April FNP Update

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Goodness, it’s been a long time since I’ve blogged. When I decided to resume blogging I had the best of intentions in chronicling my journey towards FNP but something got in the way. A lot of things got in the way. SCHOOL mainly. So instead of crafting an eloquent blog post about some existential nursing concept, I’m going to give you a stream-of-consciousness update and be satisfied with it because I’m already working on borrowed time. There’s an open review book waiting for me, scolding me with all the facts I do not yet know about rheumatoid arthritis. And you DO NOT want to ignore rheumatoid arthritis.

So what has been keeping me so busy for the past few months?

Working! What in the world do you think I’ve been doing?

I’m currently finishing up my second-to-last semester in my FNP program with a tentative graduation date of August this year. (OMG DID I REALLY JUST WRITE THAT?) I’m over a third of the way done with my total hours and the days seem to be flying by. As my cumulative hours sheet grows longer and longer, I grow one hour closer to freedom. One. day. at. a. time.

Clinicals have been an unexpected success- not that I always make the right choice, believe me, I’m made some epic blunders- but I am enjoying it more than I ever thought I would. The patients are wacky as ever, the complaints are unpredictable and varied, and the physical exam findings sometimes make me put on my ICU nurse face so that I don’t show that I’m HORRIFIED BY YOUR FEET RIGHT NOW. Or, I’M HORRIFIED BY YOUR LAB VALUES. Or, I’m HORRIFIED BY YOUR NON-COMPLIANCE. It’s the same face I put on in clinic when a patient asks me to look at something I never thought I’d see in a place I never thought I would have to examine. Primary care is awesome, never boring, always full of characters. It’s definitely where I want to be as a nurse practitioner.

Plus, sometimes I do make the right choice. I pend an order and then my physician says the exact same thing I just put in the computer. But I did it before he said anything! I proved to myself that I actually know something! I CAN take care of patients by myself! This victory over putting in the correct dose of valsartan (big time stuff, people) lasts for a brief period until I completely forget to address his preventative care needs or forget to ask him what his home blood sugars are or try to order two serotinergic drugs at the same time (gasp!). Then I come back down to reality and remember that I still have plenty of hours to go but that those small wins are not insignificant. I am learning and I am going to be the best NP I can be (insert girl scout wink).

Other than clinical, I’m working two shifts a week at the hospital in the ICU seeing the end result of all these complications that I’m trying so desperately to control in primary care. I’m also studying for board exams, going through my review book slowly, trying to jam all the details into my brain about lab testing for Hepatitis B and the difference between gout and pseudo gout (who gave them those names? Can I punch that person in the face?)

Oh and I have a husband and a daughter who like to see me once in a while when I’m not off saving lives acutely or saving lives preventatively (see self-inflamed pride above). In all seriousness, my family has been amazing throughout this entire process. My husband adjusts his schedule, cooks, does laundry, picks up my daughter and even scheduled me a nail appointment the other day after I thought I was going to lose my freaking mind. Even my daughter has been flexible in her own three year old way, telling me that she’s going to work at the children’s hospital while I go to work at the big hospital. She sends me a toy everyday in my bag so that I “have something to play with while I’m at work.” A big part of me is doing this for them and I couldn’t do it without them.

A few quick resources I’ve found helpful along the way:

The Curbsiders Podcast– If you’re going to be in primary care, you need to listen to this STAT, every episode. Seriously, you should’ve started yesterday. I have (more than once) pulled out an expert answer based on something I recently learned in one of the podcasts and impressed my physician with my vast knowledge of obscure details (yes, my preceptor DEFINITELY thinks I’m smarter than I am). The podcasts are funny, entertaining, and chock full of useful information. Plus, no one from your school is holding a letter grade gun to your head to do it, so the freedom to listen willingly is a plus.

This review book– There are several good review books out there but this is the one I got attached to so I’m talking about it. If you’re just starting FNP school you might want to get through the first few classes before you break it open but this is what I use to study and I wish I would’ve started reviewing it before I started clinicals. Most of the sections are short enough to where you can do it when you have a small sliver of time.

AAFP articles– After I read about a section in my review book I usually look up a AAFP article on the topic to give me more information and solidify what I’ve learned. The articles are simple enough to read and can usually be scanned quickly for the highlights. Top notch, in my opinion (my opinion that literally means nothing to anything).

That’s enough for tonight. I’ll try and share more consistently, even if it is short and sweet. There’s a part of me that comes alive when I’m writing and it’s especially important that I don’t let that flame die out under the oppression of my schedule and upcoming board exam. It doesn’t help anyone if I graduate in August as a talking shell of a FNP who can’t remember how to type her own name.

Thanks for reading!

 

 

 

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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.

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.