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.

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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.