Before You Commit to Nursing

http://giphy.com/gifs/black-and-white-bampw-nurse-jackie-TJD9iYe9kHjCU

I was reading this Gomer article titled "Things Residency Has Stolen From Me" that was such a deluge of terrifying truth that it completely lost its satire quality.  It made me remember my first day of nursing school two years ago when I was sitting with my PN cohort, a full 35 strong, going around the room and introducing ourselves, and then stating, per our professor's request, the reason why we wanted to become a nurse.  The other 34 students talked about how they had taken care of ill family members, thought they would be a good nurse, wanted to help people, always played pretend nurse as a child, and I desperately tried to concoct some kind of ideal story about how I always imagined I would be a nurse, but I'm a terrible liar, and I hate platitudes, so I told the truth.

"I never wanted to be a nurse," I said.

My new colleagues gasped.  My professor's eyebrows flew up to the ceiling.  One student snipped, "Then why are you here?"

Well damn.  I might as well blow the whole thing out of the water.  I continued, determinedly, "You get yelled at by everyone.  You're overworked, underpaid, you never see your family.  You're pissed off and nasty to your loved ones because you use up all of your niceness at work and at school--and it really strains your family dynamics.  All of society thinks you're the failed medical student.  The world just treats you with disdain when you have done nothing but sacrifice and prostrate yourself for others to walk across your back.  Why would anyone ever want to be a nurse?  But I'm good at science, and I'm good with patients, and nursing has a predictable path and a reliable income source.  I think if I'm honest with myself, I can admit that I never wanted to be a nurse, don't want to be a nurse, and will never be one of those nurses who just loves her job.  But, I don't have to love something to be really damn good at it.  And I can be happy with that."

My professor was smiling.  Smiling.  Then she started laughing.  She clapped her hands together and said, "You remind me of me.  I can tell, you're going to make it."

She was right.  Tomorrow I will be walking across the stage for my pinning ceremony for my RN degree.  I have survived 8 weeks in CNA training, 2.5 years in prerequisites while working as a CNA, 1 year of PN school while working as a CNA, and 8 months of RN school while working as an LPN.

I always knew that nursing was a tough job, but I had never considered how difficult the path to becoming a nurse might prove to be, and I want to make sure that you, potential future nursing student, are given as fair of a chance to walk away as possible, because this is no joke.

I went to the best high school in the state of Illinois.  I went to one of the best private colleges in America.  I worked hard.  I failed repeatedly.  I failed so hard and so often that it beat any trace of pride, dignity, and self-esteem out of me, but nursing--not just nursing school--is still the hardest thing I have ever endeavored to do.  My previous college experience prepared me for nursing, but nursing is still the only thing I have ever done that has no margin for error because I am entrusted, every day, to preserve and protect the most fragile thing to exist: human life and dignity.  I may have cried in the security office after every Organic Chemistry exam I ever took, but that feeling of defeat is nothing compared to what you feel after your first patient death.

The reason why nursing is so difficult is medicine has no boundaries.  It is overwhelming in its vastness when you're trying to consume it in school.  It seems an impossible task, like standing in front of a fire hydrant trying to drink the water through a straw.  When you sit down and begin preparing for the NCLEX, you will inevitably discover, to your dismay that what you learned in school was only a fraction of the material out there.  You were trying to drink from a fire hydrant, but the field is really more like Niagra Falls.  And when you become licensed and go to work for the first time, you will realize that nothing--not even Niagra Falls--could prepare you for what happens next.  When you step into the real world, you're flung into outer space, where there is no friction, and no light, and no one around you to slow you down or save you.  You're just there, in a space without boundaries, and an eternity of unknown, with just your training and your wits, tumbling over and over, trying desperately to get your bearings while your world of school, and NCLEX multiple choice questions, and clinical and the safety of your instructors fade away like Earth in the distance.

Now if I haven't scared the living daylights out of you and sent you screaming in the opposite direction.  I want you to please consider these things that people never think about when they decide they want to go to nursing school.

Hahaha.  I only wish I meant it the way Maggie did.

http://giphy.com/gifs/weekend-maggie-smith-teaching-qUK8svS7sKuWc

1) Say goodbye to sleep.  You think you can handle the fatigue.  You can't.  If it's not just the sheer amount of material to read, it'll be your boss calling you to cover a shift, or your clinical instructor giving you something else to add to the concept map or care plan or research paper or whatever.  Your eyes will always look and feel like they've been rubbed with sandpaper.  You'll have black circles around your eyes so big you'll wonder if you've been punched in the face.  You'll look like a vampire.  Your mouth will always be dry and your throat always scratchy with a persistent cold.  Your brain will feel like cotton all the time.  You will be so tired that walking, getting out of your car, getting into the shower, taking your clothes off, even the mere action of breathing will seem like it requires more energy than you can possibly muster.  All of this because of sleep deprivation.  Oh, and weekends?  What the fuck is a weekend?  You're thrilled when your boss schedules you on Saturdays and Sundays because that allows you to just focus on school from Monday through Friday.  Nursing owns your life.  If you still have a job.  Bosses will fire you for having to switch your schedule 5 times in a week because your school keeps losing clinical sites or clinical instructors.  Oh, and you can say goodbye to holidays too-you think people stop being sick just because Santa's coming?  Sorry to break it to you, but you'll be spending Christmas Eve holding a dying infant, or the hand of someone making the decision whether or not to sign the DNR.
2) No sex either.  Who has time for sex?  Or meeting people?  Your friends will think you have been abducted by aliens.  You will miss almost every important event (unless you're a woman actively giving birth--which, honestly, my classmates who gave birth while in nursing school, you ladies blow my mind).  Weddings, anniversaries, bat(r)mizvahs, baby showers, birthdays, opening nights--you won't be at any of those because you will be studying, or at clinical, or in class, or at work.

http://38.media.tumblr.com/tumblr_m3ig9sA0HU1qkcmqlo1_500.gif

3) Same to food.  You won't have time for breakfast.  You'll live off Cheerios and protein shakes.  You'll be lucky if you have a minute to chart, much less eat lunch.  And if you're working a double, I hope you have candy bars in your pockets because you won't be eating dinner either.  When you finally sit down to chart, you'll realize you never even drank your coffee and it's actually cold and staring at you accusingly from next to the keyboard--oh wait, no, your coffee won't be by the keyboard, because food or drink is not allowed on the floor due to infection control.  You don't eat or drink on the floor.  Which means you didn't eat or drink today at all.
4) Your pee will look like Cola when you get home, and your throat will be on fire because you will have not drunk anything all day, because you have not taken a break all day.  The stress of it all will probably even drive you to drink or to smoke.  It's not ideal to be a health practitioner who smokes, but sometimes it's the only thing that keeps you from going over the edge.

Sometimes you go on a pee break and when you come back your world is like: 

http://whatshouldwecallnursing.tumblr.com/post/23105024856/the-first-time-i-pulled-an-art-line-and-didnt

5) Oh, you'll have taken over 10,000 steps in half a shift.  God help you if you're working a double.  No wonder your feet are on fire.  Also, since you're barely able to walk at the end of the day, forget about going running, or weight lifting, or any sort of athletic anything.  You're going to be fat, out of shape, sloppy looking, because all you'll want to do is sleep when you're not at work.  Oh you thought walking was healthy for your heart?  Well it is, if you're a 60-year-old CAD patient.  But for you being on your feet for that long gives you varicose veins.  Enjoy those sexy, sexy legs!
6) Someone will poop, pee, vomit, sneeze, cough, spray, hemorrhage, or diarrhea crop dust all over you.  It will happen.  Just accept it.  Always bring back up scrubs.  And wash your hands--oh, and your hands will always be dry and cracked, and using hand sanitizer will hurt like the dickens.
7) No matter how smart you are, how hard you study, how well you know the material, you will make mistakes.  You will misjudge.  You will be late.  You will say the wrong thing.  You will miss the clues entirely.  Failure.  It happens.  And you will hate yourself.  And you will learn to let go.  You will learn to function in the face of overwhelming terror because you must function in the face of near-crippling fear.  Realize that the path of nursing student leads you to being the nurse.  When the patient codes and people scream for help that means you're up to bat.  That is the reality.

You see this?  You must never do this.

http://giphy.com/gifs/mulan-nervous-run-away-mgW7qk28vnSms

8) The only way to keep yourself from exploding about #7 is to turn off your feelings.  You become great at compartmentalizing.  When your best friend, boyfriend, or mom yell at you, "God!  How can you act like you don't care?" or "Ew!  How can you talk about C. diff or Fournier's gangrene or _____insert any of the numerous things that non-medical people will find disgusting______  while eating?  You're gross!"  you'll realize it's because you've somehow, even though you swore you wouldn't, slowly turned off pieces of you so that the rest of you can survive.  Be it the fear of test taking, or the third patient to die on you in a row, you will have to learn this skill.  Never fear, the rest of the nursing world knows that you laugh inappropriately to keep from crying.
9) Trust and expectations?  What are those things?  You don't trust anyone unless you see the minimum of 3 primary sources and the actual lab results with your own eyes.  And even then, you may not trust yourself.  Your professors--maybe you can trust them, maybe not.  You always check with primary sources--that means a LOT of extra reading.
10) No alcohol, or drugs, or anything fun at all ever.  Drug tests, and the nurse practice act will put the fear of God into you.  You'll have pot brownies frozen in your freezer from now until the day you die because you're afraid the day you eat them is the day they'll ask you to pee in a cup.  Plus you have to be at the clinical site at 6 in the morning, which means you have to get up at 5, or 4 a.m., which means you ain't got time for being hungover.
11) Say goodbye to money.  Hahaha.  Whoever told you going into nursing was lucrative was lying to you.  LYING I SAY.  If you were on Medicaid before, say goodbye to your healthcare.  If you were well off enough to not be on Medicaid before, say goodbye to your money because it's now going to tuition, and books, and uniforms, and stethoscopes, and transportation between clinical and school, and coffee.  And after you graduate you still have to pay for test prep books and licensing fees, and fingerprinting fees, and drug testing fees, and NCLEX fees, and malpractice fees...
12) Say goodbye to sunlight.  Seriously.  6 a.m. to 6 p.m. clinical in the winter means you're basically a vampire.
13) You will rip awake in the middle of whatever scant amount of sleep you can steal thinking you heard a bed alarm, or a vent alarm, or something equally alarming.  And then lay awake analyzing everything you did and wondering if you did the right thing or if you did enough.
14) There is a good possibility you may fail and have to repeat a class, or retake the NCLEX.  Almost 1/3 of every class I was part of was eliminated by the time graduation came around.  Even the most secure of students will have at least one moment when they think they're going to have to repeat.  And part of it is not having the single-minded focus on nursing school, but the other part is also, you just may not jive with a certain type of teaching.  It happens at all schools.  There will always be that one professor who just seems like she's out to get you. Just because you were a straight A student before does not mean you're a straight A student now.  "C's get degrees," is something a fellow nursing friends said to me.
15) This never stops.  Seriously.  Never.  Nursing never stops being hard.  You never stop learning because you are human and you will make mistakes.
16) People love to sue you for those mistakes.  You will have given up the better portion of your twenties, and part of your thirties, paid tens of thousands of dollars for school and books, clothes, and shoes, and takeout, and licensure and certifications, and interview suits, only to have people do their damnedest to take your license away from you.
17) It will age you faster than you need to age.  It takes its toll and the cost is very real.

And lastly,
18) You will get it.  In the end you will understand what it means when people say "nursing is a lifestyle of service."  You will finally feel the truth in your bones when someone says that "nursing is a calling."  You will get it, because if you don't get it, if you don't feel that inside of you--if that spirit of stewardship and compassion for your fellow man, if that drive for excellence, the hunger of knowledge, the joy of science, and all of those other seemingly Hallmark remarks about being a nurse was never inside of you to begin with, you will never make it out the other end.  It doesn't mean that you'll feel that way on day one, but after the first midterm, after the first final, after your first failure at clinical, after the first time a patient screams at you, after you see your first crack baby,  after you smelled gangrene and have to take a shower and drown yourself with a neti pot to get the smell out of your sinuses, after you've listened to a burn victim scream, after you go home after 12 hours of hell to no dinner and a sinkful of dishes you'll get to next Thursday, after (for the millionth time) you've fallen asleep while brushing your teeth and then drunk a gallon of coffee so you could stay up all night scribbling med cards until the birds have already started chirping in the pale grey of morning only to put your mildly ripe scrub uniform back on and go take a test you haven't had time to study for, you'll come face to face with yourself and realize that you've surrendered to it.

If the idea of that frightens you, good.  You should definitely ask yourself, as we all did, "Can I really do this?  Is it really worth it?  Do I really want this?  Am I willing to prioritize clinical and studying over everything else in my life?"

I was lucky in that I didn't have children while I was in school.  For me, it was just about giving up my music career.  I wasn't much of a social person to begin with, so not going out was fine.  Drinking wasn't a much-loved ritual so giving it up was easy.  I was single and had a job that only required me to work one day a week.  Most of all I was built to study, write papers, and take tests--it's the only thing I've done for 23 years of my life.  It's what I do.  But it may not be what you do.

My goal is not to discourage you from pursuing nursing.  I just want you to come into this field with your eyes open, because it will increase your chances of success.  There is nothing worse than giving up a year of your life, losing that income, and missing out on making memories only to fail--for whatever reason.  It's not fair to your current employer, your family, or your friends.  But most of all, you would be doing a disservice to yourself if you weren't prepared to give everything, because that is what it takes.

So ask yourself these questions: "Can I really do this?  Is it really worth it?  Do I really want this?  Am I willing to prioritize clinical and studying over everything else in my life?"

I hope the answer is "yes" because we need you.  If after reading all of that you still want to be a nurse.  Cool.  I support you, and I created this blog for you in the hopes of making your life easier than mine was while I was in school.  Don't be afraid to ask for help.  We'll all be here.  Good luck.

Diminished Breath Sounds: Story From the Trenches

The Leap.  It's what makes the difference between student and practitioner.  The Leap is when you see the theory in real life and recognize it, and apply the theory in practice, because you recognize it. I know I said "recognize it" twice in that last sentence, but seriously it's kind of the whole point of, well, everything.

Every student wants to make the leap.  And I totally, absolutely missed it.  Face planted like there was no tomorrow.  In front of two ex-paramedics turned into triage nurses in the ER--and thank God there were two ex-paramedic triage nurses to catch my absolute face plant because what I missed was pretty damn big.

The part that gets me is that I had just learned about it four days ago in lecture.  I learned about it, and every time my professor said it (and she said it at least once per lecture for 8 weeks) I could feel myself wanting to slam my own face into the table from the tedious repetition of it.  My professor was obsessed over airway.  Every day she would say: "If you have two patients--one, a man passing a kidney stone and screaming his lungs out with 10/10 pain, and the other a child in with exacerbated asthma and wheezing but now no longer wheezing, you better run in there and make sure that kid is breathing.  The guy next door has got very healthy lungs.  The kid is suffocating."

How many times did she say that?  And yet!

This was my very first, and only time, in the ER.  I didn't have an actual preceptor so I was just being bounced from one nurse to the next, from one case to the next--which isn't an excuse, I know.  Assessment is assessment, and it's the same no matter where you go, no matter which patient you're on.

I just didn't make the leap.  I don't know why.  I've been going over it again and again in my head.   Why didn't I see it?  Why didn't I stop and question when I heard what I heard?  What if I had been alone and triaged this man down?

This is what happened:

He was the third patient to come in.  I had just come back from delivering another patient to her bed, and the two triage nurses had already finished assessing, but they handed me a pair of stethoscopes and asked me to assess breath sounds.  The man was sitting with one hand braced on the table and one hand on his knee.  They had also already taken the pulse ox and bp cuff off so I had no vitals.  I know because I looked to see if his pulse ox would give me a hint.  And I had missed the intake so I didn't know what his complaint was.

http://e-safe-anaesthesia.org/sessions/06_03/gif/tripod.gif

"Okay, sir, sit up for me," I said, anticipating that if I was being instructed to auscultate lung sounds on a 25 year old male, the patient probably had asthma.  I expected to hear wretched crackling like the crumpling of a paper bag.

I chirped, "Deep breath please."

I didn't hear any wheezing or crackles on the back.  Nothing at all.  I had heard it in the front but not the back.  Puzzled, I stayed in the same spot.

"Breathe deep.  Please.  Deep."  (I mean, really, L.  SO OBVIOUS.)

I didn't hear anything, in fact, but I had a 15 dollar stethoscope, and I was listening through two layers of clothes and in a loud ER bay,  so I assumed I probably wasn't going to hear the most detailed of sounds.  Plus the man wasn't gasping for breath.  He didn't appear in distress as he was calm, and quiet.  Not just quiet.  Silent.  He didn't say a word.  (Which I didn't know was a big deal, but it seems so obvious to me now--the man was silent because he could barely supply himself with enough oxygen to keep from gasping like a fish out of water.)  And I did hear breath sounds in the front.  I also had no idea tripod was so subtle. It's subtle because the man can't breathe.  He's not exactly going to be making a lot of movement if he can barely breathe. Honestly, when I first saw the patient I thought to myself: "He's hunched over.  He looks tired."
So, like an excited, nervous puppy, I followed the pattern bilateral listening pattern, on his chest then on his back, and then took off the stethoscope and said, "Clear."

This is essentially what I heard: http://www.youtube.com/watch?v=O8OC7EiqBKQ&t=0m47s.  And, no, there wasn't even the faintest of crackles.  I didn't hear much, but there was some in and out, and there weren't crackles.  I've been kicking myself for over a week about missing this, because I swore there weren't crackled but dammit, L, that's the point!  You weren't thinking!

I didn't make the leap.

I just checked each part of his lungs like they were checkboxes, like they were tasks to overcome, not pieces of evidence to be examined and critically analyzed.

I was wrong.

I was so, so wrong.

"Clear," I said.
"Clear?" the first nurse asked, with the tiniest note of doubt.  Or maybe it was incredulity that I was as dumb as a brick.

Basically, the look he gave me.

"I don't hear crackles," I affirmed, a little less certain.
He gave me this look, then gestured to the other nurse.  "Take a listen," he said.  "Diminished?"
"Yeah," the other nurse said, nodding his head.  "Diminished."
The first nurse nodded and finished the paperwork, essentially dismissing me, and I, embarrassed but not really sure what had happened backed up against the supply table.  Silent.
The second nurse turned to me and said, "When people have really bad asthma, the bronchioles close up.  Wheezing means sound, just like when you blow through pursed lips you get a whistle.  When you open your mouth wide, there's still sound, it's loud and hollow.  When you close your lips.  There's no sound.  No sound is bad.  No sound is always bad."
"I'm sorry," I said after we had delivered the patient to the back for treatment.  "I messed up."
"No, you didn't mess up.  You're just new.  Next time, before you have the patient sit up, just step back and look.  He was tripoding, using accessory muscles--that's textbook respiratory distress--which you would have seen if you physically stepped back instead of standing right next to him.  It's not an emergency emergency, so, if the man isn't passed out or clutching his throat and turning blue, or hemorrhaging, you have time to look him over.  We'll just give him a neb treatment and refill his Albuterol, but, now you know.  Don't get sucked into just one part of the assessment.  Step back and look.  And if you don't hear anything it's not 'clear' it's 'diminished.'"

Q-Pap: A Story From the Trenches

This is a true story of badly worded orders, and mathematics.  Essentially, there was a patient who claimed he couldn't swallow pills, so one of my coworkers took a phone order for liquid Tylenol.  It looked something like this:

Give Q-PAP 15 mL PO TID PRN 150mg/5mL.  

COME ON!  Don't write down an order like this.  Never write an order in the form of:
drug name-volume-route-frequency, because concentrations vary.  What can happen is the next nurse, who is bleary eyed from pulling 3 days of double shifts, will read your sloppy handwriting and read any of the following:

Give Q-PAP 5 mL PO PRN 150mg/5mL (Translated: Q-PAP 150 mg PO TID PRN)

In which case, the patient will be screaming at you for more pain medications in 1/5 of the time.

Give Q-PAP 5 mL PO PRN 150mg/mL (Translated: Q-PAP 750 mg PO TID PRN)

Which is actually a reasonable dose in theory, but in reality it's wrong because the concentration given to you from the pharmacy is 150 mg/5mL and NOT 150mg/mL.

Or worse, you'll confuse yourself and end up transferring from the MAR to the POS incorrectly because you'll have confused yourself.  And you'll end up with an order like this: 

Give Q-PAP 15 mL PO PRN 150mg/mL  (Translated: Q-PAP 2,250 mg PO TID PRN)

In which case, the next shift will be tempted to call an ambulance because on first glance it looks like you gave your patient way too much Tylenol, and he will need a liver transplant.

Always write your orders down as: drug name-dosage (mg, mcg, etc.)-route-frequency.  So, let's take this jumble order and 1) solve for the correct dose, and 2) rewrite the order.**

Give Q-PAP 15 mL PO TID PRN 150mg/5mL
In other words: You are giving 15 mL of Tylenol at a concentration of 150mg/5mL.  How many mg are you giving?

15mL x 150mg
              5mL

=3x150mg

=450mg

The best way to write this order: Give Q-PAP 450mg PO TID PRN

                                                              drug      dosage route frequency 

**In real practice, you would have called the doctor to clarify the order.

Caveat: Some pharmacies, like Walgreens will need a quantity of medication (7 pills, 30 pills, 90 pills, etc.), and a duration (for a week, for a month, etc.) in order to carry out the order.