6/26 WILTW: Littlefinger's smirk makes me feel violated

You don't want AN to be come ineffable?

Hope your son has a quick, safe, and un-eventful turn around!

I have been sick. First I had the migraine of all migraines for a whole week. Then if that wasn't bad enough I got the mother of all UTIs. I haven't had a migraine or UTIs in so long & both were the most painful things I ever experienced. Child birth wasn't that bad compared to my migraine & the UTI.

I am still trying to get better. I'm still exhausted from being sick & a little nauseated. I don't wish that migraine or UTI on anyone.

I learned:

I still get triggered but can handle any DV, or PTSD pts; being proactive in their journey by educating, supporting and giving resources about the "experience", while not putting myself in their shoes and self-preserving and remaining in the clinician role while empowering, is exhausting and all in the same night will make me wake up with some form of an emotional hangover...I only expect it to get better.

I am moving forward with support on my education subject that I'm undertaking...the support is awesome, although the subject is overwhelming, it is suggested to not get overwhelmed.

I'm putting my feelers out to work per-diem in Adult ERs; I learned I like PediER, but want to at least dabble in the AdultED experience; it will help when we get a adult dumping special at our Ambulance Bay, and give a little variety (and extra cash) without having to do the mandatory hours, and mandatory holidays. I hope all goes well!

Sorry Ixchel - I hope that your son recovers quickly and that you make progress after surgery ....

Most of my knowledge from the last week is related to palliative care.

Since palliative care is my work focus and I am passionate about sharing some knowledge I thought I write about it.

Recently, I had the pleasure of seeing Dr.Atul Gawande in person. He wrote the book Being Mortal: Medicine and What Matters in the End

which has become THE book about end of life care. He also writes for the New Yorker and is involved in other initiatives.

He said something that made total sense to me. It was along the lines of "if we realize that we are mortal, the quest is not to have a good death but to have a good life". Having said that - how do we spend our life when we get sicker or seriously ill? How do we spend the time we have left when we are seriously ill?

This blog has an excerpt from the book:

End of life medical decisions: Atul Gawande book excerpt on no risky chances.

The way we take care of seriously ill patients and patient at the end of their lives is often not congruent with their wishes or reflects quality of life. So - to figure out what kind of care people would want when they become seriously sick, it is important to talk about goals and values.

Example to make it easier to understand: If a patient with metastatic disease says that their goal is to spend as much time as possible with family at home, not in pain and not hooked up to machines in the hospital - but instead sitting in the living room watching sports and have a cold beer - shouldn't the care plan reflect this wish??? Patient-centered care?

Here an article about this topic:

http://www.conversationsofalifetime.org/downloads/Article-CommunicationAboutSeriousIllnessCareGoals.pdf

Here is a "guide" about how conversations in the outpatient setting should happen with patients who have serious illness. A structured way, checklist format, that walks the clinician through the questions that will lead to relevant information. Please note - "giving a diagnosis and prognosis" is not the scope of a nurse .... this guide is for MDs / NPs but a nurse can be involved in other parts of the discussion and it is important to know about the concept.

https://www.ariadnelabs.org/wp-content/uploads/sites/2/2015/08/Serious-Illness-Conversation-Guide-5.22.15.pdf

So - this is all still "pretty new" but I m sure that it will become best practice soon. Ideally, the PCP or specialist would have those conversations with anybody who has a serious illness and again after certain "trigger" events like re-hospitalization and document in a way that it can be found by other professionals. So that way, if Mrs COPD stage4 comes into the hospital it is clear what her goals and wishes are, she might have advanced directives, her family/HCP knows about her wishes, and she had conversations about her illness. Unfortunately the way it goes now a lot is "what??? you mean I cannot live forever? COPD stage 4 can kill me? I might not be able to get off a ventilator? What do you mean - Chest compressions most likely won't be successful ?? as witnessed when physicians have this kind of conversation with patients.

Our society seems to think that "dying is optional" and it seems that we need to normalize that getting sick and even death is also part of life.

If you have made it until here and are interested in another article about "overkill" please look here:

Overkill - The New Yorker

I also learned some more about errors in healthcare, risk management and micro systems.

System thinking is essential when we want to put processes in place to prevent errors. Just looking at the front line worker and blame that person for an error without looking at the system and how that design contributes to the mistake is not a successful strategy.

If you want to learn more about designing microsystems and have a lot of time or interest - I found this pdf helpful (but long...):

http://clinicalmicrosystem.org/wp-content/uploads/2014/07/CMAG040104.pdf

I continue to struggle with my diet efforts as my appetite with replacement hormones is just not normal. I swear that I do not feel satiety at all. I tried the Mayo clinic diet but gained weight with it. I looked into low carb but that somehow does not really work for me either. To be honest - at this point I just want some kind of magic wand ... I even changed from doing mostly weights and little bit cardio to fitness kickboxing several times a week for 30 minutes. But fact is that I sit a lot with school and work plus really LIKE to eat (which never happened to me before replacement hormones). I tried without hormones but the hot flashes were basically killing me and I was not sleeping - NO quality of life - which is really not what a palliative care nurse who focuses on quality of life wants...

Also, there is the renaissance of dry shampoo! I remember that it was sort of popular when I was a teenager for people who had problems washing their hair for whatever reason. But it left powdery residue on the scalp and I remember patients complaining of itching. Plus it was sort of sticky. Now it is popular again! I actually tried a sample I got and need to say that it was ok. In a pinch when late in the morning it is ok instead of washing my hair every morning...

I have been sick. First I had the migraine of all migraines for a whole week. Then if that wasn't bad enough I got the mother of all UTIs. I haven't had a migraine or UTIs in so long & both were the most painful things I ever experienced. Child birth wasn't that bad compared to my migraine & the UTI.

I am still trying to get better. I'm still exhausted from being sick & a little nauseated. I don't wish that migraine or UTI on anyone.

I hope you get better soon!!!