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.

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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.

Here is the World.

 

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I’ve been trying to find the words for this blog post for a long time, actually long before I even stopped working at the hospital. Maybe it began when my daughter was born. I’ve talked about this shift before, the irreversible schism that happened in my soul once I had a child. My emotions expanded in ways I didn’t think possible; places of my heart that I had shut off became uncorked and years of suppressed feelings came pouring out like a waterfall. I changed and I started to think that maybe being an ICU nurse forever wasn’t feasible for me anymore, or at least desirable at this point in my life.

It really was a strange phenomenon. Suddenly with the addition of a tiny person in my world, all the pain and loss and heartbreak that I saw at work everyday and had been able to subdue, rose to the surface. I could no longer stuff it down or shut it away. My patients became real in a new way, as if blinders had been removed from my heart. Not that I didn’t care about my patients before; I just cared for them in an alternate capacity, one that closed me off enough from my emotions to be able to deal with these most heartbreaking moments of their lives. In many ways it had been protective and even beneficial. But I had lost that and it was making it very difficult to do my job.

All of my emotional volatility culminated when, a few months after I had returned from maternity leave, I was asked to take a fourteen year old boy who was most likely going to die from brain damage. By the end of my shift, we were coding him and I was staring at his mother’s face knowing that this was the end, for him physically and for her emotionally. It sounds very bizarre but I saw his life flash before my eyes in those last moments and all I could think about was how his mother had nursed him as an infant, chased him as a toddler, hugged him after his baseball games, and now held his hand as he slipped away. In that moment her pain became my own, tearing my insides in two, and I couldn’t imagine losing my precious daughter in the same way that she was losing her son. It was unfathomable. It was a tragedy. It was life and death. And I knew I couldn’t do it anymore.

Now, a year and a half removed from my ICU days, my life looks very different. I wipe a runny nose and fix lunches that my daughter may or may not eat, make a fool of myself chasing her around the playground and take the dishes out of the dishwasher day after day, the same actions on repeat. It is full of monotony and I can honestly say that’s been the best thing for me. I needed days where no one died. I needed to forget that terrible things happen to normal people everyday. I needed my most frustrating moments to be about getting Evy’s shoes on in the morning rather than running back and forth between two crumping ICU patients. I needed the monotony and it is healing me, helping to give me my perspective back.

I read this quote the other day and it quite literally blew my mind. I’m not sure why, it’s not complicated or verbose or even that eye-opening. But to me, it was profound and I’ll tell you why.

“Here is the world. Beautiful and terrible things will happen. Don’t be afraid.” – Frederick Buechner.

These few words stopped me in my tracks. Gosh, I wish you could feel what I felt when I read this quote. This man, Frederick Buechner, deserves my thanks because this was the truth I had been trying to say in many more words and had yet to capture.  I realized why my soul had needed rest and monotony, how emptying the dishwasher day after day was the best kind of catharsis. Because I needed to remember that the world was full of both terrible and beautiful things. I had actually forgotten that.

As I transition to becoming a different kind of nurse, a nurse practitioner headed for primary care, I have started to grieve the loss of critical care. I realize that I probably won’t ever again work with patients on ventilators or draw an ABG or help run a hospital code. There are many things I will miss and many things I won’t. I think it’s that way with any job. But now I’m moving on to a less severe, although not less important world, wanting to try my hand at the flu and immunizations and much less life-threatening problems. It sounds boring in comparison maybe but I don’t think so. I think it’s exactly what I need.

There are a million different kinds of people in the world and, accordingly, a million different types of nurses. Some can work in the ICU forever, some stay in primary care their whole career. Some transition from one area to the next, taking advantage of the endless opportunities in this field. So where do I fall? Maybe I could’ve stayed in the ICU longer. Maybe not. But I chose to go a different direction, not because I got “burned out,” but because I knew what my soul needed at that time. I needed to be home with my daughter and heal from the very real tragedies that I had had the privilege of being part of for the past six years. After working in the ICU for almost seven years I thought I could handle anything, when in reality, seven years in the ICU is what I could no longer handle.

There is beauty in watching my daughter dig in the sand. There is beauty in being a part of someone’s last moments on earth. The important thing is that I remember that the world is full of both. Beautiful, terrible moments. And everything in between.

The Double-Edged Sword

This is a re-post of a blog post I did years ago when I was working at the bedside in the ICU and I’ve had several requests to post it again on this site. Still rings true!

Natalie-17Sometimes I wonder how to maintain a balance.

Just the other day I watched a man in his early forties, who had come to the hospital after an accident, bleed to death. With his leg wrenched off, a mess of shreds of flesh and coagulated blood, he had reached the end. The doctors took his wife to the bedside and calmly but firmly explained that there was nothing else they could do. The damage was too severe, the injury too great. The dripping blood collected in a pool underneath him like a morbid summary of the sad tale.

I watched for a few seconds like an unattached observer, noticing the inconsolable wife and other family members with a haze of self-protection between us. With only a ting of grief, I watched as the wife laid her body over her husband, begging and pleading into the air for him to live. Her desperate requests fell upon a silent room as she screamed and wept. Her tears wet his face but he didn’t move, already drifting in the middle place between alive and dead. Finally he passed away slowly and quietly and the family was left with some privacy to grieve. After such a commotion, the silence was deafening.

Functioning as the charge nurse that day, I was aware of the situation but because of the hectic pace of the unit at that time, I didn’t have the mental energy to soak it in fully. I cognitively understood but I held back my emotions for the sake of the job, for the sake of keeping the unit functioning at the highest level. Patients needed to be admitted from the  ER or OR, nurses required help with bedside procedures, and some of our other patients were declining at a rapid pace, requiring all hands on deck as we hung blood pressure medications and put in chest tubes. If you’ve ever been the charge nurse, you understand the feeling of the weight of the hospital world on your shoulders, the responsibility of life and death weighed around your neck. When you’re the charge for the trauma ICU, with everyone in the hospital calling you to fix a problem or make room for a patient, in many ways those are accurate assumptions.

There’s a fine line between entering into the emotions of the situation and preserving yourself for the sake of the job. A conundrum common to any area within the hospital realm. Nursing can be a diabolical and equivocal profession for this very reason: the maddening crux of self-protection and compassion. It’s a double-edged sword that boasts both danger and power.

On one hand, I consider myself to be an extremely sensitive person who relates to my patients and families on an emotional level. In my job working with families, I sit and listen as they vent about frustrations or griefs. I cry with them as we turn off the machines and let their family member drift into breathless silence. My heart aches inside of me as families have to make impossible decisions about the future of a loved one’s care. Few choices are straightforward and easy, and most require all they have left emotionally, mentally, and physically. Sleep, proper nutrition and self-care become obsolete as families focus whole-heartedly on the task at hand, the healing or demise of their loved one. I’ve gone home and cried helplessly because of a devastating patient situation, the grief and loss too much to bear. Seth has listened as I relate some of the horribly unfair circumstances that are inherent in a broken, fallen world. I function in deep compassion for my patients and families, empathizing with them over their heartbreaking situations.

Regardless of the specific area, nurses are not strangers to the unlucky, unfair circumstances that plague humanity. From oncology to NICU to outpatient clinics, we all encounter the unexpected test result, the unbelievable diagnosis, the unexpected and tragic turn of events. We experience on the ground level variations of pain and loss that many people can’t comprehend. We are exposed to some of the most triumphant and desperate situations, watching people defy the odds or succumb to the inevitable. Nursing is a highly emotional profession with the pendulum swinging between hope and loss, pain and victory, life and death.

On the other hand, I felt completely unattached to the man dying that day, knowing that if I let myself indulge, a deluge of tears would follow. I went to a party after work that night and as my  mother asked me, “how was your day?” I related the incidences in a matter-of-fact tone that seemed to shock her. I realized abruptly that it wasn’t normal for someone to say they watched a patient bleed to death while sipping iced tea at a wedding shower. In my callousness and self-preservation, I hadn’t even stopped to wonder at my own disillusionment with the situation.

But as nurses, we can’t always allow ourselves full depth of emotion at a certain time. It’s one of the disadvantages and hard boundaries that come with the job. If I imagined Seth lying in the bed as the patient and me, the desperate wife, weeping over him, I surely wouldn’t have been able to continue with the day. I would’ve been overwhelmed with inconsolable grief at simply the thought. I would’ve sat down dejectedly at the bedside and ignored the other duties required of me.

Nurses get very extensive training in assessment skills, safe medications practices, and the scope of our license. But treading the fine line between emotional indulgence and self-protection is something you have to learn on your own, in your own way, so that you can go back to work the next day and be satisfied with your profession. Everyone comes to that place, the place of peace with difficult circumstances, at their own pace and in their own fashion. And it changes as you move through various stages of life. You constantly have to reevaluate yourself, your calling, and your emotional reserve to adapt to the situations before you.

Sometimes I’m amazed at my ability to push my emotions aside and continue in the job of saving lives. Sometimes I’m surprised as I can’t seem to stop ruminating over a seemingly routine but difficult situation. I shock myself with how I react to some predicaments and not others, or the degree to which I react.

It’s an impossible double-edged sword, the blade of self-protection and compassion. It gleams at you, waiting for you as you walk into work everyday. You wield it as best you can, trying to make the wisest choices, but sometimes it cuts you when you least expect it. Then you remember it’s both your weapon and your downfall, and you grow in respect for it.

We pick it up before a shift and lay it down afterwards, but we all know it’s never far from us.