April FNP Update

StockSnap_RB5L88OP5Y.jpg

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!

 

 

 

Advertisements

The Plague

StockSnap_5YUFL6LC0E.jpg

I believe there is a plague that exists within healthcare, something that I would say is worse than burnout, more devastating than compassion fatigue, and more debilitating than job dissatisfaction. This plague is insidious, internal, individual and communal, and often goes unaddressed for far too long. It has affected me personally, changing the way that I view not only my job but also my own life, seeping into every arena of my mind, contaminating my ability to deal with suffering. I often hear people discussing a host of other issues as they try to determine the problems that our healthcare system faces but I don’t hear many people talking about the plague that I deal with on a daily basis. Maybe someone out there has a solution or a way to deal with it but in my nine years in nursing I have barely heard a whisper about it.

I’m writing today in hopes that I’m not the only one who has been infected.

I heard a speaker the other day talking about trauma. I was expecting the lecture to be about patient trauma, aka the trials that they encounter in life before coming to the hospital. At my facility most of the patients are disadvantaged, economically strained and have had to face dramatic challenges in life. The speaker did briefly address this topic but then she took the conversation in a direction that surprised me. She expanded the definition of “vicarious trauma” to apply to those of us who witness horrific things everyday at the bedside and then have to figure out how to structure our lives around it. Basically she asked the question that I’ve struggled with for years- how do we come back to work day after day, shift after shift, after seeing such potent suffering and death?

To put it lightly, her words struck a nerve with me. I’ve fought to put words to this concept for years now- the idea that I am forever changed because of what I’ve experienced as an ICU nurse. And I’m justified in wanting answers to these questions, of wanting to deal with this plague, because the horrors I’ve gone through are not insignificant.

I’ve watched fathers bleed to death in front of their children. I’ve seen young men become quadraplegic after hanging Christmas lights on their own suburban houses. I’ve watched young mothers hemorrhage to death after a catastrophic childbirth. I’ve held the hands of parents as they let their adult children go after they attempted to blow their heads off with firearms. I’ve seen more attempted suicides than I ever even thought possible. I’ve watched helplessly as we’ve adhered to family wishes and coded little old ladies, cracking their ribs as they flailed like ragdolls on the bed, knowing we would never get them back. And this is not specific to the intensive care unit. No matter what area of healthcare you work in everyone has a story that they would classify as “the worst thing I’ve ever heard.” I’ve seen things that I can never forget and gone through emotions that I wish did not exist.

And yet we go on because that’s what we do in healthcare. But then we’re left to figure out how to categorize and deal with these traumatic experiences on our own. We’re left to figure out our own answer to “how do I come back to work tomorrow?”

I’m not saying that facilities and organizations are not trying to help healthcare providers work through these issues. I know there are support groups and free counseling and a host of other options. But, speaking as a nurse, I also know that nurses are probably not going to be too apt to take advantage of these resources because we pride ourselves on being able to do the job with a straight face and come back the next day as if nothing had happened. We develop callouses of the heart, probably to keep up from getting infected in the first place. I know this because that is how I’ve operated for years.

So why did I start to face this plague in the first place? Because I hit a wall. The experiences I had gone through had shaped me, whether I realized it or not, and I could no longer ignore the behemoth in front of me. I had seen so many horrible things that I started to assume that everything was worst-case scenario. In my mind, nothing could ever be a minor accident, only an accident that led to death, dismemberment or paralysis. I had no middle ground anymore, no rationality, and a very-present fear of something terrible happening to me or my family. I realized I needed to deal with my issues. I also realized that I needed to find the root cause if I had any chance of coming up with a solution to my vast and overwhelming problem.

You might be thinking that I’m just one of those people who is prone to feel anxious, prone to worry. And you would be right. But you can’t attribute this entire plague to personal tendencies. I know men, women, new nurses, veteran nurses, physicians, respiratory therapists….and the list could go on. And they all have felt this way at some point. At some point everyone wonders why in the world we keep coming back to work.

So we’ve narrowed down the major question but finding an answer is a much more difficult task. How do we process these experiences in a helpful way? Do I just live in fear of something horrible happening? Do I try to rationalize my emotions and keep telling myself that I’m overreacting? Do I quit healthcare altogether?

I don’t have the answer, even after years of searching, but I can tell you what I’ve learned along the way:

The first thing I had to do was realize that the world is full of suffering and there’s no way around that. Ironically, I learned this lesson as an adult through both my own experiences and the experiences of others. Unfortunately many people learn that the world is a bad place at a very young age and they grow up with an understanding of this truth. Mine was acquired and left me feeling like I had been lied to all of my comfortable life.

Another thing I had to accept is that the world isn’t fair. I wanted life to operate in some predictable manner. For example, I adhere to the rules, I play nice, I strive for honesty and integrity and things will work out. Seems plausible, right? Only to someone who hasn’t lived in the real world. The nicest people get fatal cancer and the most horrid people in society recover without a scratch. That’s just the way it is sometimes.

So the world is full of pain and suffering and it is by no means equitable. I accept that life is fragile and I have only a miniscule amount of control over it. Well now I’m just depressed and left with a nihilistic viewpoint that robs me of any motivation.

That might be true except here’s another thing about nurses- it’s hard to keep them down. When they hear something impossible, they want to do whatever it takes to turn the situation upside down. They don’t give up. They don’t back down. Nurses are the definition of making lemonade out of lemons. Healthcare providers sacrifice their own time, their own lunchbreaks, and even their own health sometimes to make sure that others are taken care of.

If there is a plague, then there are people fighting against it. When there is trial, individuals always rise to the task. And so I decided I had to do the same. I had to find a way to fight back against the sorrow, the heartbreak, the unfairness of it all.  I came to terms with these realities and then decided that my only method of fighting back was to do my job to the best of my ability and to push back the darkness one kind word or one hug or one smart clinical decision after another. I decided to face my fears, knowing that I would still be impacted by the trauma of others but that I was actually trying to turn the equation in a positive direction. What else can I do? I can’t change what has already happened to people but I can change how it goes from here.

This is my working thesis and it is still very much in progress. I don’t have the answers and I still have days when I feel an overwhelming amount of pain for the people I’ve taken care of that day. But I know I’m not the only one who has had to make a real, all-encompassing effort to deal with the things they’ve seen. We all have and we need to see the good we’re doing in the midst of all the sadness.

For every tragic story, there is a family member who leaned on you to get through it and they will never forget your kindness. For every unfair circumstance, you have made a good call that benefited your patient. For every time you’ve wanted to cry at work in the supply room, well, you’re justified in letting out that emotion. Your job is not in vain, although it seems like it sometimes. And there is a reason to come back tomorrow. The darkness is real and weighty and potent but it does not have to win.

We won’t let it.

 

 

The Weight I Cannot Carry

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

The Bottom of the Ladder

StockSnap_YN4OUM2FN6

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

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

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

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

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

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

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

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

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

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