5/21 WILTW: The journey sucks and the end isn't pretty either

OlivetheRN, ADN, BSN, RN · May 22, 2016

Being that this was my first week in the OR I don't think I've fully wrapped my head around what all I've learned lol but these are some things that stand out:

- I learned what a morcellator is and that seeing one used is strangely fascinating. On the flip side, I also learned that having the nurse training me saying the bits of uterus and fibroid look kind of like shrimp as she dumps them into the specimen container is enough to turn me off of shrimp for awhile. Who knew?

- I got to see a Meckle's diverticulum this week. It was the biggest one this particular surgeon had ever seen and was an incidental finding. I thought it was pretty cool considering when I was 7 my brother had Meckle's diverticulitis and it about killed him. Let me rephrase, it was cool to see one, not cool that one almost killed my brother.

- I learned that it's okay to feel like an idiot again. When I moved from the ED to PACU I kind of had that, but not nearly as much as I am now that I've moved to the OR. But on the upside, I don't feel like as much of an idiot as I was anticipating. No one has given me crap for me saying, "Hey, can you show me how to do this" or "I don't want to eff up your sterile field so please remind me how to blah blah blah." I knew the nurses already from working in PACU but so far the scrub techs have been super helpful and super patient.

- that while I'm not a huge fan of getting up every day of the week, it's awesome to get off at 3. Like, really, super awesome.

Kitiger, RN · May 22, 2016

As a patient approaching 6 weeks post op from spinal fusion, I have learned...
...that the torso I see from the side in the mirror doesn't look like mine. My lordosis is gone.
...I am thankful to have cut my med list down so much.
...being really skinny means my hardware presses against my skin and incision site when I bend. I really hoped this would stop by now.
...I never knew how much I relied on pain to be the friend who cautioned me to hold back. I've felt anxiety over losing the pain.
...^^^^ that??? It's crazy.
...I CAN SLEEP ON MY BELLY!!!!!!!!
...I'm EXTREMELY bad at unknown. My post op appt this week will show whether I am fusing at all yet. I just want to know.
...the hardest lesson is this mountain of defeat I'm feeling after such a big few months. I'm seeing pics of graduation, celebrations of employment, and worthy bragging moments on my facebook historical posts. I felt like life was hard then, I celebrated something hopefully becoming easier. It didn't though.
I've lost my muchness, guys. Lots of it.
Bonus:
...it comforts me to know my LEO hubs and his coworkers have devised an apocalypse plan. I also just realized being nurses makes us all valuable (like, save the nurse, kill that guy instead, valuable).
So what have you learned? (And please, if you can, bring it back to nursey since I couldn't! (Sorry, mods!) We need to stay yellow.)

Ixchel, you're teaching me a lot of nursing in this post. I'm learning what 6 weeks post op spinal fusion looks like. Thank you.

nutella, MSN, RN · May 22, 2016

Ixchel - I am sorry you are somewhat struggling after surgery. I think that when a person had chronic pain, there is a lot attached to it, emotionally and physically. Also, if you had been on chronic pain medication before surgery and are able to reduce now you may perhaps feel a touch of withdrawal at times creating anxiety...not that I am saying that is what is going on but it is something that I have seen in patients.

However, I wish you a speedy recovery and that things will straighten out and healing will continue on all levels.

What I learned this week:

There is the National Patient Safety Foundation that offers some great information for health care professionals but also patients and caregivers, some of it is very useful for patients. The goal is to empower patients and caregivers to take charge of safety for example with transitions or medications. Here is the link in case you are curious:

For Health Care Professionals - National Patient Safety Foundation

Advanced Care Planning : A big part of my job. I learned this week that it starts to sink in with some physicians that an acute situation is not the ideal time for advanced care planning and asking somebody who is in acute distress "do you want us to do everything" will most likely result in the person nodding. Unless they had a discussion with their healthcare provider already and have decided to change their code status. This is why advanced care planning is so important and should also include a conversation with the MD/NP about their wishes in terms of resuscitation, especially when the person has a serious illness, or chronic serious illness and such. Unfortunately, providers are not trained sufficiently and often do a poor job with those discussions. Plus there is a huge discomfort attached to any end-of-life discussion.

However, some providers finally understanding why palliative care likes to see patient outpatient in the office. In that setting, when they are less acute sick, the NP and MD have the time to sit down and start and continue a discussion about code status and advanced care planning in general. They collaborate with other professionals like oncology and PCP. Here is a general link for advanced care planning:

https://www.nia.nih.gov/health/publication/advance-care-planning

and another link for "the conversation":

The Conversation Project - Have You Had The Conversation?

Home Dobutamine iv therapy becomes more "popular" for heart failure patients who have no other option left. While I understand the desire to maximize heart function, I feel conflicted when the person is in general low functioning due to advanced illness and not a candidate for left heart assist device or transplantation. If somebody has a lot of comorbidities and is unable to leave the bed most of the times - does this add anything to the quality of life? Of course I can see why a person who is looking into maximizing their life span may grab that straw but I think it is an option that needs to be explored carefully. There can be significant costs and overall quality of life may not be much better or not better at all in some cases (in my opinion). And patients need to understand the implications and the degree of their illness. There should always be a discussion about the bigger picture with the cardiologist.

Here is a link with some general information about home infusion of positive inotrope medication in home care:

https://vmw-lmsc.duhs.duke.edu/production/DHCH/inotrope/INOTROPIC_INFUSION_THERAPY_procedure.pdf

I also learned (again) that patients often have problems to understand their illness and put it all together.

The National Patient Safety Foundation (mentioned above) has in initiative that targets that problem and encourages patients to ask 3 questions:

Ask Me 3: Good Questions for Your Good Health - National Patient Safety Foundation

In fact, I did not know about this initiative but have been writing down questions with patient to ask their provider or specialist so they get a better understanding. Most commonly I write down with patients questions like "what is my diagnosis" "what does it mean?" "what is my prognosis?" "what are treatment options?" "what are next steps?". I found that this really helps the patient (or advocate/relative/HCP) to stay on track when the provider meets the patient. Often, patients are so stressed out and anxious that they forget to ask those questions or do not speak up when they do not understand medical English. I have met patients who had cancer stage 4 and had no understanding of what it means, or who patients who did not know what kind of surgery they had - sometimes leading to tragic misunderstandings (I thought I was cured). And I am not blaming anybody - the problem is that communication is often limited and patients do not speak up or misunderstand and the provider thinks they have an understanding.

I learned a lot about sanitation in nail salons as I did some research on it. I usually avoid nail salons and prefer to do my own pedicure. But I really wanted some nice looking feet for my mini vacation and decided to do some research. I found a place that is a short drive out and was actually able to relax while my feet were done. Knowing what to look for is really helpful including that not all salons follow the law and cut corners plus going on days where it is crowded due to a "special" they may not pay as much attention to the required sanitation time. And apparently it is not good to go on the day you shaved your legs because it increases the risk for infections. One physician also mentioned that those "whirlpool" functions can be questionable as bacteria can harbor in there -- uahhhh!

And last but not least - my diet efforts have not resulted in much change. Now I am back to counting calories with an app and scan all the food plus I had the NP increase my Hormone Replacement Patch dose. And I started fitness kickboxing and have been going three times a week for 30 minutes, which is all I can do right now. Seriously - I am so out of shape because for the last year I have focused mainly on weights (I had surgery last year and had to start from square 1 after). The heavy duty cardio part of fitness kickboxing leaves me with a dark red face, subtle nausea for some while after exercising, and the realization that everybody else there is much younger AND in better shape.

AspiringNurseMW · May 22, 2016

This week I've learned.

*I still feel like I don't have enough time even though the semester is over. And I still can't get my house together. Cause every time I clean a room to satisfaction I can count on it staying that way for no more than 4 hours. Kids.

* I feel like time is slipping through my hands like sand. I want to enjoy this summer so much that I feel like I'm going to blink and be back at school. Unlike last summer, waiting for nursing school to start felt painstaking excruciatingly slow.

* The cohort ahead of us were pinned yesterday. And I was one of a few students who participated in orientating the incoming students on Thursday. So I guess that officially makes me a 2nd year nursing student!

*I think we did a adequate job of being real and honest but also giving them hope. I think we may have said time management every 30 seconds. I hope they listened.

* technically my nursing class is only 9 credits but you need 12 to be considered full time. But a little birdie told me that my school considers nursing a full time program regardless of credits taken. I rally hope that's true because that means that I won't have to take any additional classes my last semester and still keep all my aid! Time for some research.

* I have another contender for RN to BSN, UTA. The price tag is great but I don't like having to do discussions and I won't have the go at your own pace benefit that WGU has. BUT, I'll have an actual GPA, not just a 3.0, which is the absolute minimum that the school where I aim to get my CNM requires. (although they have accepted graduates of WGU and consider other criteria than just GPA. Decisions decisions.

ETA also, while my attempts to eat healthier (not a diet) and exercise (mainly walking jogging 3x a week, thanks S Health!) have not produced any changes in my appearance that I can tell, I have noticed a decrease in my appetite and my desire for carbs! Slow but steady is the goal. I'd really like to tip the scale AWAY from the 200 I am very close to. I've averaged 150 the past 10 years or so, and I'd like to get back to that.

NotAllWhoWandeRN, ASN, RN · May 22, 2016

And last but not least - my diet efforts have not resulted in much change. Now I am back to counting calories with an app and scan all the food plus I had the NP increase my Hormone Replacement Patch dose. And I started fitness kickboxing and have been going three times a week for 30 minutes, which is all I can do right now. Seriously - I am so out of shape because for the last year I have focused mainly on weights (I had surgery last year and had to start from square 1 after). The heavy duty cardio part of fitness kickboxing leaves me with a dark red face, subtle nausea for some while after exercising, and the realization that everybody else there is much younger AND in better shape.

Nutella - first of all, I have a crush on your nursing knowledge. I'm going to sink my teeth into all those links when I've found my brain again (just got home from a shift)

Second, if you're doing vigorous exercise and lifting weights, it's very helpful to take measurements and not place too much stock in the scale. Different body compositions can have radically different sizes and appearances at the same weight because muscle is so compact pound for pound.

nutella, MSN, RN · May 22, 2016

Nutella - first of all, I have a crush on your nursing knowledge. I'm going to sink my teeth into all those links when I've found my brain again (just got home from a shift)
Second, if you're doing vigorous exercise and lifting weights, it's very helpful to take measurements and not place too much stock in the scale. Different body compositions can have radically different sizes and appearances at the same weight because muscle is so compact pound for pound.

thanks for your advice of measuring instead of using the scale. I need to say that my clothing size has not changed at all and my legs look as big as before... I never had a weight problem until perimenopause and now menopause hit me. I can already picture myself ending up with weight loss surgery.

I hope you will find those links helpful, educational, and inspiring...

calivianya, BSN, RN · May 22, 2016

Ixchel, I have been thinking about you, and I'm glad you're doing well. I am especially glad you can sleep on your belly - that's the best feeling! I love sleeping on my belly.

Home Dobutamine iv therapy becomes more "popular" for heart failure patients who have no other option left.

My knee-jerk reaction is that this is absolutely horrible and the physicians prescribing this need to have someone set a stethoscope on their chests to see if they have any hearts left themselves. Hooked up to an IV 24/7 just to keep your heart pumping at any sort of level to sustain life? Ugh. That is just straight up torture for the patients.

I have learned that being short staffed sucks the most when we have a code, and the coworkers in the other section are taking the recent talk of "stay in your section!!!" to heart and don't come to help. I had to do six rounds of compressions last night, and my shoulders are so stiff I can't stand it and my calves aren't much better. Clearly the massage I got on Monday was premature - I need another one. And I'm also a little angry that the main four people rotating were all out of shape females, myself included. I also learned by watching the A-line that my first round of compressions when I'm fresh can get a 130s systolic, but that lasts about ten seconds and by the 30 second mark, the patient systolic is down to the 80s and dropping. Where are all the men when we need them? Oh yeah, that's right - in their sections. Sitting on their butts charting. :madface:

I have also learned that being alone and tipsy on a Saturday night results in texts to work crush... which have yet to be answered. I think I'm just going to go hide under a rock somewhere and pretend I don't exist now.

NotAllWhoWandeRN, ASN, RN · May 22, 2016

WILTW:

I really, really, really love hospice care. Even in my nightmare first nursing job when everything was new and I was always unsure of myself and my skills, I was comfortable caring for the dying and tending to their families. I haven't had a great number of patients who are comfort measures only, but I've had a sprinkling at each job.

People who are grieving the anticipated loss of a loved on are fragile, angry, and intense... and it doesn't bother me. "My mom is in pain and you need to do something about it Right Now" is a-ok coming from the son of a hospice patient - who really was in pain and I was able to explain to him that I was at that very moment taking action to get her meds adjusted (the family was actually there to make the decision of whether or not to go to palliative measures, and the transition was a little bumpy). "Any idiot can see this isn't acceptable" coming from the son of a LOL who is perfectly alert & oriented but whose O2 sats dropped a few points after getting IV pain meds in ED for a fracture will have me fuming for years.*

*Insults don't usually stick in my craw, but it's the first time someone has been that direct about an insult in front of me. The daughter was saying this to someone on the phone as she threatened to take mom home AMA - while the charge nurse and I were trying to make her happy by turning up the volume on the continuous pulse ox that the daughter decided was necessary. The gall of someone calling nurses "idiots" for not obsessing over a perfectly stable pt's nearly-normal VS will stand out in my memory.

This patient had a number of children present most of the day, and they asked me about my previous hospice experience and thanked me for being able to handle it. I told them it's a privilege to help preserve comfort and dignity at the end of someone's life.

I learned that drug addicts will try any number of wild concoctions to enhance the high or decrease side effects. I'm honestly not sure anyone would benefit from hearing the specifics of that...

I learned that waiting on a second opinion is just as scary as knowing you don't trust the doc who's been responsible for your care. I have a diagnostic test on Monday that will hopefully point toward whatever the heck is going wrong in my body. I feel like a pebble in the surf, being worn down a little at a time from constant pain. I know others have it much, much worse, though, and I try to smack a little self pity out of myself now and then.

NotAllWhoWandeRN, ASN, RN · May 22, 2016

ixchel, I'm sorry you're having a rough time. I don't know your story, but I wouldn't wish spinal surgery on anyone. I suggest we have a potlock. Everyone throw in a pound for ixchel to help pad the hardware.

OlivetheRN, ADN, BSN, RN · May 22, 2016

ixchel, I'm sorry you're having a rough time. I don't know your story, but I wouldn't wish spinal surgery on anyone. I suggest we have a potlock. Everyone throw in a pound for ixchel to help pad the hardware.

Can I throw in more than one? I have quite a bit to spare....

calivianya, BSN, RN · May 22, 2016

Can I throw in more than one? I have quite a bit to spare....

If you're throwing in more than one I will too - I have about ten I could afford to lose right now!