The Weight I Cannot Carry

Carefree woman arms outstretched on the mountainIt drives me crazy sometimes that I really don’t have control over anything.

I see this everyday as a nurse and it often makes me feel powerless. I can hang all the antibiotics in the world but I cannot cure someone of ARDS. I can hope that this patient doesn’t have to go back for more surgeries but nobody, not even the surgeon, can say 100% that it won’t happen. One inch to the right and the bullet would’ve killed him. One inch to the left and he would’ve lived. I can do everything in my power to help save someone and they can still not make it. I can tell a patient a million times over to limit alcohol consumption but they can refuse. And then they could die in a week or live to be ninety, who knows? For all the miraculous interventions that we’ve come up with in medicine, many, many aspects are still out of our control. And while we all intuitively know this, we ignore it most of the time. We want to be the masters of our own fates, and our patient’s fates as well.

The randomness can be terrifying, the fact that we have no control over the majority of things that happen. This man was just walking down the street and someone shot him. This lady was minding her own business and someone stabbed her. This child was living a healthy life and now has cancer. This can breed fear like wildfire in your life if you let it, if you don’t find some way to combat these thoughts. You have to find a balance, the line between defiance and acceptance. Resignation and initiative.

I’ve recently gotten a taste of this lack of control in my own life. A week before Christmas my NP preceptor for January informed me that she was leaving her practice and basically wished me luck in finding a new one. Being only a few weeks before the start of my semester, you can imagine how I felt about this news. I threw a big fit (not to her), if I’m being honest. So now I’m going to have to defer the start of my semester and I’m scrambling to find a new preceptor on such short notice. It’s frustrating and discouraging and I hate that there’s a big hole in my perfect plan now.

I have absolutely no control over the fact that my preceptor decided to leave me with no options. I can’t fix the fact that I have to wait six more weeks to start my clinical semester. I can blame everybody and everything in the world but that won’t change the outcome. It’s out of my hands. But as maddening as that is, I’m starting to accept that this is how life works. Plans don’t work out. People get unexpectedly sick or laid off. Storms hit and car wrecks happen and pregnancies don’t make it. This is the reason why hospitals exist! I can fight against this and I often do, but it’s futile. I exert very little control over anything in life and yet I still try very hard.

To be fair, sometimes the uncontrollable turns out to be good news. A positive pregnancy test or an unexpected promotion or an accident that turned out to be a fender-bender when it should’ve been worse. Just as many bad things are out of our control, many good things are too. And there’s hope in that. Without that juxtaposition, I think we’d all give up and live meaningless lives. This is the reason why we hope for remissions and good lab results and why people work in labor and delivery. Sometimes life unexpectedly throws you something joyful.

There are a million insidious questions that I believe every healthcare provider has to face at some point. Questions like: Why do bad things happen? Why did this person die and not this one? Why is everything so out of our hands? How much impact can we really make as healthcare professionals? How much should I push and how much should I leave it be?

Obviously we believe that our words and actions carry some weight otherwise we wouldn’t show up for work in the morning. I can’t make someone get a screening colonoscopy or a mammogram but I can inform them of the benefits and risks, try to convince them that it would be good for their health. I can rejoice when someone decides to quit smoking at my advice. But sometimes I will also have to lament when someone refuses to take their insulin and ends up with an amputation, despite my admonitions. I will never give up advocating for wise choices because it’s not all up to genes or luck. We are still responsible, while not being in full control. We have to become comfortable with this oxymoron, as frustrating as it is.

Control will often fail us for another reason. People are allowed to make their own choices, even bad ones. They’re allowed to sign out AMA and ignore medical advice. They’re entitled to refuse that surgery or to keep doing IV drugs. They don’t have to listen to and follow your advice. People are not black and white and neither are their motives, choices and responses. You can’t control the heart and as healthcare providers, that should never be our aim, even when you see the train coming full speed down the tracks for someone.

For me, it comes down to humility. I have to accept that many things are out of my control. I don’t control the universe. I don’t control my patients. I can’t control many aspects in my own life! I can kick and scream about all of it or I can resign myself to do the best that I can- promoting smoking cessation and praying for that sick ICU patient and hoping for a good outcome. But then I have to leave it. I can’t live my life in paralyzing fear of the unknown but I also can’t think that I can control every outcome.

The only thing I can do is decide not to carry that weight on my shoulders.

I don’t know the answers to the questions. I don’t know why this person was allowed to live and this person’s life was cut short. I will never know why this person smoked for forty years and never got cancer while this child died of leukemia at two years-old. I don’t know the answers, but I think it’s still worth struggling with the questions. Even if we don’t find answers, we find out something about ourselves. We discover why we get out of bed at the crack of dawn and go to work day after day. We remember why we spend hours in surgery. We realize why we always, without fail, mention smoking cessation at every visit. We don’t limit our tears when someone close passes away. We learn to embrace everything that comes, in full measure, the whole spectrum.

We learn to live in an unpredictable world- to rejoice over the good and mourn over the bad and appreciate what is in front of us. We learn to embrace both joy and pain, exaltation along with sorrow. We learn what it means to live openly and humbly. We learn not to fear tomorrow no matter what it holds. We learn how to truly love, even with no guarantees.

We learn what it means to be human, the full messy whole of it.

And that is the best thing we can do for our patients, and ourselves.

 

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The People Fade, but the Stories Do Not.

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In 1957 my grandmother received her nursing pin as a graduate of a diploma nursing program, in the era before the emergence of formal nursing education. Nine years ago my grandfather gave me that pin when I graduated with my BSN and now the pin sits in a pretty box in my room like a treasure, something full of lost memories. It’s grown tarnished over the past sixty years, fading to a dusky golden color that has lost it’s original sparkle, but every time I look at it, it grows in value. That pin has become a symbol to me of many truths- that my actions are bigger than me, that legacies really are something to strive for, even in our culture that seems to think that nothing lasts, and that this profession will never die. The pin has meaning to me now because I ended up with the same job title and because I know how hard she had to work for it. How much she had to sacrifice to be a nurse. How I benefitted from her perseverance.

Although I don’t know a whole lot about my grandmother’s story, I know that she worked on the weekends while my grandfather watched my mother and her sister. I know she wore white shoes and a white hat to accompany her white uniform. I know that she worked at a psychiatric facility, probably straight out of One Flew Over the Cuckoo’s Nest. I know that she was a kind, caring person who loved her family and I can only assume loved her patients in the same way. She passed away when I was in middle school and I wish so badly that I could hear her stories, that we could go out to dinner and that she could tell me the honest truth about what it was like back then. The good, the bad and the ugly. I think I’ve been in the trenches in the trauma ICU but I’m sure she could beat me by a long shot. Working in a psych facility in the 50’s automatically trumps any crazy stories I could tell.

What’s the point of this? Yes, my grandmother was an amazing woman and she should be honored as the first nurse in my family and a contributor to my own career path. But I’m getting at something else. We all have nurses who stand out in our mind, those who have worked extremely hard to love people day in and day out, those people who have impacted you in a significant way. Some of those people are memorable because they’re valiant soldiers who braved bedside dangers and trials, maybe even on your behalf. Others remain lodged in our memory because they were crooks and narcissistic thieves, people who spread shame like a contagious disease across the great name of nursing. Most of us have interactions with a plethora of people but there will always be those who left a mark. Here are a few of the memorable nurses in my life, for both good and bad reasons, and I’d love to hear your thoughts on the nurses who have impacted you.

  1. My very first preceptor as a new graduate in the ICU– I spent the better part of the five months wondering whether she actually hated me or not. She was a fireball, always looking over my shoulder to correct me, always pushing me farther than I thought I could go. I had more than one day where I disappeared into the supply room to cry. She made me take patients that I thought were out of my league, assigned us to double isolation to learn clustering my care, and gave out smiles like rare jewels, reserved only for special occasions. I couldn’t wait to graduate and be free from her. It wasn’t until I started precepting new nurses myself that I realized how great of a preceptor she had been, for stretching me while I was still young and under her care, for actually caring how I turned out as a nurse.
  2. Night shift nurse who scared the crap out of me as a new grad– On one of my first nights on my own after graduating from my ICU nurse residency program, I was assigned to a patient. My patient happened to be positioned next to the patient of a scary-looking night shift RN. She was unknown to me, with bags underneath her eyes and ratty, nasty hair. Her eye liner drooped haphazardly down her face. She told me weird stories about her daughter as I tried to escape her and do my work. And then she told me that nobody actually gives the insulin prescribed on the sliding scale protocol. What good does 2 units actually do anyone? she argued. I politely disagreed and spent the rest of the night avoiding her, terrified of what else was going to come out of her mouth. She got arrested and fired for being high at work only a few weeks later.
  3. My mother’s friend who let me shadow her in high school– As a junior in high school I was fairly certain that I wanted to work in the ED or ICU as a nurse so one of my mother’s friends let me shadow her for a night in the ED at a major hospital. I borrowed a pair of scrubs and fastened all the bravery I could muster as I walked in to the hospital with her that night, having no real idea what I was walking into. I pretty much failed at being helpful, even at taking a temperature, and I almost passed out when we received a trauma patient who had been thrown from a horse. But I walked out after that experience feeling like I had found my true calling, a job that was hard-core and exciting and would push the limits of what I thought I was capable of at that time. I followed that dream and have always been thankful that this nurse took the time to show a high school student what nursing could look like.
  4. The nurse that made me almost have a heart attack– one night when I was a new grad, another nurse told me that I was getting a level one trauma hit in my empty bed. I had never taken a level one on my own and I was literally speechless. He told me to get the rapid infuser and a few other pieces of equipment and I spent the next ten minutes racing around the unit, trying to keep from peeing in my pants. After those ten minutes he couldn’t stand it any longer; he told me it was a joke. I didn’t understand and at first I thought he hated me for playing such a cruel trick. But then I realized that it actually meant that people liked me on the unit, otherwise they wouldn’t have teased me like that.
  5. My many friends on the unit– Seeing death every day bonds people together, and I think this is seen acutely with nurses. I cannot tell you how many of my friends, three specifically, treated me more like a sister than a coworker. We helped each other when one of us was getting overwhelmed. We cried when we lost a patient.  We took snack breaks together. We vented about whoever was on our nerves that day. We switched shifts when someone needed it. We sacrificed ourselves for each other, not out of duty, but out of love. And those memories never disappear.

This is nothing to say of the many physicians, chaplains, managers, patient care assistants, and others who will live on forever in my mind. A few physicians that I would like to never see again (and a few that I loved!), a chaplain who I still miss seeing her shining face, a manager who truly always had my back. I remember the stories because of the people in them. I wonder if I am burned into anyone’s memory, if I live on in their story.

I have no idea whether anyone in my family after me will go into the medical profession. My two year old daughter has a Doc McStuffins bag and carries it around giving “check ups” so I’m hopeful for her. But regardless of whether I hand her my nursing pin one day or not, I hope that she will know that her mother loved her and loved other people and was brave and kind and smart and often made mistakes but always asked for forgiveness. I hope my coworkers remember me in the same ways but in the vein of honesty, maybe I’m even tattooed in someone’s brain for something negative, although I hope not. Nobody is perfect. Legacy is inherently built inside of a family, including a hospital one, and I believe there is value in pursuing a memory that leaves a mark.

A woman wearing white shoes passing out pills to psych patients probably never though she would end up being the subject of a blog post one day. I would venture to say the same thing about us. We simply cannot understand the ramifications of our actions and how they may alter the future. Life is ironic like that. We remember faces long after we forget the names.

We remember the stories, long after the people have faded.

 

 

The What, Why, and How of RN to FNP

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When I talk to people outside the medical profession, I often get asked, “so why are you becoming a nurse practitioner? Isn’t that a lot of school to essentially do the same thing you’re doing now?” I smile. I explain. I do my best to educate. But I still wince at that question because many, many people do not understand the difference between a nurse and a nurse practitioner. The tide is slowly moving in the right direction as nurse practitioners become more prevalent but there is still a huge knowledge gap in the public.

With my friends within the healthcare world, the questions are quite different. “Why did you decide to do FNP?” or “How much time do you really need to commit to school?” or “How in the world are you doing that school along with everything else in your life?” All valid questions based on real concerns. Deciding to become a nurse practitioner is a big career move requiring time, support, money and a huge portion of your sanity. This is part of my story along that journey.

Ever since I graduated from nursing school in 2009 I knew that I wanted to eventually get my master’s and become a nurse practitioner, even before I really knew what that entailed.  To be honest, I didn’t have a whole lot of backing behind that desire other than I had always been a “school person” and wanted to say I had a master’s degree. At that time I was nearly as ignorant as most people on the street about the qualifications, the education, the job description. I think I even revealed my professional plans in my “welcome to the unit” profile at my first job (so naive, not the smartest move). I just though it sounded cool and made me look like I had ambitions.

The WHAT: After a few years in the ICU I started to get a handle on where I could go with my career. I could stay in my unit and pursue a management position. I could go to CRNA school and live in the OR. I could stay where I was at as a RN. I could become a nurse practitioner. And a few more options that I never seriously considered.

After ruling out all the other possibilities for one reason or another, I decided on nurse practitioner only to discover that, like nursing, the NP job description varies intensely from position to position and environment to environment. I could become an acute care NP and work nights in the ICU responsible for thirty very sick patients. I could move to a specified clinic like nephrology or neurology and work solely with those patients. I could transition to outpatient and pursue a career in something completely foreign like family practice. And that’s ironically what I chose.

The WHY: Why did I choose family nurse practitioner over the other varieties? The standard reasons are obvious: no holidays, more money, less time on my feet, more responsibility. I wanted a weekday schedule with no weekends and holidays. I have a young family and it’s difficult for me to spend twelve-hour shifts away from my baby plus I’m tired of fearing that I’ll have to work on Christmas. I was also weary working in a job that required so much physical exertion. Turning large male patients, standing on your feet for hours on end, and sometimes not being able to take a lunch break until 3pm are all taxing on your body. I know I just turned thirty, but I could see the future and it was full of back problems and tired feet. I didn’t want all that exertion for the rest of my professional career.

The most professionally motivating reason for my career change was that I wanted more responsibility for patient care. I had finally gotten to the point where I wanted to write the orders instead of take them and felt that I had enough experience to take that step. I had always been afraid of such great responsibility (and rightly so) but I had gained enough self-confidence to know that I could learn and practice and become a proficient, caring provider. And while it’s the least romantic of my motivations, a better salary was definitely on the list. Getting paid more money for less physical labor is always a good thing.

But the question of why I chose FNP over ACNP (acute care nurse practitioner) also puts me in a honest place because I’ll have to give you an honest answer. The most compelling reason, the one that comes from a deep place in my heart, is that I was tired of seeing the worse case scenario day after day. I was heartbroken from seeing family members weep and watching people kiss their loved ones goodbye. As much as I loved the intensity of the ICU setting- the adrenaline of codes and the significance of standing in the gap during those crucial moments- I wanted something different. I wanted to work normal hours and to treat happy kids sometimes and to forget that those terrible, horrible things happen everyday. To those of you who are in that setting as ACNP, I respect you more than you can know. You’re dealing with vast responsibilities and dying patients and desperate families. You’re in a different spot than me and it’s a good thing we’ve both found our individual callings.

The HOW: So I applied for a FNP program at a local university, got accepted, and signed up for my first class. However, it didn’t quite work out like I had planned and I will tell you a slightly embarrassing secret about my journey through NP school. I took one class and quit in 2013. I had thrown myself into my nursing graduate research class for that entire semester only to discover upon completion of the class that I did not have the stamina for the program. There were many reasons behind my decision to not resume school, mostly to do with my tenuous health at the time, but I felt embarrassed. I had touted this new career ambition to almost everyone and then found myself backtracking, having to admit that it was too much for me right now.

When I think about that decision now, I see clearly that it was the right call. I wasn’t ready to take on life as a FNP. Two years later in 2015 I started school again and now here I am only two classes away from graduation. During that interim time period I took a new position in the ICU and gained valuable experience that I wouldn’t have had otherwise. So for those of you who find yourself in the same boat, don’t give in to the voices of guilt or shame or insufficiency. Maybe it’s just not the right time for you and there’s nothing wrong with that. Maybe it’s not the right career move for you at all and that’s ok too.

I’m not going to discuss choosing the right NP program because that is a whole other blog post in and of itself. There are a plethora of programs and they each have varied requirements, advantages, and disadvantages. Since I have a daughter, I chose a program that had all the didactic course work online followed by three intense semesters of clinical. I will say that online school is not for the faint of heart- you have to be disciplined and self-motivating. You have to make time when you don’t want to study. You have to stay up late and get up early and make your school work a priority in the midst of everything else you do in life. It’s grueling but in my case, it was worth it to not have to travel to school and find someone to watch my daughter. Choosing a program is a unique decision and you should be prepared to do some investigation.

Finding clinical preceptors is also an arduous part of this journey. Wait, let me rephrase that, an exhausting part of this journey. For my school, I was left on my own to find preceptors, which meant pleading for friends and family to help me. I emailed NPs and never got a response back. I cold called offices and never heard a thing. I did end up finding three fantastic preceptors in my area but that was only because of nice friends who put me in contact with their provider friends. This is where the word networking comes into play. You can never underestimate the value of establishing good relationships with other people in the medical world. If you’re trustworthy, kind and smart, they’re likely to endorse you to other provider friends but if you bad-mouth other people, seem uncompassionate towards your patients, or don’t care about your job, you may have a harder time finding someone who will spend a chunk of time investing in you. In short, make friends and don’t burn bridges.

Remember, preceptors for a NP program (MDs, NPs, PAs) aren’t getting paid to teach you (unless you’re involved in a paid preceptor program). They are giving of their time and energy willingly with no guarantee of a return. Ideally, I would like to get a job at one of the sites that I worked at during clinical because I already have an understanding of how the clinics work, the types of patients they see, and the responsibilities that I would be asked to take on. In this instance, it pays off for everyone because the clinic doesn’t have to spend as much time training you, but this isn’t the norm.

Making the jump into graduate school isn’t for the faint of heart. You have to have a clear vision for your future and be motivated enough to stick with it. You need the support of your family and friends and your job. You will have to give up some things now for a better return later. And if you stumble along the way? Forgive yourself. Nothing in life ever goes the way that we think it will.

I hope this gives you a glimpse of what it takes to go from a RN to a FNP. I hope you can understand my reasoning and my desires. And I hope, if you’re sitting at home contemplating these same things, that this helps you along your journey.

Go get that MSN.

 

The Bottom of the Ladder

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Nobody likes standing at the bottom of the ladder, gazing up at everyone above and knowing there’s nothing but time, labor and learning that will get you any closer to the top.

It’s a well-established phenomenon that nurses have a hard time transitioning from expert nurse to novice nurse practitioner. This makes sense- you’ve gotten really good at your job, knowing what every medication does, what those labs mean, what the physician is going to order next- and now you’re back at the starting line, feeling more insecure than ever, hating the fact that you don’t have all the answers anymore. If you stayed in your area of nursing experience, I can imagine that this transition is less jarring since you’re already accustomed to your future role but I think regardless of where you came from, the rules are different as a NP. And this can make for some serious anxiety.

If you’re entering into a new clinical environment like me then this transition may leave you feeling breathless, alone and scrambling to catch up. I spent my first six years as a nurse in a surgical ICU learning how to titrate vasopressors and check for compartment syndrome and draw ABGs. I will be thankful every day of my nursing life for the experience of learning to handle such acute patients in a tenuous environment because it gave me an extensive knowledge base about both medicine and people. Over a period of a few years, I rose through the ranks, climbing up the rungs, and finally found myself near the top, confident that I could handle any trauma patient that rolled in the door. But  since I had always wanted to pursue a career as a NP, I felt it was the right time to move on and grow in my capabilities as a nurse.

So after years of hospital life now I’ve entered into the world of clinicals in a family practice outpatient clinic. On the first day I asked, “where’s the crash cart?” and everyone looked at me like I was crazy. Eventually I found the AED and that was it. They didn’t even have an IV start kit! Every bone in my body was rebelling, thinking what in the world would we do if someone codes? Call 9-1-1 and start CPR like everyone else, I suppose. The outpatient setting is vastly different and at first I wondered whether I would enjoy the slower pace or whether I would be sitting at my desk the first day of clinical thinking, oh my gosh, have I just wasted the past two years of my life? But thankfully, I have adjusted more easily than I even thought possible, finding the challenges of a clinic different but not less than, still experiencing the thrill of seeing patients except these patients can actually talk to me.

With two clinical semesters to go, I am still at the bottom of the ladder, dreaming about the breeze of graduation on my face and yearning for the freedom of practicing on my own in the high, clear air. After doing online classes for the past two years, I found that I had in fact learned a few things but I still came home everyday with more questions than answers. I spent my hours at home looking up articles, listening to podcasts, trying to be better. Fortunately, I had a preceptor who allowed me to ask dumb questions and look up answers and Google pictures of skin rashes. He made no ultimatums; he didn’t shame me in my ignorance and for that I will forever be grateful. Plus, I quickly realized that even after years of practice, you never stop learning. You never stop reading articles. You never stop changing your care plan based on the newest evidence. In short, I will be a learner for the rest of my career.

I had so many instances this semester where I felt out of my league. Patients who came in and hadn’t seen a health care provider in forty years. Patients with hemoglobin A1C levels so high the point of care machine couldn’t even calculate it. Patients with feet so disgusting that I literally didn’t know if I should send him to an emergency podiatrist (do they have those?) Patients who told me they had thought of committing suicide. Patients that were medical minefields with a list of diagnoses several pages long and too complicated for me to navigate without some help. Patients who asked me point blank what I should prescribe, in front of my preceptor, and I had to admit that I didn’t know. I was out of my league and that’s just part of adjusting to a new role, of being a student.

Even with my preceptor as a safety net, I still feel the weight of the job like a heaviness in my chest, the responsibility crushing at times. There is a holy reverence when you’re taking care of another human being because they’re putting their trust in you. They look you straight in the eye and believe what you tell them. They listen and consider and take the medication you prescribed. So even though I long for a day when I feel comfortable in my new position as a NP, I can’t too easily wish the anxiety away because it’s going to keep me from getting too comfortable and making a mistake. Hopefully, eventually, anxiety and reverence fuse, leaving me a great nurse practitioner with a holy level of fear.

Am I nervous every day that I show up to clinical? Of course. Will I carry that anxiety with me as I graduate, get a job, and start practicing? I’m sure of it. It’s like when I started in the ICU as a RN and someone told me it would be about a year before I was able to come to work and not be terrified that I was going to kill someone. And they were right; it took me a year to feel comfortable there. It’s like that. From what I’ve heard and read, there are some factors that help lessen this anxiety but nothing replaces years of experience.

So here I am, at the bottom and climbing my way back up. It’s a different ladder of course, one with no weekends and holidays and better pay and different responsibilities. It’s comforting to know that I’m not alone; that every nurse practitioner student in the world probably feels the exact same way- excited, nervous, and a little bit terrified at times. There is hardship in this transition but there is payoff too, mostly in the faces of the people I help or the exultation of knowing I made the right call. There will be falls along the way, missteps. Scraped knees and elbows as I try to hang onto the rungs.

But despite all the challenges, despite those days when I wonder if I can do this, I’m confident I’m headed the right direction. I can see the top from here, and it will be worth it.

 

A Clinical Conundrum

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Have you ever found yourself in a sticky situation with a patient? Of course you have; we all have. I recently found myself locked into an awkward moment with a patient during my FNP clinical rotation, unsure of how to proceed. I had to navigate around the issue of divulging personal information and I was unprepared. Do I share my own story with her? Do I hold back and hope that she can find commiseration someplace else? What do you do when you get shoved into these tenuous situations with patients? I don’t think there’s one right answer. It’s not black or white; it’s not a clear divide drawn in Sharpie, although we all wish it would be that easy. No, it’s simply a blurry, gray pencil line that leaves smudges all over you no matter which direction you go with it.

When I was young, unmarried, and working in the ICU I had my fair share of sticky situations, most of them surrounding requests for my phone number. A grandfather patient asking on behalf of his couch-potato grandson (yeah, that sounds promising) or creepy older guys who think it’s funny to make jokes about nurses giving bed baths (let me go find our two hundred pound male nurse and he’ll help you). People get delirious sometimes; they make statements or assumptions that are inappropriate because they’re on narcotics or recovering from head injuries. So, to some extent, you can easily forgive them their verbal fumbles.

Now that I’m a bit older and in the outpatient environment I don’t encounter those invitations as much anymore (probably thanks to that ring on my finger) but I still have awkward moments with patients, mostly around revealing information about my personal life. It’s a fine line that creeps up from time to time and I found I wasn’t trained for it.  Nobody tells you in school how you should act or react to personal questions, probably because it varies with each patient and situation. Sometimes you develop a relationship with a patient and voluntarily want to share more intimate aspects of your life. Stories about your kids, details of your recent vacation with your husband. In these cases, those topics come up naturally and since you both recognize the inherent formality to the relationship, you feel free to share personal tidbits and look forward to seeing that patient again in three months.

Other times patients press, wanting to feel like they know you, searching to get some need met from your relationship that falls outside the boundaries of professionalism. These needs can be obvious or complex. They want to be best friends or they want to manipulate or they’re desperate for attention. They have good intentions but it comes out wrong. They feel like they can’t talk to anyone else in their life so they completely unload on you. These conversations sometimes leave you feeling unnerved and you know that this patient isn’t capable of putting in appropriate stops in your relationship right now. But not every case is clear cut. It gets sticky. And if you actually talk to your patients when they’re on the exam table, you’ll surely encounter this problem at some point. You have to learn to straddle the amorphous line between being a healthcare provider and a friend, a listening ear and a professional.

To be fair, the inverse can be true. Sometimes healthcare providers are searching to get a need met from a patient- approval, attention, friendship- and it can make the patient uncomfortable. In short, the door can swing both ways.

I’ll share my recent example. One day we had a middle-aged woman with autoimmune complaints come into our clinic, so exhausted she could barely sit up in the chair. I had never met her before so I went into the room prior to my physician and talked with her about her chief complaint, did a focused history and performed a physical assessment. From the instant I saw her, my heart hurt for her. Between bouts of crying, with mascara staining her cheeks, she related the events of the past few months- how she had gotten sick out of nowhere, how she couldn’t get out of bed to go to work, how she felt useless to her family. She described a whole host of physical symptoms- fatigue, joint pain, and an inability to eat- and I knew how she felt. It was all too familiar. It was like listening to myself talk years ago when I went to the doctor’s office, desperate for help.

What this patient didn’t know is that I had been diagnosed with an autoimmune disease eight years prior and had struggled along the roller coaster of a relapsing-remitting condition ever since then. I knew what it felt like to be so tired that you can’t even get up and take a shower. I knew the physical symptoms that come from having an autoimmune disease. I knew how depressing it is to feel worthless, useless, permanently glued to your couch and addicted to prednisone.

She was understandably angry. Life had dealt her a harsh hand and she wasn’t coping with it well. She was bitter and hurt and experiencing all the emotions you would expect to feel if you were confronted with a life-long disease that you didn’t ask for and didn’t expect. As I gently asked more questions, she grew more and more hostile. She was taking out months of frustration on me and I couldn’t blame her for it. The conversation culminated when I said, “I know how you feel,” and she shot back sarcastically, “really? Do you know what it’s like to have an autoimmune disease?”

Ha, if she only knew. And I immediately started to feel conflicted. Do I share with her that I have a similar condition? Is it appropriate to commiserate that way? Would it make her feel better or make her feel like I was invalidating her feelings? I had no idea what to say and all the words stuck in my throat as I sat paralyzed in indecision.

Without knowing the right answer I blurted out, “actually I do. I have a similar autoimmune disease and I know how you feel. I’m so sorry you’re going through this.”

And the woman broke. Before I knew what was happening, she was bawling, telling me how hard things have been and expressing relief at being able to talk to someone who understood. I held her hand; she cried some more. We finished talking through the necessary components of the visit and then she actually smiled. I hadn’t done anything profound besides write a prescription for some prednisone (the best and worst drug in the world). Mostly I had helped her feel like she wasn’t completely alone. Someone else knows how you feel. Someone else can relate. It won’t always be this hard.

Was that the right thing to say? Should I have kept my big mouth shut? I don’t know. In this case, she responded well to my confession. I saw her several more times during my clinical semester and she remembered my name, asked if I was going to be there during her appointment. I gained her trust and while I still tried to keep the focus off of me and not reveal many specific details of my condition, we developed an appropriate, professional, beneficial relationship.

Afterwards, my preceptor and I discussed the situation. He laid out the pros and cons for me like I’m trying to explain it to you. Both extremes of the spectrum- sharing too much or not relating to your patients at all- can be detrimental. You’re a human being too and your patients should know that. You have a life, a family, your own issues. But you need to be self-aware enough to know when you’re searching to get a need met from a patient relationship. You need to be able to stay professional. In the end, he thought I had made the right call and I let out a huge sigh of relief.

There were other times during the semester when I had patients with similar complaints and I didn’t share my personal experience. Why not? I have no idea. I guess I just listened to that voice in my gut that whispered yes or no, and I went with it. Call it clinical intuition. Call it timidity. Call it whatever you want- you know what I’m talking about.

This topic of divulging personal information with patients is complicated and I make no claims to have it down. I’m not even suggesting approaching the issue from one side of the spectrum or the other- simply relating my own experience. I know I will have to continue to navigate these blurry lines for the rest of my career because I want my patients to know that I care. But I also want them to know that I’m competent and professional, someone they can trust with their life and sensitive information.

We all find ourselves in sticky situations every now and then because medicine is tricky business. Dealing with people is tricky business. We’ve all regretted saying or not saying something to a patient. And we all will have to find our own way of managing the tightrope of professionalism and friendship. It’s blurry; it’s difficult. We all walk around with smudges on our cheeks. But for the sake of our patients and ourselves, I believe it is a line worth walking.

A Collector of Stories, a Reader of People.

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Everyone who sits in the chair or lies on the bed is there to tell a story.

Some stories start with a misadventure- a careless turn taken on an abandoned road or a flailing, drunken mouth at a local bar or a pop that came out of nowhere, annoyingly enough, and is now here to stay. Some are more memorable than others- breaking a bottle of Tequila on your foot for reasons that no one can quite figure out- and some are less romantic like a contagious illness acquired from a sick kid or a bland case of persistent indigestion. Despite the circumstances, the patient still ends up in the office, led to your chair by an element of surprise. Very few people come to the doctor’s office willingly, on a good day. Usually there are wrinkles in the story. Something has to change the direction of the plot and that is the reason for same-day appointments, plain and simple.

Other stories are more despondent, predictable, birthed from the same relentless situation of getting old. Cartilage does not rejuvenate itself; knees do not grow on trees (as much as the orthopedist might want you to believe otherwise) and people are not getting any younger. No, they are not, they are definitely not. No one can cure inevitable decay, just delay it as long as your insurance will allow, and many stories are repetitions. Slight deviations from the usual, symptom-riddled routine. Tentatively turning the page of a book that may snap shut any moment.

Regardless of the reason for the visit, there is always more to be discovered in the story. Always more details and more complications and other diseases waiting to emerge on a routine set of labs. There’s always more because people are vast and endless, full of the unexpected. People are the most complicated subjects in the world and I get the pleasure of trying to decipher them. To learn to read them.

There is always more to the story.

So what is my job? To find out the particulars of the story. How do I do this? By asking questions. By gaining facts, collecting them in my mind like a child gathering polished stones. At first glance it seems formulaic and in many ways, it is. These formulas are exactly what is taught to all the students who have degrees that enable them to ask such questions. What brings you in today? When did that start? How long has that been going on? Occasionally, you’re allowed to ask a question like How do you feel? but even that is too esoteric for everyday use, a special indulgence reserved for an open afternoon on a boring day. Most of the time it’s a fact-finding mission. Does it hurt a little or a lot? Is it acute or chronic? Can you walk on it? Has this ever happened before? The questions are the title page, the introduction, the scattered highlighted portions that catch your attention as you skim through the chapters. These are the facts.

Some people only tell the bare minimum while others, let’s be honest, tell far too much. Sometimes you’ve already done a full assessment, ordered all the appropriate labs and medications, written the discharge summary and the patient is still telling you unnecessary details, much to your chagrin. That’s where practice comes in- being able to to navigate to the right details, ask the right questions, make people feel like their story has been heard, and still get them out then door feeling satisfied with the plan. You become a narrator, guiding them towards a path you think is the best course of action or leading them away from a more deleterious one, from those singed, cigarette-smelling pages at the end. Sometimes your efforts work and everyone leaves happy and on time. Sometimes you spend the rest of the afternoon frantically trying to catch up. And in almost every circumstance, the extra time is worth it because certain people need a little extra listening, to know that their story is weighty and unique and significant. They need to know that their story matters, even to you.

The real down-in-the-dirt interesting part comes when people won’t tell you some vital detail of the story, something that you know may change the crux of the plot and the direction of your diagnosis. These questions are trickier and consist of types like: How many beers do you drink per night? Would you like to be tested for sexually transmitted infections? Have you ever thought of harming yourself? I try to be an unobtrusive as possible by explaining that I ask everyone these questions and I don’t judge; I just need to know the truth. It’s even more fascinating to watch someone unweave a tale they just told you, realizing that they’ve gotten themselves in too deep. The wiggling in the chair, the lame excuses, the backtracking that has no end. Don’t get me wrong- I’m not trying to catch anyone in a lie- but those things have a way of rising to the surface when the patient is lying naked with a hospital gown on, even without my questioning. A nakedness of the soul, if you want to think of it that way.

Some people think they’re lying successfully but it’s almost always painfully obvious that you drink more than one beer a night or that you haven’t been checking your blood sugars, especially because I’ve become accustomed to patients lying to me from years of being in healthcare. (And even if I miss the deception, labs are always unsympathetically honest). People will try almost anything to get away from shame and sometimes you have to leave the visit in the discomfort that there are pages that the patient simply will not allow you to see and you must do your best despite that reality. It’s unfortunate but I cannot force my way into a story that I’m not invited to read.

It’s even more invigorating to watch someone divulge those details to you willing after you’ve established some trust. They recognize that you have to see all the pages, like an editor who must know every upcoming plot twist, and that they will ultimately suffer if they hide sections from you. They tell you their story; they let you in. They admit things that even their spouse doesn’t know, emotions that they’ve locked away, memories that made them who they are today. It’s a humbling experience, reverent almost, and you don’t forget those visits easily. Those are the lines that you memorize and hold close to your heart, the pages you reread on the days when you wonder if you’ve gotten into the right profession.

And then it doesn’t just stay their story- you enter in. You become a character and establish yourself in a scene, as a life-altering influence who informs them of a cancer diagnosis or a reoccurring character who resurfaces every so often to fix a smudge or wipe some tears and then recedes into the background until needed further. My story blends with theirs, just for a twenty minute appointment, and suddenly we have shared memories, communal pages. That is the true magic of medicine, the part that I fell in love with a long time ago. It’s the part that keeps it all so darn interesting and keeps me wanting to go back and read more. I am a collector of stories. I am a reader of people.

People never get tired of telling their stories and I hope I never get tired of hearing them, of turning pages that always end up surprising me. I am in love with the narratives of the people who wander in to see me. I am infatuated with being a part of a bigger story than my own. I am a nurse practitioner (or at least well on my way to being there) and a storyteller at heart.

And, strangely enough, I have figured out that those are really the same thing.

The Thing About Clinical.

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Here’s the thing about clinicals, and it is may be the most important thing, I love it.

After doing two years of online class, squeezing in study sessions whenever I could as I chased around a toddler, I am out of the house and going to clinicals twenty hours a week, working with a family practice physician at a family practice clinic. I will do 180 hours over about 11 weeks this fall and again in the spring before finishing up with 360 hours before graduation sometime towards the end of next year. And while the concept of graduation has always felt like a mirage, a distant and unrealistic possibility, I’m starting to be able to taste it now and feel like maybe it will eventually happen.

I absolutely love being a primary care provider (in training), a notion that I was honestly wary about the closer and closer I got to clinical. But I only have ICU experience! What if I go and hate it and all this school was a waste? What if I think it’s boring compared to the ICU high-stakes? What if I end up completely not caring about someone’s sore throat and wishing that they would code in the office instead? Yes, these are real questions that I have had and I’m trying to be honest about my hesitations, as silly as I see them to be now. I had real and tangible doubts about switching to such a drastically different work environment and those were not insignificant.

So, what do I think now? Would I jump into action if someone coded at our office, letting my ICU adrenaline rush back as I pulled out all those life-saving skills that I have grown so fond of? Yes. Of course. I would love that. But there is something SO NICE about knowing that you can stop and go to the bathroom before seeing your next patient and that you don’t have to go completely nuts if you get behind in your morning. No one is going to die if you don’t get in there and look in their ears RIGHT NOW. No one is going to crumble with a hemoglobin A1C of 8 while they’re sitting on that examination table. No one’s life is hanging upon how quickly you can put in those orders for thyroid labs. It’s freeing and it’s still taking me some time to get used to. And even more importantly, I feel like I’m making a huge impact doing primary care, keeping those people from ending up in the ICU to begin with.

I’ve had to be careful not to live out of my ICU experience, which has been harder than I would’ve thought. It’s frustrating to be so good at your job and then suddenly back at square one, wearing a student badge, not knowing what to do with that growth on my patient’s arm. Is it a mole? Is it cancer? Can I just pretend I didn’t see it? It doesn’t matter anymore that I can put together a ventriculostomy and help a neurosurgeon insert it. It doesn’t matter anymore that I can use a rapid infuser and get several pints of blood into a patient in only a few minutes. It honestly doesn’t really matter that I can code a patient because my physician has never had that happen in his office after twenty-five years of practice.

So are all those skills a waste, all that fine tuning of my nursing expertise? Should I just shut up about all the things I’ve seen and done (and some of them are QUITE ridiculous btw) or can I use all of that prior experience somehow? Well, I think it’s a little bit of both. While I have had to stop telling stories of my glory days as if that makes me more legitimate, I have gleaned something from seven years in the ICU and that brings me to my second point: I’m actually, surprisingly, doing pretty well as a PCP.

My physician came to me last week and told me what a good job I was doing, that he was really surprised that this was my first clinical and that I was a natural at this. You cannot even imagine how much those words meant to me. After two years of getting no feedback other than grades on tests, I finally got some real-life affirmation that I made the right decision in going back to school and that I will end up in a job that I will excel at. He went on to describe the difference between the medical residents (who have had no real patient interaction before) and me in one slightly amorphous but significant variation.

He said I’ve got really good “clinical judgment,” which basically means that I can tell a mountain from a molehill or “see through the BS,” as he also put it. When the woman comes in talking about her ankle pain, giving me details as I ask questions and dig a bit deeper, I can somehow tell that she wants to talk about getting on medication for depression instead of treating her ankle. When the schizophrenic teenager comes into the office complaining of abdominal pain, I can somehow figure out that she just wants to talk and there is absolutely nothing wrong with her belly. When the older lady comes in wanting an MRI for knee pain, I can see that it’s osteoarthritis rather than an injury and a MRI would be a waste of time for her. Some of it is reading people, some of it is physical assessment skills, and some of it is just remembering all the stuff I’ve learned over the past two years.

While this ability to distinguish between what the patient is saying and what they really want seems innate to me, apparently not all providers have this. From what I’ve heard, many physicians have to learn this over a long period of time, while I seemed to have picked up this intuition from years at the bedside. I’m not saying I’m better than any of the residents I work with; we just have different acumen at this point acquired from our different backgrounds. And if you think about it, it makes sense- people are just people and you get good at dissecting them, reading between the lines, getting to their true needs the more time that you spend with them. So it seems that all my ICU experience has not been a waste and although I’m not using the same medications or doing the same procedures, I have become pretty good at reading people and that’s more important than I could’ve realized.

And despite my initial preconceived notions, primary care is anything but dull. We had a man walk in off the street who hadn’t seen a doctor in twenty years with feet that were practically necrotic from years of uncontrolled diabetes. I saw an entire family in the same exam room, each with bipolar, who all wanted Adderall and antipsychotics, and I barely got out of the room in under two hours. I had an older woman tell me very seriously, to my face, that “sugar is the new smoking” as she divulged her health plans to me. I’ve had people ask me about getting their animals registered an emotional support animals, which I had no idea was even a real thing. I had to bite my lip as a young male patient explained the intricacies of martial arts to me, with an in-office demonstration.

I have met so many interesting people, some of them nice, some of them grumpy, some of them fastidious about their health care, some who haven’t ever been to see a health care provider, all in only a few weeks. People are just people! Same as they are in the ICU or at a clinic or walking down the street. And people never fail to provide entertainment.

Finally on a personal level, starting clinical couldn’t have come at a better time for me. After our recent pregnancy loss, I needed to get out of the house, to feel valuable, to feel affirmed, and to feel like I still had a future full of hope. And thankfully, I have felt all of those things. Evy seems to be doing fine with the transition and I enjoy only having to split my week, not devote all of it, to work. Seth and I are working as a team to make sure that groceries get bought and dinners get made, and after all the hard things that have happened for us over the past year, God allowed this one thing to go so very right. And I’m so very thankful.

I’m sure I’ll have more stories to add as the weeks go by but I wanted to give you a glimpse of this wonderful new world that I’ve entered into. Thank you to everyone who has prayed for us over the past weeks or months or years. Life is painstakingly hard sometimes, but it is worth it and we have no option but to move forward. So forward I go, into this new world of prescribing metformin and writing for thyroid labs and learning way too much about SSRIs.

It is going to be worth it. It already is worth it!

Not Just Math and Science

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I recently remembered something that I had pretty much forgotten: being a nurse requires creativity. Being a nurse means you are a creative person.

Let me back up. My husband and I have been talking a lot about creativity lately- what it is, what it means, what it looks like- because our definitions have grown very skewed, a veil over our eyes that has kept us from being able to identify it in ourselves. It’s not that we aren’t creative or full of ideas; we just have been labeling it as that. And that truly is a loss, as we have discovered.

For most of my life, I have equated creativity with artistic proclivity such as the ability to draw or paint or sing, usually materializing in the form of someone with brilliant tattoos who carries around an expensive camera at their side. Someone carefree and whimsical, someone with visions of grandeur and a disregard for menial things like budgets or timelines. And that is definitely not me. Before I started really delving into writing, which is very clearly a creative endeavor, and before my husband started calling out these qualities in me, I saw myself as linear, rationale, organized. I even had a nickname of being the “rationale” one, which I never really contested, although I always felt a bit hurt by the label. I didn’t want to be uncreative (aka boring) and I didn’t want to always be the reliable one. But in the midst of a strict nursing schedule, work out schedule, and stringent eating requirements, I figured everyone else was right. I wasn’t creative.

To make a long story short, my husband Seth has helped me over the years to realize that I am not only very creative but that even during that time- when I was working full time and seemed to be very organized- that I was operating in creativity because I was a nurse. And nursing requires a very unique type of creativity that many nurses don’t realize. And I’m writing this blog post because I wonder how many nurses feel the same way? That you are the sum of rules and time tapes, medication deadlines and charting restrictions, rather than dynamic problem-solver who manages one of the hardest jobs day in and day out. Admittedly, it is less fluid than being a freelance photographer but it’s no less artistic. I’ll show you what I’m getting at.

Say you have two ICU patients, one is sick and you’re titrating Levo and Vaso and running fluid boluses. You’re managing a vent, a feeding tube, an A line, a central line and you’re busting it to make sure the bags don’t run dry, the pressure doesn’t fall too low, the patient gets turned. Now in your other bed, you’ve got a walkie talkie who needs ice chips and to take a walk and some help in using the urinal (omg seriously, can you not do it yourself??) But you’ve found yourself in a tricky situation where you’re needed in both places and yet you can’t be there. You’ve got to find a way to elicit help from others, delegate, and prioritize in order to keep everyone safe. In that moment, you’re not worried about getting your charting done on time; you’ve realized that there are bigger things going on and that you’ve got to find a way to make it all work. And you do. If you’re a bedside nurse, you’ve got loads of creativity leaking out of you as you problem-solve every hour of the day, as you communicate with difficult family members or staff, as you form a picture in your mind that is so much more than tasks. As you impact people, who are so not linear.

When I was functioning as the family care nurse in the ICU, helping to coordinate donor patients, family meetings, and a whole host of other miscellaneous jobs, I had an encounter where I found myself completely in over my head. A grandmother was dying and the family was bent on blaming someone, so naturally, that became anyone in sight. The physicians, the hospital, even me. They were grieving an inevitable, natural death but they didn’t know how to process it and so the situation became riotous. With the entire family running back and forth from the hallway to the room, yelling and cursing, shouting into the air, it was my job to do something. They were scaring the other patients and it was quickly approaching a level where I would need to call the police to intervene. This kind of behavior wasn’t good for anyone and it couldn’t go on.

Then I did something that was risky and possibly even uncouth, based only on a gut feeling, a thick skin, and the kind of courage that only a nurse can have. But I did it because I was responsible for finding a solution to this problem and I would go down trying. At 26 years old, barely strong enough to pull a woman twice my size, I dragged the mother, the leader of this family riot, into the hallway and out of the ICU. Once out the door, I whipped her around to face me while she kept yelling, not even saying comprehensible words, and with my blue eyes blazing, I told her to shut her mouth, probably in about as many words. I will never forget the look on her face as her jaw dropped to the floor, stunned into silence. She immediately stopped talking, probably out of complete shock that this tiny white girl would command such a presence before her, and started to listen to me. We stood in the hallway and I explained, clarified, comforted, snapped her back to the reality of the situation and twenty minutes later she was hugging me and thanking me for bringing her back down to earth. Was that rational? Definitely not. Was it even the most logical solution to the problem? Probably not. But thank God it worked because I had to get creative to stop the mayhem and restore order. I had to find a way to make this better.

As I prepare to start NP clinicals, I find myself training for similar scenarios, ones that require a depth of understanding and communication that goes far beyond training in a classroom. Skills that only come from experience and freeform thinking, skills that are born out of creativity. How do I get someone who has been smoking for thirty years to consider quitting? Do you think telling them that smoking is bad for them and that they should quit is going to work? No, it won’t. They’ve heard it before. But if I can get them to think about what they might lose or how far they would have to get before considering stopping, then maybe I’m getting them somewhere. Closer to where I believe they should be. And this is only one of so many scenarios that I will encounter in primary care that require finesse in order to solve.

Everyone has heard from a nursing instructor or a textbook that nursing is an art, not just a science. But I wonder how many of us have lost that realization, who don’t acknowledge that what we do everyday requires intense problem-solving, creative solutions, and out-of-the-box communication? It’s more than giving meds on time, keeping people from dying, clocking in and out, and administering health advice as a provider. Being a good nurse or NP requires accessing that core creativity that each of us possesses and using that to excel at our jobs.

Some people probably doubt that creativity inside of them and that’s a shame. It’s part of what makes us human, relatable, and worthy of confiding in. But it’s true. Nursing is so much more than math and science. In fact, I would venture to say that nurses are some of the most creative people in the world.

Hypochondria of Advanced Medical Education (H.A.M.E.)

 

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Hypochondria of Advanced Medical Education (HAME) is a spectrum disorder ranging from acute to chronic that occurs when a person overreacts about his or her own medical problems due to an overload of knowledge about disease and dysfunction. This leads to distortion of reality and the inability to rationally process. Risk factors include being a healthcare professional, being a student in a healthcare field, having a type A personality, stress, and having comorbid medical conditions. This disorder can also occur in people with no prior medical issues. It is most commonly identified in healthcare students, ranging from medical students, PAs, nurse practitioners and others. This condition is the result of the constant inundation of comprehensive information regarding every disease known to man.

In this disorder, the student does not use rational clinical judgment and decision-making skills in diagnosing his or her own symptoms. Instead he or she reverts to a primal state of panic, throwing out the most likely benign diagnoses and instead attributing even the smallest of his or her ailments to catastrophic disease, nearly all of which lead to death. Of note, this only occurs for the individual herself and does not apply to her ability to diagnose others, except in the case of the student’s children, which only seems to intensify the symptoms. Usually the student can make accurate and rational diagnoses for non-blood related individuals but cannot apply those same algorithms for themselves or immediate family. For family members, this turns into sheer panic and an in-depth study of all possible ailments starting with the most life-threatening. The disease ranges from mild to moderate to severe, which is classified as the insomnia-producing, worst-case-scenario-imagining, assumed-to-be-life-threatening form.

Some examples include:

  • Diagnosing ankylosing spondylitis rather than mechanical low back pain (probably due to lifting a 27 pound toddler on and off the potty 25,677 times per day)
  • Diagnosing hypothyroidism instead of general life-related fatigue (see above toddler)
  • Diagnosing a pheochromocytoma instead of anxiety (see above toddler)
  • Attributing excessive thirst to a pituitary tumor instead of increased dietary consumption of salt (hyperphasia of snack foods related to said toddler)
  • Diagnosing Meniere’s disease rather than sporadic tinitus that only happened one time (I was just feeling plain crazy this day I guess)
  • Diagnosing cancer instead of about nearly anything else (because it’s CANCER. Yeah, I’ll say it again, CANCER.)

Only non-pharmacologic treatments are available at this time and include cessation of all activities that provoke the hypochondria including studying, mental rest in the form of binge-watching frivolous TV shows, margaritas, getting back normal lab results, and hearing a radiologist say “yes, you are actually perfectly fine.” Studies are currently being conducted on the use of Xanax for this disorder and counseling from a spouse has only shown negative outcomes. The only cure currently is removal of the individual from the healthcare setting but because this is unrealistic, studies show the next best treatment is completion of the advanced medical education. The disease seems to dissipate as the provider increases in skill and knowledge, although many providers never experience complete cessation of symptoms.

If you’re a family member of someone with HAME, there are support groups available for you, most likely in your immediate area. The best thing you can do to love and care for your family member is to support them during their education and let them give you as many physical examinations as they need to in order to feel that you are healthy and not dying of an obscure autoimmune disorder.

If you suffer from HAME, you’re not alone. I am sitting right there next to you, assuming I have gastric cancer instead of indigestion. But there is hope. There will be healing. And until then, stop looking up all your symptoms on UptoDate. Choose the benign diagnosis, even when it hurts. And keep up the good work studying. It will all be worth it in the end when you get those extra letters behind your name.

You will be worth it, including every single one of your moles that is not melanoma.

They Called and Said They’re Thankful

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You may not feel appreciated at your job as you hang antibiotics and suction trachs, wipe poop and deal with dementia patients who are trying to escape. So I called a few friends who wanted to express their gratitude. I hope this gives you some satisfaction that what you’re doing day in and day out is, actually, very important.

Remember that woman who asked you to update her a husband, a boyfriend, and seven kids all (separately) on the phone several times during the day? She called and said she’s grateful. What about that guy who kept making the crude jokes about nurses giving bed baths? He said thank you (and he’s sorry about that). What about the septic, schizophrenic homeless man who cussed you out for twelve hours while you titrated his Levo and ran his CRRT? He sent a note, very heartfelt thanks (oh, and he wanted to mention that he’ll be back.) And then there’s the belligerent family member who you had to call the police on. Oh wait, everyone else says thank you for that. The family member definitely does not.

Then there’s your mom’s friend’s son-in-law. You remember, the intern who didn’t know a head from a foot and you successfully kept from killing anyone for an entire month’s ICU rotation? He’s a plastic surgeon now and he said you’ll be getting a thank you bonus check real soon. And you can’t forget the 400 pound lady who you had to push all the way to MRI, TWICE. And the family who asked you 46,578 times for ice chips. (sure, another cup? ok, well just wait a minute, I’m almost done. Can the pca get it? another cup, sure. it’s not cold enough? it’s crushed instead of cubes? it’s not made from Fiji water? DO YOU HAVE PICA?? LET’S GET A CBC STAT.)

Sometimes people actually do say thank you, bringing kind words, a heartfelt note or maybe even some cookies. Their words speak to our hearts and affirm our efforts- the pouring out of our souls for people we don’t even know. Other times people are too overwhelmed, or they forget, or they are unconscious. So even if they can’t or won’t say thank you, I will.

For all the times you’ve accidentally gotten splashed with urine a centimeter from your eye or had a Flexiseal pop out a few inches from your face, I say thanks. For all the times you’ve had to change scrubs during a shift. For every time you’ve almost gotten slapped by a delirious patient or bore the brunt of a family member’s exasperation. For every time you got stuck with double isolation… I’m grateful. For every time you sweated through your underwear during that burn dressing change. For the fact that you can smell CDiff from a mile away.

For all the TB patients. For all the times you had to travel with a TB patient. For every time the physician opened the wrong door to your TB patient’s room. For the fact that you’ve memorized the TB med regimen at this point. If I haven’t said it enough, you’re a rockstar.

For comforting that medicine doctor who cried for twenty minutes after sticking himself during a central line insertion (the patient did have Hep C by the way.) For all the times you’ve had to politely say “just a minute!” on the portable phone to your other patient as you do chest compressions. For holding a hand and wiping a tear while you watch the heart rate go flat. For charting long past your shift. For all the times you’ve patiently reassured people that Webmd is not the ultimate medical authority. For the number of times you’ve gotten a unit lecture on CLABSI’s. For all the times your friends have texted you photos of their rashes.

No one can disimpact like you. No one has trach suctioning skills like you. You’re a nursing gem, a diamond in the rough (or at least that’s what you look like most days). You get up at 4:45 am and get home at 8:15 pm. You can think of at least one shift where you didn’t pee for the whole 12 hours. Your kids think you’re a superhero, armed with shots and pills, taking on the demons of disease with one hand behind your back. There’s a reason they look up to you, a reason they tell their friends that their mom or dad is a nurse. Although you’re officially banned from telling stories at the dinner table. You’re doing a fantastic job.

To the patients and families who actually do say thank you, we appreciate it. We hold on to those moments when someone is yelling at us in a language that we don’t understand or a physician rolls his eyes (yes, I was right. That patient did need to go back to the OR.) And to the ones who don’t, it’s ok. We know that what we’re doing is bigger than a thank you. But in case you haven’t heard it in a while, hear me now.

You’re a great nurse. And we’re thankful for you.