alcoholics.

I realize that Steven is a dramatic illustration of the consequences of someone’s addiction. But it is real, and although most that are affected by alcoholism do not bare Steven's physical abnormalities, they are nonetheless affected in a manner that is similar to Steven; they bare internal scars and pain that they will carry with them for the rest of their lives. Call it what you will: a bias, a stereotype, or even prejudice. Judgment based on experience is what I prefer to call wisdom. Oh Jesus Christ I sound like a televangelist. Sorry. Just let me have my televangelist moment though and I will go back to trying to be well adjusted.

Here’s where it starts and ends for me: I’m absolutely willing to give the next recovering alcoholic a fair shake—just not after three months. How can an individual consider himself or herself cured when they’ve spent a much longer period of time slowly poisoning themselves? They’ve proved time and time again that they are not competent to make healthy choices, so why would we prolong that process? I don’t have time in my life to wait for the lightening to strike. Someone who deserves a new liver, in my mind, would be hit by that lightening, bottle it up, and bring it to the god damn hospital and show everyone that they deserve a new liver. That’s just me though.

I’m sure I sound like a pessimist right now. Rest assured, I’m not. I’m a horribly sensitive, bleeding heart optimist. You know how I know? Because despite my animosity towards alcoholics that have caused pain everywhere, I will still do my best, as a student and nurse-to-be, to provide quality nursing care to that alcoholic--even to Steven's mother. Why? Part of me is still invested in the hope that a person can change, even though the odds are against it. Pragmatic optimism? I don’t know what to call it. Most of me, however, just knows it’s the right thing to do.

A Day at an Abortion Clinic

2007-12-11T19:43:00.000-08:00

REFLECTING ON: Observing at an abortion clinic and confronting my previously unchallenged ideas on the subject...

Having not donned my forest-green scrub top in a while, at 5:30 yesterday morning, I found myself again feeling like a complete fraud as I dressed up to “play nurse”. I moved slowly as I pulled up my multi-pocketed, khaki scrub pants, and closed my eyes for long periods of time. At the end of one sleepy head nod, I opened my eyes to stare down at my left sleeve: the iron-on UCSF patch—my official sponsor. I wondered if or when I ever was ever going to feel confident or competent as a nurse. Such is the life, I suppose, of a student in an accelerated program.

My destination was a San Francisco abortion clinic where they perform abortions for patients in their first and second trimesters (up to 22 weeks). As someone who had never been to an abortion clinic in any part of my personal or professional life, my expectations were distorted by the vague abstractions of what I had heard in lectures, seen in the news, and read in books. Though it was vacation, I had chosen to volunteer at this clinic for this very reason: my total lack of actual experience with the subject. In addition to educating myself, my decision to volunteer was intended to confront my fears regarding abortion. In being totally honest with myself, I realized that I wanted nothing to do with the abortion process. My natural inclination is to run away from situations like these due to some misplaced instinct to survive. I have quickly realized, however, that being a nurse often requires me to walk towards these less-than-comfortable situations in order that I better serve my patients. How can I be objective and caring if the greater part of my brain is sorting through basic instincts? So I take a deep breath and take a step closer to my fears.

Although these greater, mostly inexpressible thoughts were swirling around my gray matter as I got ready, I could verbalize one constant preoccupation: I was nervous and concerned that I wouldn’t be of any use. I suppose “being of use” isn’t so much the point during a day of observation, but I always like to show that I can be helpful. Part of the “disease to please” I suppose, where I always try to find someway to help. Later, after I had observed eight abortions, I was glad to just sort through my thoughts.

While on BART and Muni, I spent my time reviewing pregnancy and abortion terminology as well as the pharmacological actions of Mifeprestone, Misoprostate, and Methotrexate—drugs used in medically induce abortions. Memorizing things like these is a part of my “comfort-routine”, where I control for as many variables as possible. Memorizing facts, though challenging and requiring discipline, is easier than wrestling with the swirling and unpredictable emotional variables. I can memorize what is known and understood. In contrast, I can only blankly repeat sentences when something is beyond my mind’s grasp. As much as I crammed, there was no way I could prepare myself for truly understanding the mechanics of abortion.

I foggily made my way through the hospital’s labyrinth of hallways and, after ringing a doorbell, stepped into the clinic. Luz, another nursing student in UCSF’s MEPN program, was already there. Everyone was friendly and this surprised me somehow. I even heard one of the nurses say, “Oh good, the students are here.” Reflecting back, my surprise was the first clue to my true, thoughts on abortion. If I had been completely honest with myself, I halfway expected that everyone in the clinic would be quiet and forlorn, perhaps in constant state of mourning, because after all, weren’t they killing babies here?

And with that flash of thought, I was truly taken back. Floored really. Completely and totally shocked. Did I really just think that? But I had always flown the pro-choice flag…and now…shit…was all my talk just lip-service and yet another unchallenged idea in my personal cache of thoughts that define me as liberal and open-minded? Am I really that naïve? In the abstract, I had somehow rationalized that there was a clear delineation as to the point where life began and ended such that each of these medical professionals, with exacting precision, were able to determine beyond a shadow of a doubt when and how life began so as not to destroy any potential, any thought, any love, or any laughter…as if the next great Mozart or Martin Luther King might be at the clinic in fetal form, or perhaps just a really good kid. I don’t know…starting out with thoughts like these, I knew it was going to be one hell of a day.

At the nurse’s station, I stood next to Luz, blankly repeating words and sentences to myself. Luz seemed more at ease than I. Madison, an experienced nurse at the clinic, approached us while tossing up a coin, which I knew had something to do with me. Without asking, I called heads, won the toss, and was asked to choose my preceptor: Madison or some other woman. As I hadn’t met the other woman and I liked Madison’s style—direct, thorough, and smart—I chose Madison.

Madison shot out a million words a minute and walked about just as fast. Talking while walking seemed to synergize her speed, making her blurry on any photograph. One minute we were in the med room drawing up a cocktail of fentanyl, versed, and atropine and the next we were whirling passed the nurse’s station and reviewing patient information. She explained that the fentanyl, an opiate, is for stopping pain; versed is a central nervous system depressant used to relax the patient; and the atropine, a parasympatholytic, is employed in order to maintain the patient’s heart and breathing rate, as well as for prophylaxis against a vasovagal response. Madison had not only told me the pharmacological action and reason for each drug, but she had also managed to summarize the procedure, and even began to discuss abortion complications—all in about 3 minutes. My head was spinning when we entered the procedure room where there was a already a patient prepped and ready to go. I would need more time to take it all in.

As I learned and asked questions, twenty-three abortions would take place that day. The patients ranged in ages from 14 to 30 years and their fetus’ gestational age ranged from 7 to 14 weeks. I observed no immediate complications.

Ella was our first client. She was thirty-three, married with two kids and didn’t want another. She told me as much while I sat with her during the pre-procedure counseling session. She had had this procedure once before and somehow seemed cheerfully resolved to go through it again. Her “cheerfulness”, I admit, was my bias, but I can only report what I see. Who knows how she really felt?

In Ella’s chart, we would write that she was a G4P2—gravida 4, para 2, indicating that she had been pregnant a total of four times, and had carried two of them to at least 20 weeks. This fetus was 14 weeks. Ella’s confident body language and willingness to look at medical personnel in the eye seemed to indicate that she was at peace with her decision. Somehow that put me at ease, too, which allowed me to pay close attention to the tools and mechanics of her abortion.

The procedure took place in an older operating room with wall-to-wall tile. The room was extremely cold and in the center of the room was Ella, lying on the operating table with her legs propped up, spread, and secured by the stirrups. She was draped with the infamously small hospital gown, but probably didn’t care about the cold because of the fentanyl. Behind the table sat the equipment that monitors each patient’s oxygen saturation, respiration rate, heart rate, and blood pressure. At the foot of the table was a draped cart of sterile tools. Under the drape was a bowl for betadyne, which is used to clean each patient’s vagina inside and out. Near the bowl was the speculum, a vice-like tool that is inserted into the vaginal canal so that the clinician may have direct access to the cervical canal and uterus, where the fetus is developing. Next to the speculum was a wrapped sterile cloth that contained several sterile dilators—10-inch metal rods of increasing diameter that would probe from the external to the internal os of the cervix, allowing for full access to the uterine cavity. Depending on the age of the fetus, the clinician will use either a manual or electric vacuum, either of which would require a plastic tube, the cannula, to be attached to it. The cannula is inserted through the cervical canal and into the uterus. One one end that is insertedinto the uterus, the cannula is beveled and the other is attached to the vacuum. The cannula serves as the primary tool for terminating the fetus and is guided into the uterus via an ultrasound image. The ultrasound is live, essentially showing a video of the procedure’s main event: destruction of the fetus. The amniotic sac is more salient in earlier pregnancies, with a small but distinguishable fetus growing at one side of the placenta. The head is just barely visible, as well as small arms and legs. If the fetus is in the second trimester, like Ella’s, the fetus’ spine is obvious, and upon careful examination, one can even see a tiny fluctuating blur of black and white: the beating fetal heart. The plastic cannula would normally be invisible on an ultrasound image, but is obvious because of its barium coating. Once the cannula is placed into the uterine cavity next to the fetus, it is twisted and pumped up and down while connected to suction. The fetus, placenta, and amntiotic sac are being speared, broken apart, and then sucked into the vacuum container. The clinician performing the procedure will make several passes with the cannula in order to ensure that all of the contents are aspirated. Then, to further ensure that there are no more fetal contents within the uterus, another tool, the curette, will be employed. The curette has a handle similar to a screw-driver with a long metal rod extending from it. At the end of the rod is a metal loop that is used to gently scrape the uterine walls to ensure all fetal material has been removed. Both of the physicians that I observed carry out this part of the procedure described the sensation of scraping the empty uterus as “grainy”. Once empty, the uterus shrinks back into its flattened position, the walls of which are now flush unto themselves, with no fetus present. On the ultrasound, the physicians described the flattened uterus as having two parallel “silver” lines that represent the uterine endometrium.

Ella’s abortion followed this precise operation. No complications. No pain. She was groggy from the medicine, but after recovering from the procedure, she left the hospital and was driven home by her sister. In the recovery room, she smiled at me, ate crackers, and talked easily with the nurses and other patients. Again, I found myself surprised by the ease in which she and everyone around her had adapted to the events I had just witnessed. This included myself. I did keep my surprise quiet for fear of being branded a heretic. I suppose if I had I been injected with a fentanyl cocktail, I could have watched a train wreck while singing “Frère Jacques”, but I hadn’t, and nor did I have the years of experience that could allow me to fully gain professional distance and objectify the patient while sinking into a rhythm of automaticity.

I had a strong emotional reaction. What I had observed was this: one minute there was an observable human figure on the ultrasound and the next there was not. In the interim I observed blood being suctioned from Ella’s uterus and into glass jar that had a cheesecloth filter for catching solid tissue. At one point, the electric vacuum became clogged and the doctor had to withdraw the cannula from Ella. A scant amount of blood dripped from Ella’s vagina to the blue drape beneath her. Clearly, there was tissue obstructing the beveled end of the cannula. The doctor brought it to a bowl and tapped the cannula twice on the bowl’s edge. A clump of tissue loosened and fell; the doctor returned to the procedure and all eyes were back on Ella except for mine. My gaze remained fixed on the bowl where saw a small, dismembered arm with a hand. I counted five fingers and noticed the arm was bent at the elbow.

I strained to hide a flash of grimace. My eyes watered for a second and would have betrayed me had I not looked with feigned interest at the vacuum. Ella had her eyes closed anyway. Nobody in the room was looking at me. My nostrils flared and I thirstily inhaled air. All I could think was, “Get it together Nat…we’ll work this out later,” which I repeated at least seventeen times. My eyes returned to the arm and I noted veins below translucent skin. It was the left arm. I thought I could see the head of the humerus. It was approximately 5 cm long.

The facts were comforting to me. I looked around and noted instruments and where we were in the procedure. And with that, I moved from being emotion-filled to diagnostic-filled, which I found as alarming as first seeing the arm. The sting of what I had just seen was still with me, but was sublimated into fascination by examining the anatomy of the fetal remnants. My head was in two places at once.

Upon leaving the operating room, the emotional pull returned, forcing me to bend my mind around what I had just seen. This was heavy, heavy stuff but there was no time to think; there was another procedure to perform. I was on Madison’s schedule now. The rest of the abortions were for fetuses 8 weeks or less, which somehow seemed more acceptable to me. I couldn’t see the fetus as well, and they weren’t as developed as the 14 weeker, so it wasn’t as hard to watch. There were no more tissue obstructions either.

In between patients, Madison and some of the other nurses expressed their disbelief that some of their patients actually wanted to take the fetal remnants home with them for a funeral. Madison was clearly frustrated, “I mean, I can see wanting to have a funeral if it is a medically necessary abortion and you wanted the child to begin with, but for an elective abortion? I just don’t get it. And besides, most of our girls are on Medicaid…so you’re telling me you can’t afford an abortion, but you can afford a funeral?”

“Maybe they’re trying to show somebody,” I said, surprising myself. I had turned a corner and tried to picture the life of the person who had been on the operating table outside of the procedure. “Maybe they’re trying to let someone know that this is what they had to go through.”

“True,” Madison said, “there’s a million reasons to get an abortion, and we only see part of it. I guess the bottom line is that everyone should have access to it, regardless of their reason or means so they can be safe—it’s going to happen no matter what. I know we sound callous, but don’t think for a second that we don’t love what we do. It’s important. Women need to be bale to safely choose this procedure.”

Clearly, the day one decides to have an abortion shouldn’t be a happy day in anyone’s life. But for Luther, it clearly was. Although all the nurses had discouraged Susan from having her partner in the room while the procedure was taking place, she was adamant about having him there. “I didn’t get pregnant by myself,” she insisted. At with this, everyone acquiesced, and he was fetched from the waiting room. It was late in the day and this was the next to last procedure. When Luther came into the operating room, Susan was already laying back on the table. Her face had changed as soon as he entered the room: passionate to impassive in two seconds flat.

When I first saw Luther, all I could think was that he was a grubby little boy. Mannish in stature and size, I suppose, but his body language put him at 17 tops. His sweats were crusted up with dirty liquid stains and a distinct odor followed him into the room. I recognized the smell immediately—that of a dirty, neglected home. I had been in hundreds during my days as a social worker and group home counselor, and most of them smelled the same: stale cigarette smoke, dirt, must, and sweat all combined to create one of the most pungent smells in my memory.

Luther was taking off his hat as he entered, which I offered to take from him. He handed it to me and was signaled to sit down next to Susan. When he spoke, his words were saccharine, “It’s gonna be alright baby, baby—you’ll see. All these people are gonna take real good care of you.”

It sounded like bullshit to me. His words were hollow and unconvincing like those of a bad actor. Luther looked around at the staff after each sentence, as if looking for approval, and spent very little time looking at Susan. As the procedure progressed and the staff would offer encouraging words, he would mimic them like a myna bird, “It’s going alright baby, baby…just breathe baby, baby.” And although he said all the right things, I couldn’t help but think he was quietly celebrating because I could see him smile. A new feeling overwhelmed me during Susan’s procedure: that she was brave.

Perhaps Luther was relieved to not be a father at such a young age. God knows I was relieved to hear that an old girlfriend’s pregnancy test came back negative when a much younger Nat went through a pregnancy scare at age 18. So perhaps he was happy, but Susan was clearly not, and I think she wanted him to see that. Later, Madison told me she noticed the same thing, “I hate it when they perform like that.”

While Susan was in recovery, I realized that I had not given Luther back his hat. I went to find Luther in an otherwise empty waiting room and before I even got to the door, I noticed a new smell: the small room reeked of marijuana. Nobody had been smoking in the room, otherwise there would have been smoke, but somebody had clearly smoked recently and brought the smell in with them. When I looked at Luther, his eyes were bloodshot. I held up the hat, and said, “I have your hat.” Luther stood up, breathed heavily, and then sat back down, clearly overwhelmed. I tossed him the hat and said, “Good luck. Take care of Susan.” His head darted back to the television without another word. Stoned was no way to start out as a father.

Now I was relieved that Susan had the abortion. She knew she was doing what was best for her, Luther, and her unborn child. Having seen the situations that unwanted children can be born into, and the havoc that being brought up in a poor, neglectful, and/or abuse-ridden home can do to a child, I am certain that some people are better off not having been born. It hurts me to say it, but I think it’s true.

The gross reality of the abortion procedure leaves a lot for me to reconcile. Am I justifying a form of murder? Perhaps, but when exactly does life begin? Is it with the first mitotic cell division or the first heart beat? Is it the first lucid thought? A lot of unknowns. And what would happen if the child were to be born? Have I grown so self-absorbed to think that humans are so important that every single hint at a life should be preserved when there are millions of already born humans that don’t even get their basic needs met? More unknowns, though I’m inclined to answer yes to that last question.

I suppose it doesn’t really matter how I answer any question, because the reasons that a woman has to get an abortion are her own, and determining their “validity” is as difficult to ascertain as determining when life begins. The reality of the situation is that the procedure will continue to take place, whether legal or not, and to provide women with safe options is of the utmost importance.

My head was still spinning when I got on the bus to go home. It still is.

Stanford Life Flight

2007-12-07T19:06:00.000-08:00

Phenomenal. Today I did a "fly-along" with the folks at Stanford Life-Flight. I got to go on three flights. The first was to a public relations event where we showed off for the some folks in Santa Cruz county. The second flight was to a hospital in the central valley to do a transfer and the third was to do a "scene" landing for a traffic accident. We were not able to land at the traffic accident because of its remote location, it was dark, and the fog prevented any and all visibility. Seriously fun.

All I can say is that this experience was riveting. I find the whole nursing thing pretty overwhelming on land--imagine trying to put an I.V. in a trauma patient while enclosed in the tiny passenger quarters of a helicopter! Amazing. One day I might get there, but for the time being I think I need to get things right while not wearing a flight suit.

Some may think this is a strange way to spend winter vacation, but like I've said before, I'm all in. Here are some pics of the day:

http://homepage.mac.com/gnattychad/PhotoAlbum26.html

"Only-oxycodone-will-make-my-muscles-strong-again"

2007-11-07T21:47:00.000-08:00

REFLECTING ON: Maintaining objectivity even in the face of a med-seeking patient...

It had already been a long day before Grace and I had entered a Community Care Home in the East Bay. My feet were dragging as we passed the neglected lawn and entered the assisted living facility for adults. Folks here at the “home” have both mental and physical disabilities. We were there to see Polly, whom Grace, my preceptor, told me was a hard case. We got much more than that.

The front waiting room was a mix of 1970s décor that I’ve mostly seen in shitty dive bars, funeral homes, and my grandma’s living room. The walls were olive-green velour and the furniture was of the finest cracked vinyl. Doilies adorned the coffee table and ceramic Halloween decorations sat on top of those. Halloween had passed a week ago, but the heavy layer of dust let me know the decorations had been there longer than that. The front desk sat unmanned, so we peered down the nexus of hallways that sprouted off this bizarre portal. The halls were wide and dark and smelled strongly of cigarette smoke with a hint of emesis, emptied colostomy bags, and chicken curry. As I searched for signs of life, I only noticed shadowy corners and a cold breeze that did nothing to alleviate the pungent smell of “group home” living.

Grace and I called out and were answered with muffled, unintelligible shouting. For some reason, we took that as our cue to walk further down the hall. A man in a wheel chair with one leg suddenly rounded the corner. He wore old hospital pants and booties, a stained white v-neck t-shirt, and a brimmed beanie. Around his neck he wore a money sign medallion emblazoned with plastic gems. Never looking up, he moved quickly passed us while sneering at everyone and no-one.

As we worked our way from the a slowly disappearing exit sign, we found a second desk with a short, stout, worn and once-pretty Filipina woman passing out meds from behind it. She wore no identification, had deep, dark circles under her eyes and was only identifiable as a staff member because she donned Dickies scrubs and was behind the counter instead of in front of it. Without identifying herself, Grace asked if we could see Polly. The worn woman looked down at our badges, sniffed, and then shouted something in Tagalog down an empty corridor. A short man, whom I later found out was named Ben, scurried around the corner, gestured for us to follow him, and then disappeared again. We walked briskly toward the spot that he had disappeared at, only to find him at the end of another hallway, pointing towards an open doorway. He disappeared again. I felt like I was following the white rabbit down the hole. It was only at this point that I realized the hallways were lined with doors, which were painted the same color as the walls. Ben had moved so quickly I never saw his face.

As we entered the tiny, double-occupancy room, a trembling mass of a human lay awkwardly in its bed. She lie with her neck pinched so that her head deviated at a near perpendicular angle from her body—as if she lacked the will to move from a clearly uncomfortable position. This was Polly. I smelled pee and stale smoke and hoped that my nose would habituate soon. A mop of unkempt hair that I vaguely recognized as a grown-out bowl-cut hid her glazed over half-mast eyes. I watched a flash of recognition cross her gaze and Polly launched her into her performance almost immediately. “I-am-in-so-much-pain. I-am-shaking-all-the-time. Oh, Grace, what-am-I-going-to-do?”

Her staccato words came out like a 4th grader reading aloud round-robin style from a history book. This was clearly a script. She never deviated from this style. I kept looking for an unpredictable inflection in her tone or something that would give actual meaning/life to her words, but found nothing but all-too-recognizable med-seeking behavior. As the act played out, with Grace responded by making monotone, half-hearted assurances that everything would be okay, I half predicted the back of her hand to fall to her forehead like a damsel in distress. Then, as if I willed it, she did exactly that, “Oh why-oh-why won’t-the-doctor-give-me-oxycodone?” Her hand fell against her brow. “Only-oxycodone-will-make-my-muscles-strong-again-and-I-will-be-able-to-walk-again. Oh, oh. What-will-I-do?”

I looked away to hide one of those smiles that just can’t be hid, inhaled deeply, and attempted regain my composure before I took her vitals. In order to get her blood pressure, I had to unwrap her from the four sweatshirts she was wearing, which was a near impossible task given her unwillingness to sit up. I finally settled on taking her radial BP on her forearm. 140/80. She cried out when I mentioned this number but stopped when I told her that 140/80 was my normal BP. Not horrible, but not great. Temperature was 36.5 C, HR 85, and RR 20. Unremarkable really, outside her slightly lower temp, which I attributed to her lack of movement and the many open windows. Her physical exam yielded still more unremarkable information except for her right lower leg being edematous (+2 pitting), which I attributed to her recent knee surgery. The site of the surgery was reddish, but seemed to be healing well. When I felt around the site of the wound, she launched into a new script, “Oh, please oh please do not touch me like that. AHHHHHHHHHHH! So much pain. So much pain. I was attacked last week by a man that lives here. He’s crazy. He ran into me on purpose with his wheel chair. He’s got one leg. I don’t know why he did that. He’s so mean. I think they are going to evict him. Oh. Please. Let me escape this place.”

Her last sentence actually sounded convincing. I was ready to leave too. My ears burned, which they do sometimes when I’ve about had enough of just about anything. By herself, Polly was manageable, but I had already seen too much that day. Luckily, Grace dismissed us, “We’re going to go see what is going on with your meds and we’ll be right back.”

The hallway smelled better than the room, but I quickly realized that I didn’t want to be there either. As we approached the med desk, I felt like a re-enactment of Michael Jackson’s Thriller video was taking place. People were moving everywhere in random directions with various parts of their bodies hanging while other parts twitched. All of them wore blank expressions and were moaning or drooling. One woman in a wheel chair with a lazy eye and a half paralyzed face was shouting, “I want my god damn mail. It’s a fucking federal crime to withhold my mail. Give me my meds and give me my mail. You fucking crooks.” The one legged man in the wheel chair egged her on, and then turned quickly to face me, flashing a sly smile.

I found it easy to dismiss both the wheel-chair-lady and Polly’s complaints because they were crazy, looked funny, and were incredibly manipulative. Any legitimate concern that they might have was so hidden beneath the layers of lies and psychosis, I felt less than obligated to advocate for them. I was concerned and surprised by how easily I switched into that mode. Judgment. Hmmmmm. “Better get a handle on that, Nat.”

Grace had worked her way through the zombie melee and was talking to the worn woman. As I sat down at the med desk, Grace handed me a list of the meds and asked me to cross-reference them with what they had behind the counter. My mind switched out of judgment mode and phased back to my very green clinical skills. I was trying to remember everything to check: medication name, dosage, time, expiration date, prescription date, mode of administration…what else? I was sure I would miss something with the groans in the background. Fucking hell. The woman in the wheel chair was now ramming her chair into the counter. I moved down a seat and went to work.

I wasn’t a minute into the list when I noticed something that wasn’t on my list: the vicodin were huge and there were only two of them at the bottom of the pill bottle. When I opened up the bottle and held it to my eye, I saw that there were two 800 mg Ibuprofen tabs at the bottom. Then I went to my green skills list: prescribed on10/23 with 90 pills, 1-2 pills PO q 6 hrs, PRN. What was that? 8 pills max/day? 8 x 14 days passed=112 pills. 112pills-90perscribed pills=22 pills that couldn’t have been given because they didn’t exist. 22missing pills/8pills a day=almost 3 days of missing pain meds, assuming that she had consistently getting the maximum dose at the regular six hour interval. There was not way this place was consistent. Couldn’t happen. Too god damn crazy to be regular.

I smelled bullshit because narcotics were involved. I switched back into judgment mode and was happy to observe that I didn’t just apply my bullshit detector to the patient. Was I being too hasty to judge? No I had done the math right. There’s now way this place was regular in its dispersal of the meds. No fucking way. I was, am still pretty sure someone was pocketing the hydrocodone and switching it with an over-the-counter pain med. Jesus. Okay, maybe Polly was med-seeking, but she also had a legitimate concern. Now I felt bad. My judgment almost allowed me to ignore the facts. God I love facts and diagnosis based on them.

I looked to Grace and nodded toward the bottle as I handed it to her. Grace is hip to the fact that I’m a skeptic and like unspoken communication. She looked in the pill bottle and frowned. Then she spoke, “Good catch, Nat.”

When we brought the information to the worn woman’s attention, her English suddenly got worse and she had a harder time understanding us. She also couldn’t produce the PRN record, saying that it was locked up in the boss’ office and that the boss wasn’t around. Now the bullshit smelled stronger than the piss and cigarettes. I looked around and caught more Thriller video. Then I looked at the worn woman’s tired eyes and felt a tinge of sympathy. Shit. I would want some narcotics too if I worked here everyday. I smiled at her and said, “You’ve got a hard job. I used to do this too and it’s tough.” She smiled back as she hung up the phone with her boss. Then she lead us out of the facility, closing and locking the door behind us.

Pride, prejudice, and nursing

2007-10-23T06:05:00.000-07:00

REFLECTING ON: Personal prejudices and confronting them while providing home care to patients during my community health rotation.

So I think it’s pretty clear that I have a strong prejudice towards rich folks. I judge them and am convinced that their money is what contributes to their swollen egos and entitlement. I have had enough negative experiences with them that I also hold the belief that their lack of humility within the healthcare setting is what allows them to make unnecessary demands and strike fear into the hearts of all healthcare providers because of their access to attorneys. They ask for help yet threaten lawsuits, which in my opinion, is the factor in hospitals and most institutional settings being unable to provide the necessary resources to all parts of their patient population.

Then I met Susan and all my prejudices fell by the wayside. She’s 94, has a metastasized abdominal tumor that, because of its advanced progression, could only be debulked rather than removed. Even after the debulking surgery, her GI system struggled to work through her colostomy. Sometimes her stool was green, sometimes light brown. Today it was orange, though she referred to it as “a tawny mustard”. Susan was so yellow as she lay against her white sheets, we now think the cancer has spread to her liver. I later learned that Susan used to have the healthy habit of running marathons. Her heart sounds confirmed that story: regular and strong like a Swiss watch.

Her husband, though well intentioned, was having a difficult time switching roles from high-powered banker to home-care provider—he recently had a run in with the washing machine where he put in too much detergent and flooded the laundry room. Even if he could provide competent care, Susan had an enormous amount of pride and wouldn’t let him switch her ostomy bag. Though she had tried at first to switch the bag by herself, the fact that she had relented to let us provide care indicated to me that she knew her time was close. She wouldn’t talk about that directly, though, and refused to be seen by hospice. Understandably, Susan wanted to continue to see the nurse that she had become comfortable with. Now, in her twilight, she had so little control and was being threatened with having to see a whole new batch of people. How’s that for humility?

In Susan’s perfect Pacific Heights mansion with a perfect view of the Bay, we changed her colostomy bag, switched her fentanyl patch, and drew blood for labs to confirm in our suspicions regarding her liver.

The perfect view doesn’t matter much when you’re in pain.

Nurses Come From Monkeys (Evolution Related)

2007-10-12T13:29:00.000-07:00

Today I had an interesting interaction with my nursing preceptor, Grace, for Community Health Nursing. She happens to live near me, so she was giving me a lift home at the end of the day. Now that the guise of work had lifted, we stopped talking about the vitals of others, and shifted to those of our own lives. We spoke of our significant others and various other things. I felt somewhat honored because I know that Grace doesn’t reveal much to anybody at the office. It was then I realized that I probably spend more concentrated time with Grace than I do with anyone else, including my wife!

Somehow, we came to the subject of religion, and she asked me what I believed. I explained my very grey version of agnosticism, which includes both my version of God as well as evolution. She nodded enthusiastically as I elaborated how my version of god allowed me to explain the unexplainable, miracles, and also allows me to show no prejudice towards other religions that fundamentally want to do the right thing (How can 837 million Hindus be wrong?). When I touched on evolution, she stopped nodding. Grace was clearly distraught, “So you believe we came from monkeys?”

I affirmed that I did. Not only that, I thought we came from much simpler organisms that appeared anywhere from 3.5 billion to 500 million years ago. She asked me how I could believe this. I then went on to explain meiosis and mitosis, the very real possibility of gene mutation, natural selection, and the cumulative “effort” of such selected mutations that allow us to evolve from single-celled organisms to monkeys to me. How can bacteria and humans have similar assemblies of DNA? If we’re so different, how is it that we can slip in a genetic code for a drug, such as an antimilarial, into a yeast genome, and suddenly that yeast is creating pharmaceuticals that are consumable by humans? We have got to be connected! I explained that I thought that the similarities are just too great to ignore.

Grace did not seem amused. I was thoroughly confused. Surely, I thought, this woman, who has a background in science and clearly seems knowledgeable about pathophysiology and pharmacology, could appreciate that I believed in such things. I did not think that I was questioning her faith, merely explaining mine. Somehow, in explaining my faith, however, I had questioned hers. Of course, I did not realize this until later, and since I was on a roll, I then went on to explain how, the miracle, and where I believe this greater force that some folks call God comes in (which I’m willing to accept has a different name and a form inconceivable to us at this moment in time), is in the smallest elements of our understanding. How did the atom come to be? How did the neutron, proton, and electron find each other and form elements? How did quarks and leptons create these three parts of the atom? And the force! What about the force? How does an invisible force orchestrate this fantastic dance between such small parts that create everything that we live and breathe? Inconceivable! And, in my mind, wonderful at the same time. That is the miracle. That is what blows my mind. That’s what God is to me. Wow. Right?

Almost as miraculous was that I explained all this in between the Ashby Ave. Exit and my exit—about 7 miles (albeit there was heavy traffic).

Grace had to drop me off before she could have a chance to respond. She was still friendly, but somehow “within herself”. I’m sure that she will be polite to me when I see her again, but I wonder if she will treat me any different because she know that what I believe is different than what she believes. Once we start talking shop again, I bet we’ll be back to our old selves.

This experience got me thinking about how I should deal with patients that believe such radically different things from me.

Prescribing a Squirt Gun

2007-09-27T11:21:00.000-07:00

REFLECTING ON: Community health rotation placement and treating patients in their homes...

For my Community Health clinical rotation, I’ve been assigned to work at a nursing agency that provides in-home care to patients that have been discharged from the primary hospital. Grace is the nurse that I have been assigned to work with. She’s Puerto Rican and mainly of African descent. Spanish-speaking patients do a double take when she switches fluidly English to Spanish. She’s subtle like that—holds her cards close and lets the patient reveal him/herself. I could take a lesson. Silence is sometimes the best diagnostic tool.

We visited three patients: one foot amputee, one renal failure with dementia, and one pressure wound. They had names too, but HIPAA wouldn’t like me revealing them. The foot amputee patient didn’t take to “patient education too well. We encouraged him to elevate his foot, which he explained he couldn’t do because it made him uncomfortable. I decided to play the “dumb student” and ask Grace why a patient should elevate his foot in order to heal an infected wound. Of course I already knew, but I just thought a conversation between professionals might be less irritating to the recalcitrant foot amputee. We’ll see.

I was excited to observe wound care because, although I practiced on latex models in skills lab, my clinical placement on the oncology unit didn’t have much opportunity to manage wounds. If the low-platelet, neutropenic leukemia patients had a wound, they were usually sent to the ICU. I like skills and technical stuff, so I’m juiced that my community placement opens the opportunity to work in people’s homes as well as practice new clinical skills.

The second patient we met was a 94 y.o. Brazilian woman with acute renal failure, diabetes, and slight dementia. She lives with her 84 y.o. sister and an obviously unstable dog. The dog is named “Sister” until they realized she was a he, necessitating a name change to “Brother”. Sometimes they still call Brother “Sister” due to his being neutered.

I consulted the patient’s vitals, lab values and history. I listened to the concerned cousin that provided 8 hour/day care to both her family members. In addition to monitoring her weight, liquid/food intake, diet, blood pressure and bathroom habits, I determined that the dog was a primary concern. While I was there, the dog attacked every family member at least once, Grace twice and nipped my hand until it bled. When it jumped on our patient, it went right for her slowly healing IV wound, which had become infiltrated during a recent hospital visit. Grace and I will be prescribing a squirt gun to deal with the dog. I mean, this woman isn’t exactly a quick healer.

"CLASS" test

2007-07-17T13:42:00.000-07:00

REFLECTING ON: Being obsessed with grades...writing to teacher that has urged us to stop nit-picking tests and start thinking about matters of substance.

"Dear P--,

I told myself that I wouldn’t buy into the grades and the nonsense and the madness….but I did. Damn it. I’m all in and all about learning what I need to know in order to do this job. If I do this, I will learn what is important, which may or may not be included on the class test. But, if I am to pass the CLASS test, the real definition of class, I will realize that my sincere effort and desire to be competent can’t be graded so the grades shouldn't matter as much.

I'm trying to get this new learning curve-ball that's being thrown at me. Let me explain.

I'm trying to get the actual lesson here. I've had a fair number of "teachers" in my life, at least in name, but very few mentors. I think that's what you are trying to say here: chill out and get the real knowledge of what it means to be a good nurse. Not a wanna-be doctor, not a heal thyself case, and not an academic: a nurse. Working on it.

I gotta realize that this process is a harsh reprogramming of my mind. Having forced myself to stay academically competitive all my life (I mean, I got in to UCSF, right?) has put me at a mental disadvantage sometimes when looking for the "real" lesson. Clearly, many of us, especially me, need to be challenged to get past the nit-picky details of what we have memorized to get 4.0s, 90%ile GREs and find true, substantive, practical knowledge (wisdom?).

We'll get it--just in different ways.

I personally need to have some yell, "Hey buddy, what are you doing?" every once in a while to be reminded of what I'm actually trying to do here (something I'm still not sure I even know). Keep in my ear and maybe I'll just get it. I personally look forward to you yelling "Let's get it started" every morning.

Take care,

~Nat

Patients as Heroes

2007-07-07T00:08:00.000-07:00

REFLECTING ON: Interacting with patients on the Oncology Unit at the Hospital where I have been assigned clinical rotations...

There was a distinct feeling that I got Thursday and again yesterday at the end of clinicals: this is doable. Not only that, I got the distinct feeling that I was meant to do this. I am built to be a nurse.

One of the issues that I continually confront with a “do-gooder” personality is offering help in situations where perhaps it isn’t always requested, needed or appreciated. Though there are certainly subtleties and nuances in providing care to patients, generally speaking, I am there to help and it is most certainly needed. It feels good to be needed and appreciated. Such a contrast from my last job where I continually had to grow thick skin, suck it up, and deal with all sorts of abusive language/behaviors without much of a grain of appreciation. I don’t know how I did it for as long as I did.

I am working on the oncology unit for my first clinical rotation. Everybody there is dealing with the big “C”. Generally speaking, it is my impression that in American society, cancer is synonymous with death. Sure there are treatable types, but the word “cancer” seldom describes good news unless you are defeating the disease.

These patients my heroes. They are humble, possibly because they have no choice, but nearly all of them are kind—and attitude is something that they do have a choice in. I don’t want to romanticize their situation that is so far from glorious, but then again, perhaps we need a new definition of glory.

I met this man, Alfonze, a 29-year-old father of two, who is fighting Acute Lymphoblastic Leukemia for the second time. His prognosis is not good: his cancer has metastasized. To compound matters, his youngest son is also fighting cancer at another hospital.

Bright-eyed and bushy tailed, I walked into Alfonze's room yesterday to practice taking vitals just as he had received the news that a second tumor was found in his son. The expression on Alfonze's face was clear: he already knew the second tumor was a death sentence.

Writing “Death sentence” sounds harsh to me right now, but I am not going to mince words here. I am not going rehash some tired words that “everything is going to be okay”. What a line. Try as we might, we cannot control everything—we are not gods. Not me and not the physicians who write the treatment orders. Everything is far from okay. A father and son that I know have a greater probability of dying this year than they do living and that is so far from okay.

And yet, here is Alfonze, being so kind to me as I fumble with the blood pressure cuff. That is glory: bravery manifested as kindness while facing almost insurmountable challenges. Alfonze is glorious. My definition of glory includes people that fight with dignity and character.

Nurses eat their young

2007-07-06T16:43:00.000-07:00

REFLECTING ON: Nurse burnout and the old school...

The last thing I wanted to do was make waves on my first week of clinicals. Oh well. But I swear this really had nothing to do with me…this time anyway.

So there I am, in the oncology unit’s nurse’s lounge, sitting down and trying to “play nurse” with my preceptor, Lee. I’m looking at the patient file and literally trying to figure out what “MAR” means (let alone its contents) when this mean looking nurse comes in and scolds me, or more appropriately put, tears me a new one. “You’re not supposed to be in here doing work—this area is for relaxing only.” Please meet Mildred, and for all terms and purposes, this is a fitting way to meet her.

Confused, I look to my preceptor who is now making a thorough examination of the ceiling. Mildred continues, “Not only that, the student nurse shouldn’t be taking seats from an actual nurses doing actual work.” Sweet. I just stepped on toes, got thoroughly trounced, and I don’t even know what MAR means. Since Mildred is belittling me and addressing me in the third person, I think it’s safe to say that I shouldn’t ask her.

So, wow. Okay. Let’s not lose our cool. Clearly there has been a misunderstanding. Let’s approach this logically and diplomatically. After all, we’re all professionals here. “I didn’t know”, I say, “my apologies…I’ll move my work somewhere else.” I’m a bit miffed that my preceptor hasn’t said anything to Mildred since she was the one that told me to sit in here, but I let it go. Completely resolved to avoid further confrontation, I begin gathering my effects.

“And maybe the student could clean up while he’s at it.”

No way. This is a power play and I am having none of it. I don’t care if I get moved to another floor or even if this is how students are normally treated. This woman has no manners. And if this is how nursing students are treated, I don’t want any part of it. Having worked with emotionally disturbed boys for nearly a decade, I’ve developed thick skin to insults that range from my manhood to my mother…but this third-person nonsense has got to stop. God I hate bullies.

Standing up, I look at Mildred, “Okay. I get it. I’m the new guy—and a student to boot. But the student’s name? His name is Nat.” Extending my hand in a manner of greeting I am more accustomed to, I stare at Mildred straight in the eye. “Nice to meet you.”

For all her bluster and braggadocio, Mildred crumpled like a house made of cards. Extending a limp wrist handshake, she mumbled, “Well you’re still a student to me,” and walked out of the room.

Feeling vindicated, I turned to Lee who sat there stunned. “Wow, way to stand up to Millie there. She does that to everyone. She’s of that old-school style of nurse. You ever hear the saying, ‘Nurses eat their young’, well that’s Millie.”

I hadn’t heard the saying and my first reaction was that it was just horrible. Nurses eat their young? Yuck. Just disgusting. I mean, I get it, some folks need to toughen up sometimes, but I’d rather not feel that I’m going to be consumed like the runt of the litter in some unspoken, pseudo-Darwinesque training program while learning a profession that presumably embraces compassion. I mean, there’s got to be middle way. Right?

The following week, I, yet again, inadvertently crossed Millie, but this time she avoided me altogether. You see, someone had “unknowingly” assigned me to her patient caseload because I had unwittingly done pre-lab on one of her patients. Instead of shifting me off that set of patients, they shifted Millie. When I realized what had happened, a very flushed and very angry Millie stormed passed me shouting, “Twenty-five years here and they treat the students better than me!”

Later I learned that Millie had thrown a magazine and then broken down into tears in the nurse manager’s office. Clearly, this had nothing to do with me. Another veteran nurse confided in me that Millie had been the “elephant in the room” for a while now. I just happened to be the last straw that blew in and broke her back.

Millie was clearly experiencing burnout, and was given some mandatory vacation. I never saw her again that quarter, but I certainly am reminded of her on a daily basis. Burnout is a common affliction in the nursing profession. There are tireless nurses and there are tiring nurses that are under the delusion that they are the former. Having seen first-hand the exhausting and emotionally jarring work that nurses do, it surprises me that there are not more Millies in the world. I feel simultaneously sorry for and leery of Millie. Sorry, because I later heard that Millie, in fact, was an excellent nurse. And leery because I am scared that I, too, have the potential to act like her and not know it.

If I ever act like Millie, you have full permission to put me in check. I’ll thank you for it later.

Gungo Ho Balance

2007-07-02T06:34:00.000-07:00

REFLECTING ON: General thoughts on the first week...

I’ve been up since 5:00am. I figure 6 hours of sleep is how I will roll during the week and then I will catch up a bit on the weekend. I feel so out of sorts and overwhelmed with all of this right now. We’ve been assigned like 1 billion pages of reading, and none of it is all that mellow. I mean, it all has to do with saving lives, right, so how could any of it be mellow?

As I read the pages over and over, I am inundated with the same thought: can I really do this? I answer, “Of course I can. Others have done it before me and so can I.” But I’ve never done this. I’ve never been through this. It is SOO overwhelming I can’t even describe it in words.

Then, the logical part of my brain kicks in: Okay, so if you can’t do all of the reading, then probably most other people can’t as well. Just keep working and do the best you can, Nat.

I really hope that working hard and plugging away is enough.

I’m going to school with some pretty cool and interesting people. Several of them even seem balanced so I’m going to try to take some hints from them.

Today, Sonia said that we were really lucky. We get to learn what we really want at an outstanding institution and that’s all that we have to do. We get to do this. It’s a privilege. It’s true. Not an obstacle—a great opportunity.

I get to work really hard and become competent at helping people. I get to be dedicated and focused and supported. I am lucky.

First Day at Clinicals

2007-06-29T15:44:00.000-07:00

REFLECTING ON: First day of clinical rotation of first quarter at UCSF, written to fellow classmates...

Just got home a second ago and this is where I am at: I feel tired before I've even begun. Thoughts started percolating about this whole experience so I thought I'd share...please feel free to chime in and reflect too.

As the scrubs hit the laundry basket, the gargantuan-ness (I made that word up) of what I've/we've chosen to take on hit me like an anvil. Despite the fact that I got this week's "to do" lists almost done, I've got my PDA crammed with our schedule to keep me on point, I got books (and even feel like I really dig Patho), and maybe I've got some knowledge about some things in the past, really, when I stop to think about where I'm at right now, I have got no clue.

Clinicals really brought home the reality of this situation.

While on the oncology floor this morning, immune-compromised patients strolled by us, each with about fifteen IV bags filled with chemo, I became pretty damn humble. One patient shuffled on by with her nurse and managed to wave and smile at us. Yeah, I've got good intentions, but I felt like an impostor in my scrubs. You know, kinda like dress up or Halloween. No matter how I try to build myself up in my mind right now, somehow I cannot believe I'm going to be a nurse!

I also can't believe I'm seriously considering buying a fanny pack. Seriously. Though it's ridiculous, the whole fanny-pack thing is an appropriate metaphor in this whole MEPN situation. Two weeks ago, I wouldn't have ever thought that I would DREAM of buying a fanny-pack. I have never liked fanny packs. Even in the early eighties, when I was like five, and fanny packs were considered semi-socially acceptable, I thought fanny packs were silly. Now I think I need a fanny pack and what's worse: I want it to match my scrubs.

I left the comfort of my previous identity and hung it up on the coat rack as I walked into UCSF.

Yes, I know there's a learning curve. And yes I get that I'm really only expected to be a glorified volunteer in the beginning. But that somehow doesn't change the fact that I am really starting to realize the gravity of our work. It's simultaneously intimidating and awesome.

Some part of me keeps on reminding me that starting from scratch is good. You know, like doing pull ups or eating Brussel-sprouts. Builds character--or so I'm told.

I guess that's just it: I thought I was done with my character. I thought I knew who I was. I was competent at what I did--some might even say good. Now I know nothing. Now I am rebuilding my character, or more appropriately put, adding on to what I once thought was finished.

This will be good. Just not always so comfortable.

I am humbled and honored to be in this program with all of you. Truly.

Have a good weekend.

30

2007-05-08T12:32:00.000-07:00

As my time at UCSF draws closer, I become more anxious and more unfocused, though its ironic because all my efforts are to become more focused. I spend so much time fretting about what I need to do next—the “plan”—that I seldom get anything done. The image of being stuck in the mud in a truck comes to mind. I really need to relax. I swear I’ve forgotten how, and that, if anything, is what I really need to do before starting this program—full of voomph and vitality—show ‘em I haven’t forgotten how to live. The reason I stress so much is because I feel it necessary to compensate for all the experience and things that I don’t know and haven’t been exposed to. I cannot believe sometimes that I am going into the medical profession. Clearly this wasn’t meant to be. I wasn’t ever on this path. Nobody showed it to me, and yet, here I am—heading down this path that I didn’t think possible.

My mind is a jumble with thoughts of what I was supposed to do and rebelling from that type of functional fixedness. It’s time to look beyond the perceived form and perceived function of my life and really look at what I am all about. I swear I never saw it before. That’s why it’s so important that I relax and flow a little more. Focused flow, if you will. Previously, going to Mexico and traveling would be an ideal way of finding such a thing, but, no longer—not for me right now. I get so out into the universe that I forget how to walk when that happens. If I can just sit, though, and pay attention to what is around me without freaking out everytime I see something—“I must grasp this! I must own it I must own it now. Now I tell you, get in my brain you bastard!” Well, that just doesn’t look good or seem all that enlightened. It’s the juggernaut approach to self-actualization and I like to think that I am ever so slightly more sophisticated than that. Hell, I’m thirty aren’t I? Thirty. Hmmm. 30. I just need to look at the numbers because I just don’t identify them with me. I’m not 30! Not by a long shot. I guess it’s the government and all sorts of social institutions and, by default, my interactions with them that make me tell them that I am thirty makes me thirty, but I am not thirty by a long shot. No siree. Seriously. Fine, I’m a little shook up about it, but this is exactly what I was talking about earlier—I don’t recognize the form of 30 as me, nor its function. People see 30 as old and incapable and stricken with afflictions that make them less viable. I am viable, god damn it. I am viable. I am thinking and focused and more thoughtful than I ever have been in my life. Never mind the filling in of the abs with pudge—the abs are still there—just hiding.

It strikes me now how much I associate physical capability with mental ability. As if I am physically healthier, I can think and remember better—even interact in the world in a more enlightened manner. I suppose that makes sense to a certain degree and maybe I should pursue that—can’t hurt. I do think, however, it’s all rooted in my mind—this stress that I “MUST KNOW THIS NOW”. It’s overwhelming and not helping me at all. I need to relax, sit with, and be patient with the world, and perhaps, I will actually hear what is being said to me instead of it being drowned out by mindless self-chatter.

Yeah. Let’s try that.

Youngblood and me

2007-03-29T21:50:00.000-07:00

REFLECTING ON: Adulthood versus childhood....

So, I gotta little story that I must tell. Last week, when I was volunteering at the ER, I met this guy that made me think of my whole Cal experience and thought that I would share. So. First a little background. Every Thursday, I volunteer from 9pm-midnight. In addition to the normal “go-fer” jobs and scrubbing gurneys, it’s my job to relay information between patients and families as well as calm the folks down in the waiting rooms that have been, well, waiting. If you’re a patient, it’s not fun to come to the ER—an unexpected event goes down and then: boom! There you are, stuck in the ER—totally at the whim of the institution and its elements. I get it. It sucks. Some of the waiting room folks get a little cross with me. I try to imagine switching places with them and be as sympathetic as I can. It’s not always so easy. “…No mam, I don’t know what it’s like to not pee for a whole day. It must be pretty painful [woman is also talking on her cell phone while talking to me, she finishes drinking a Diet Coke]. We’re working to get you in as soon as possible. In fact, provided we have no more ambulances come in, you’ll be next. It’s just that we had those three ambulances come in back-to-back with strokes and heart attacks so we had to bump you down. [woman becomes incredulous] Why isn’t it a first-come, first served basis? Well, we have to treat the most severe illnesses first so that those people have a better chance at recovery and, well, don’t pass on. [woman now getting gruff and demanding] Can you at least have some water? Uhm…well. I can check with your nurse, but given your condition it’s probably best that you not drink any more liquids. Drinking liquids will put more pressure on your bladder and increase your pain. I’m not a clinician, but those are just my thoughts. [woman becomes just mean] Okay, I won’t share my thoughts. [husband stands up and demands that I get her water without talking to the nurse] Sir, I understand that this is a really lousy situation that your wife is in but I have to at least check with the nurse about the water. No. No sir, I’m not discriminating against you—I would do the same thing for any patient here.”

All the while I’m trying to be cool, I am wearing khaki pants, white shoes, a white polo shirt, and a RIDICULOUS blue smock that is akin to something you would wear when you were in pre-school and about to get down with some water colors and/or finger paints. It makes me look goofy and a little less like a man. It’s okay though: I’m not there to be a man—I’m there to help out and learn.

So last Thursday, after attending to my normal waiting room duties, I come back into the ER and I notice this guy in the corner. Now normally this particular bed is reserved for the drunks that come in so that they can sober up (read sober up as “pass out and get an IV full of electrolytes and vitamins”). But I notice this guy is anything but passed out. In fact, while lying down on the gurney, he’s jubilantly shouting gibberish rhymes at the top of his lungs while arching his back, belly-up, as if in the throws of a tantric, rhyme-induced orgasm. Hey, at least he’s happy. But he’s also very loud and that doesn’t help the guy next door recovering from a stroke. I walk up to him and he’s singing…

“Ringa ding ding/I can find out if your life is in a sling…”

He’s so tickled by his verse that he shrieks like a two-year old meeting Big-Bird for the first time. It’s at this point that I notice his eyes are like freaking saucers. I mean there is barely any iris to be seen—all pupil. It’s like he’s in the midst of a full, pupil eclipse with the smallest ring of blue surrounding this vacuous black circle. I’m pretty sure he’s on a hallucinogen, though the nurse seemed to think he’s on meth. He has a healthy complexion and I didn’t notice any of the scabs or ashen skin tone that I see with folks on meth. This guy is “on one” in a way that I've seen before. My guess is LSD or mushrooms.

“Ringa ding ding/The man with the ring [he’s looking at my wedding band] thinks he’s the king, while I lay back and bask/The light the light, something I won’t fight, and that my friend is also your task.”

I smile and really look at his face. He looks like an angelic cabbage patch kid. His face is rosy and his blond hair is tussled in every direction. He’s only wearing one Teva and his shorts, I notice, are unzipped. This one-sandaled cherub has got a zeal painted across his face that, though I believe is chemically induced, I am slightly jealous of because he is obviously feeling something good that I am worlds away from. I’m pretty sure that he thinks he has the answer. I’m jealous of that too. I snap away from my thoughts and concentrate on the task at hand. Time to establish rapport. “Hey man, you’re having a good night, huh?”

He squeals with glee. Apparently he has now regressed to around six months old and starts playing peek-a-boo with me. He hides his face under the hospital blanket that is now hiding his unzipped shorts, and then re-emerges with another rhyme. “The cat and the mouse are off to play house/where will you be when…”

The nurse signals me to come over. I excuse myself, but he hardly notices that I have left because I can still hear him reciting more rhymes. The nurse asks that I establish a rapport with him so that we can get his name and insurance information. Our rhyming, saucer-eyed boy is a John Doe at this point. Though establishing rapport was what I was already doing, I acquiesce to the chain-of-command and tell the nurse he’s got a good idea. It’s better than acting like a know-it-all. More squeals in the background. The nurse also charges me with the task of calming him down. I agree, and as I walk back to him, I begin formulating a strategy. Okay, fine. I have no strategy. I really feel that this is one of those things that I am gonna have to feel out. I also wonder if this is a part of a volunteer’s normal duties. No matter. This beats scrubbing blood and feces off gurneys and making runs to the pharmacy. I’m back. He’s in mid rhyme and incorporates my presence into his ramblings. “…and was told with a kiss. Dismiss! Dismiss! The ringed man told Mathias, though I…”

“…sat in a bed and spoke gibberish.” I interrupt and finish his rhyme. He is overjoyed at finding a playmate. Gleaning his name from the rhyme, I realize that the saucer-eyed boy is named Mathias. More squeals—this time louder than before.

“Mathias, I need you to tone it down a notch. Your voice is loud and bothering some of the other patients. We got some pretty sick people here tonight and they’re not having as much fun as you.” He seems to think about what I’ve said but says nothing. I’m surprised. I guess that was the point though—he’s now quiet.

Mathias closes his eyes and smiles. I note to myself that whatever he’s tripping on, he must be having a good trip, because he hardly seems to care that the toe on his non-sandaled foot is bleeding, though not severely. Not only that, one of the veins in his right hand is connected to an IV bag of 0.9% sodium chloride. I've never done hallucinogens, but that’s the sort of stuff that I would perseverate on if I were on tripping. I’m sure I would go into a post-apocalyptic scenario where I wholeheartedly believed that the machines I was attached to were taking over my body. I do that when I’m sober.

I’m also impressed that he’s so upbeat while in the hospital. So much of how I feel is determined by where I am in physical space. I remember once being in the most disgusting bathroom I’d ever been in my entire life: shit smeared on the walls, flies hovering above me, flickering, buzzing fluorescent lights overhead, and an account of a sexual escapade scrawled on the bathroom stall beside me. After taking a quick piss, I almost ran out of there, but then paused and wondered if I was ever locked in a place like this, could I be mentally strong enough in to ever find happiness again. I’m kind of crazy, I think to myself, who thinks like that?

Damn reality…I feel that I have been dealing with it for a while.

While Mathias silently trips, I continue to trip on my own thoughts for a while. First to the front of my mind where there are lists of things to do. I check off bills that I’ve paid and think about how to find scholarships in order to pay for the nursing program I got just into. I wonder if my wife, Masako, is watching TV or studying. I then begin to worry that I haven’t been nice enough to her lately. Being married is a big deal and makes me nervous sometimes. I start thinking about our life together and the concept of “forever”. Our life is finite, but they say that we will be together forever in the ceremony. Wait. No they don’t. They say ‘Til death do us part. Why did I interject the forever part in there? Forever seems a lot more overwhelming than ‘Til death do us part. I take comfort in that thought. Typical me—always making things more overwhelming than they need to be. At least death is guaranteed. My thoughts become tangential and race around in a blue blur for a while. Then I look back to Mathias.

Mathias’ enormous eyes have opened and stare directly at me. Normally I avoid people’s direct stares, but he is so obviously content with life that I allow our eyes to meet for a full minute. Our inhalation and exhalation begins to match. We say nothing. Oh my God, I kind of feel like he’s scraping the back of my brain with his intensity. Then, as if suddenly completely lucid, he says, “I’m glad you’re here.”

I tell him that I’m glad to be there too. Taking note of this sudden fling with lucidity and forever being practically fused the task at hand, I want to ask him what he took, what his name is, and what his health insurance ID is. Bad idea. He’s only begun to come down. I ask Mathias what he’s thinking. Mathias smiles quietly but then suddenly looks overwhelmed. It’s the first time I’ve seen him without the smile of a zealot. Not wanting him to go on a bad trip, I tell him that he doesn’t need to tell me, but that if he wants to talk about what he’s thinking, I’m right there.

“I’m so juiced to be dying,” he says.

My gut reaction is to be sarcastic and condescending. Although normally I would have praise for a thought like this, I have already unconsciously characterized Mathias as a green undergraduate who has yet to truly live independently. How can he possibly be “juiced” to be dying when he’s hardly experienced life? Thoughts like this pass in a flash and then I remember my task. “Why’s that?” I ask, trying not to let condescension creep into my vocal cords.

“We’re living this monument—this huge thing and we get to experience it! Life, man. It’s really fucking spectacular. I feel it right now in every pore of my body.”

Although I continue to feel glib, condescending and dismissive, I want to believe what he’s saying because it’s true. Life is spectacular. Experiencing it is amazing. Why can’t I remember that? At the same time, this little boy named Mathias has barely begun to pay dues or feel the thumb of responsibility.

Suddenly, my mind abandons all pretense. I want to be on what he’s on. I want to feel unworn. I regain mental composure. I reach out my hand to shake his. His hand meets mine. It’s warm. I wonder where his hands have been. I like warm hands better than cold hands, though. “I’m Nat.”

“Mathias,” he replies.

“What’d you take tonight, Mathias?”

“SHROOMS!” he exclaims, and I watch his eyes just about pop out of his head. Just saying the word brings on a psychedelic roll of ecstasy. His eyes roll so far back into his head that I can only see white between his eyelids.

“Nice. So, this may be a silly question, but other than good, how are you feeling tonight? You know, is there anything else going on that you feel?” I’m intentionally not asking his last name and insurance information because I still can’t quite gauge how he will react. I really hope he doesn’t have a rhyming relapse and feel that the wrong question might send him back. Mathias ignores the latter part of my question.

“Really, really good. I FEEL SO FUCKING GOOOD! I feel lucky. Just laying here is soooo good. God damn it’s GOOD!” He begins to howl just like a coyote and bridge his back while thrusting his pelvis towards the heavens. The security guard looks to me for reassurance, I extend my open hand that signals him to hold up for a second.

“Mathias. I know you might have forgotten, but we have some really sick people here tonight. Some of them are on the verge of dying. I think they would like it very much if you could not yell.”

“They’re lucky.” I hear this and my interest in his cosmic voyage slams to a dead-stop. I thought I was condescending. How can he presume to know what they’re going though? He’s lying there, totally healthy, and aside from being in a temporary, self-induced, chemically altered state, he is completely healthy and will walk out of here in a few hours. There’s a woman here tonight who vomited up feces because of intestinal blockage. She also has pancreatic cancer and will most likely die within a couple of days. This kid will probably just get the munchies. I am angry with this boy and want to slap the taste out of his mouth. I hope I am keeping a calm exterior. He begins to speak again, “But I am like them, too. From my first breath I was dying, and so are they.”

I regain a small, tepid interest in his thoughts. At least he’s thinking about interconnectedness. That’s good. "He’s just naïve," I think to myself, "He’s not bad so much as he is green. You were like that once too. In most respects, you still are."

I calm down a bit. I can tell my ears have become red. They do that when I’m holding something in.

“I don’t think there’s any such thing as a selfish action.” Mathias says it in a way that makes me think it is an implied question. I bite. I probably shouldn’t debate with a tripped-out undergraduate in the Emergency Room that is only known by his first name, but I suddenly feel that it is really necessary to ground this guy.

“Well, I gotta disagree with you there Mathias. I think all actions are inherently selfish, except for maybe mothers protecting their children. You know, like the mama bear syndrome? Even then, she’s protecting her kin, not someone else’s necessarily.” As soon as I finish, Mathias is silent and I regret even having entertained what he was saying. Of course, he and I were just both thinking about death as being comforting, so I wonder if he picked up on that?

“What about Mother Theresa?” Mathias questions. I am glad he isn’t tripping so hard. He’s beginning to show signs of logic.

“I’m sure she gets her kicks from helping folks. I mean, I know she does amazingly hard work and it leaves her exhausted, but my gut tells me think that she must get something good out of it. If helping lepers made her feel like she was being rubbed out of existence by a thousand cheese graters, I have a feeling that she would stop. I’m no Mother Theresa, but I like helping people too. Helps me sleep at night—I feel like I’ve maybe left the world a better place than when I woke up. If it made me feel bad, I think I’d stop.” I wonder where the cheese grater metaphor came from. Mathias just harrumphs and wrinkles his forehead. I can tell he’s significantly calmer than twenty minutes earlier. I don’t know why, but I figure it’s time to ask him his name. “Look, Mathias, we gotta get you in our system and give you a name other than John Doe. Even better is if you could also tell me your medical insurance provider, medical ID number, and social security number.”

“Oh. My name is Mathias Youngblood. I don’t know my medical insurance information or my social.”

Wow. He doesn’t know his social security number. Mathias is a child, but at least he’s asking good questions and thinking about interconnectedness. At least I still am too.

“Okay Mathias. I’ll be frank with you. We can either have you figure out this information by calling one of your roommates or you can call your parents. Or, if you like, we can call your parents. Again, I can’t force this information from you, but it would make taking care of you a bit easier. What do you got?” I realize my tone has gone from rapport-building to no-nonsense and decide to tone it down a notch.

Mathias responds surprisingly quickly, as though he really wants to resolve the matter. I’m always surprised when people are cooperative. “Well, I just moved into a Co-op and don’t really think my roommate will be much use to us. Go ahead and call my parents.”

My friend used to live in a Co-op at Cal. That was a place where just about do anything could happen. Always seemed like an adventure was at hand. I remember standing on its roof with a whole bunch of folks, three stories up, and screaming at the sun to celebrate its setting. Wow. That was a long time ago. I’m starting to feel sad—like I’ve lost someone.

My thoughts return to Mr. Youngblood. He still wants to be taken care of. He willingly tells me his full name, address, and contact information for both his parents. I give this information to the nurse and he calls his folks, explaining where Mathias is and how he got there. I can hear Dad yelling over the receiver. I turn to Mathias and he has fallen completely asleep. Apparently the sedative they gave him finally kicked in. I look to the clock and see it’s well past midnight and time for me to go. The smock comes off and I say goodnight to the charge nurse and security guards. I gotta get home and get some sleep—I got work in the morning.

UCSF!

2007-03-12T22:57:00.000-07:00

A flood of things to write about. The most of important of which is that I got into UCSF!! I really can’t believe it. I almost think that I’m not worthy. There’s something there that I need to think about, but it’s too late to get too deep tonight. I had to read the letter three times and then over the phone to my Mom to believe it. Wow. Life is going to change significantly.

"You Want Mayo"

2007-02-23T15:30:00.000-08:00

REFLECTING ON: Feeding a quadriplegic man as a volunteer, written as assignment for Communications class on the importance of listening, pre-UCSF

In my spare time, which I don’t really have a lot of, I volunteer in the Emergency Department of a hospital in the East Bay. It’s a trip. In addition to cleaning up gurneys that have been peed, pooped and bled on, I spend a lot of time running around, acting as a communication liaison between patients and their anxious family members out in the waiting room. “Anxious” is a nice way of putting it. At any rate, the conversations I have, by and large, are very much one-sided where I am listening to or diffusing some sort of frustration that someone is experiencing. I sympathize with the patient’s and family’s situation—it sucks to have to wait for several hours in the ER while someone else is almost completely in control of your fate. I get it; I try not to take that little fact for granted. The conversations that I have with these folks, however, typically aren’t very long—two minutes tops. Last night, however, a nurse asked me if I could feed a man whom we’ll call Ishmael. Ish, which I called him, is a quadriplegic. He was in the hospital for some infected bedsores and just had some pain medication. The food, he said, helped settle his stomach from the medication. When I heard the cross-over about Ish, my mind immediately raced to the thought, “If he’s a quad, why would he need pain medication since he can’t feel anything.” Then I just let it go. Shit, if I were paralyzed from the neck down, would want some painkillers too.

The point here, however, is that while I fed this man his turkey sandwich, I realized I became the most attentive listener that I have ever been. I listened with my ears and eyes, watching and listening for the subtlest cues as to what he wanted to do next: talk or eat. I knew that he knew that I didn’t know how to feed him and I so I told him so. He just said, “That’s alright, just ask yourself how you would want to be fed a turkey sandwich, and then verbalize those questions to me.”

“You want Mayo?” I asked, and took it from there. I watched his eyes dart to what he wanted while we chitchatted about other things like the tattoos on his arms. I thought it was cool that a quad would get ink done despite having “non-working” arms and legs. He was a pretty self-aware person—able to see how newbies like myself saw him and made subtle efforts to distract me from be overwhelmed by his general situation in life. The tattoos were a good example of that—it diverted my thoughts from his gnarled fingers and emaciated arms and made me think of his life beyond the bed. Pretty clever really. Of course, maybe I’m over thinking things—maybe he just liked tattoos. At any rate, as we talked about the symbolism of the monkey-riding-the-elephant tat that he had on his right shoulder, I intuitively put down the sandwich, grabbed the can of coke, put a straw in it and gave him a sip. He burped, and I gave him another bite, noticing that he didn’t like eating the crust. When he was all done I wiped his mouth off with a napkin and then the transport person came and got him. While he was being wheeled away he said, “Good talking to you.”

“Likewise,” I said, though I really had hardly spoken but a few questions.

Ish’s obvious, physical need made me listen better than I had in a long time. I was able to listen with all my senses. The subtle yet distinct dignity with which Ish conducted himself made me wonder if I could be as perceptive as he obviously was. It seems to me that although many of us have the less obvious, less physical needs than Ish, we often still need to have those needs perceptively listened to.

Running While Laying down

2007-02-16T00:31:00.000-08:00

REFLECTING ON: Interaction with dying patient while volunteering in East Bay Emergency Room, pre-UCSF

Tonight, my glass is filled with wine and I’m raising it to Mrs. Martinez. I will quaff deeply, and breathe easy, for Mrs. Martinez. Just an hour ago, I watched this short little abuela struggle to breathe in her own body. Her lungs were filled with fluid from pneumonia and her cancer had metastasized to her chest cavity, putting added pressure on her lungs. Normal breathing rate is 12-15. She was breathing 40 breaths per minute while sitting down. She was running a marathon without moving. It’s weird the things that I notice while events like this are going on—she was still wearing her knit hat to cover her shiny baldhead, even when the physician was intubating her trachea. They administer drugs that paralyze her swallowing/gag reflex muscles like succinylcholine. And here I am, taking mental notes on the procedure, drugs that are administered, O2 levels, hear rate, and such, but I wasn’t totally sure that I should be there. They made the family members leave the room yet I was permitted to stay. The doctor even asked me top close the curtain so that nobody else could see. I suppose I get to stay because I know how to react in this situation—which is to not react, speak succinctly when spoken to, do what your told, and stay out of the way. The family might get hysterical, I suppose, and interfere. But it’s their grandma—their mother. I watched one nurse joke with another nurse while he was administering paralytic drugs to her chest and throat muscles. I kind of wanted to slap him awake so he could see how desensitized he appeared. Like I said, this is someone’s blood—best not to take that for granted. Then again, sometimes it’s the distance that allows us to do an “objective” job. I felt like a fly on the wall—a gnat that nobody wanted around. I guess everybody has to learn in some manner or another, and shit, that’s why I took this no-pay gig…this is all for the experience. I can’t help but be pissed at the college students that come in drunk with debaucherous, self-inflicted injuries when there are folks like Mrs. Martinez one room away. Self-inflicted injury just seems so fucking selfish and wasteful—a waste of time and resources that could be better allocated to people that are legitimately in need. It’s one in the morning and I gotta wake up early. Not only that, I got to wake up early, be on my shit, and I NEED to learn Spanish. I spoke Spanish two times this evening and made things work because of it. I gotta get fluent.

UCSF Personal Statement

2006-09-01T17:06:00.000-07:00

REFLECTING ON: I guess the entrance people read this and thought it was good enough...gives you and idea of what I did before UCSF...

Shortly after graduating from Berkeley, I found myself standing in front of thirty-five street-wise sixth graders in a dilapidated classroom in Newark, New Jersey. I was drawing a diagram of the irrigation systems of ancient Mesopotamia. My back was to the class and I heard someone cracking jokes about my drawing. It was Esperanza. After making several home visits to determine why Esperanza never did her homework, I discovered that her father was a crack addict and that her mother was a prostitute. Despite her distressing living situation, Esperanza still smiled at me and quipped that I was a better teacher than an artist. Then she stopped smiling, looked me dead in the eye and said, “Mr. Chadwick, I don’t mean to be rude, but what the f--- do I need to know this for?” The class collectively gasped and I had an epiphany: not only did few of these kids care about ancient Mesopotamia, but this knowledge could not help them at all with their most pressing problems. It was in this moment, in the heart of Newark, that I dedicated my life to helping people who had the greatest and most immediate needs.

Esperanza's question has had a profound effect on my professional career. Since that time, I have only held occupations in which I could help underserved youth with their most urgent needs. Upon returning to the Bay Area, I filled the role of surrogate parent to twelve severely emotionally disturbed (SED) boys as a group home counselor at St. Vincent’s School for Boys. During twenty-four-hour shifts, I learned to navigate the ebb and flow of their volatile natures while teaching them basic life skills. Next, I continued my work at Treasure Island Job Corps where I forged partnerships with local businesses and unions in order to place inner-city youth in construction and childcare jobs. Most recently, I returned to the classroom at Timothy Murphy School in order to teach academic subjects to the St. Vincent’s population. Though it was not uncommon for me to dodge a thrown chair in the middle of a lesson, my student’s extraordinary stories of survival and obvious need inspired me to show them how learning could enrich their day-to-day lives.

Whether I was working with a “student” or a “client”, I came to realize that the most appealing part of my work has been helping each person to gain the tools they need to survive their personal crises. I have chosen to pursue a career in nursing because it is a natural extension of my desire and talent for helping people through extraordinarily stressful circumstances. Nursing offers me the unique opportunity to integrate my crisis management experience with a precise set of science-based assessment and intervention skills that will have a significant impact on the health of an individual. Taking Chemistry, Physiology, and Anatomy has only confirmed my sincere interest in understanding the human body and has further inspired me to learn the methods to heal it. In order to help the people that are most critically in need, I intend on becoming a Critical Care Clinical Nurse Specialist in an Emergency Department. Through direct patient care, I believe that nurses are the critical link between a patient’s needs and the road to recovery. I am excited to combine the skills I have acquired as an educator and social worker with those that I will learn in order to become an outstanding nurse.

To gain a better understanding of Critical Care Nursing, I have been volunteering weekly in the Emergency Department of an East Bay hospital. Knowing that all experience is what one makes of it, I have observed, investigated, and absorbed as much as possible. Mostly though, I clean as many beds and stock as many supplies as quickly as I can so as to let the nurses and doctors do their work. And they do work. Hard. I once asked a veteran nurse named Maureen why she had become a nurse. Immediately “Moe” sized me up for what I was: a little green. She said that although she did her job because she enjoyed helping people, “it ain’t all superman stuff where you’re bringing someone back from the brink of death. Sometimes you’re just wiping butts.” At first I was puzzled by Moe’s blunt response. Then I realized that she was testing me. Moe was trying to tell me that there are many parts of caring for and healing a person and some of those duties are far from glamorous.

Although indeed “it ain’t all superman stuff,” each interaction with a patient or their family is a unique opportunity for assessment and intervention, no matter where that assessment might take you. I have watched in awe as RNs skillfully and thoughtfully navigate the countless different situations that bombard the Emergency Department. I have observed RNs assist in resetting dislocated shoulders, rapidly assess heart attacks and administer nitroglycerin, restrain violent drunks, soothe a woman that had to identify her deceased sister, irrigate the wound of a man that was hit directly between the eyes with a hockey puck, calm an erratic 17 year-old that had ingested psychedelic mushrooms, do a blood transfusion on a woman with a hemoglobin level of three and a scabies infestation, and perform countless other duties that boggle my mind. Even more impressive than the breadth of technical knowledge the RNs applied in each case was the obvious compassion they showed each patient.

I want this job. I want to know how to do what they do.

I am resolute in my decision to become an Emergency Room nurse. Emergency nursing enthralls me because I can fundamentally help people to heal, and in turn, pursue the things that give their life meaning. It would be an honor and a privilege to undertake my nursing education at UCSF.