And So It Begins…

There are no training wheels in nursing. There is no easing into the deep, deep waters of responsibility when it comes to caring for another human being. I can no longer rely on my standby phrase: “I’m a student, but if you can wait a moment, I will ask your nurse.”

I am the nurse. I am uncomfortable with the authority that comes with that role. Is this how it feels when one becomes a parent? Like, “whoa, who died and put me in charge!?”

I am getting to do all sorts of things that I have only been allowed to observe previously. I have access to people’s most intimate secrets about their health, their mind, their body.

On my very first shift, I witnessed the amazing, intricate choreography that comes together when you think you are losing a patient. And, then, I have witnessed the stunned silence that creeps in among doctors and nurses when that same patient returns from the liminal space between life and death.

On my second shift, I learned just how labile human emotions can be when a patient is under extreme duress. It is not entirely uncommon to go from being someone’s “angel” to their most hated adversary in a matter of hours. It is an exhausting roller coaster ride that you are forced to endure with them. Over and over again.

I felt beaten up by the time Friday rolled around, but I am going to do it all over again come Monday because there will always be those bright, shiny moments when someone says “thank you” or you receive some much needed affirmation from your preceptor or the patient that has been hospitalized for many weeks tells you to have a good day that ultimately remind me that there is beauty in what I am able to do for others in these critical moments.

 

 

 

A Meditation on Rumi

This summer, while vacationing in Maine, I stumbled upon a beautiful and simple necklace from Heather Murray at a craft show in Bar Harbor. The necklace is a clean, curved line of silver with a flat gold orb at one end. Etched all along the piece are these word from Rumi: “Let the beauty of what you love be what you do”. I was instantly drawn to the piece. What a beautiful sentiment! I wanted it to be mine to remind me to pursue the things I love and to always remember what is beautiful about the things that I put my heart into. I’ve been wearing the necklace ever since.

Nursing is one of those professions where you are almost guaranteed to have days where you say to yourself “why am I doing this?” It is physically, mentally, and emotionally demanding in a way that commuting between home and a cubicle is not. There are, of course, other unpleasantries about the job that keep others far from the health care field. As a nurse-mentor of mine remarked the other day “We are, perhaps, the only educated individuals who, voluntarily, deal directly with poop”. Quite an astute observation, I would say. It is particularly important to me as I begin my nursing career that I remember to see the beauty in the job I am doing; to remember how exceptionally privileged I am to be with individuals when they are most joyous, the most vulnerable, the most despairing, when they are coming into this world and when they are leaving it. It is also important to me that I remember that nursing is only one facet of my life and that I need to take time to nurture the other aspects of my self.

When I put on my ID badge last week for the first time, I found myself continually glancing down in amazement. BSN, RN. What a wonderful reality! I think I love nursing to such a passionate degree because it took me so long to find it. Growing up, my mind was firmly shut against any career other than medicine. On days off from school, I trooped around the hospital behind my father  in a lab coat several sizes to large during rounds and imagined the day that I would join the staff and we’d be side by side as not just father and daughter, but as colleagues as well. I never paid attention to the fact that much of the time I spent with hospital staff was with the nurses. They were the ones taking me under their wings, showing me the intricacies of patient care that involved not only compassion, but cutting-edge science and medicine. It wasn’t until I was forced, by the unfortunate circumstance of my father’s illness, to become a caregiver myself that I felt how naturally the role came. Suddenly, and without warning, that dream of becoming a physician shrank away and, like a childhood sweater outgrown, no longer seemed to fit. It was a difficult time; the letting go of one aspiration and the realization of another that I had not yet fully embraced.

Now that I have come to the end of this particularly journey, I can’t remember being more excited about anything else in my life. I am finally a member of an institution where I have wanted to belong since I was in grammar school. I always thought that my father would be part of the realization of this particular dream, and it’s painful to know that I will never receive a surprise visit from him on my floor. Part of me knows that his spirit is firmly embedded in the hospital and that makes the transition easier. I think I will be looking at my ID badge with absolute giddiness for some time. I hope to never get over the awe I feel about becoming a nurse and being truly responsible for helping to effect change in the lives of strangers. Nursing, for myself, is not merely just a “job”, it is a philosophy and a vocation imbued with a certain beauty even on the worst and most frustrating of days.

Reverb 10 for December 27 – ORDINARY JOY

December 27 -Ordinary joy. Our most profound joy is often experienced during ordinary moments. What was one of your most joyful ordinary moments this year?

Nursing brings me more joy than I had thought. Yes, it is messy and complicated and patients can be infernally frustrating, but I still feel that it is such a privilege to be able to care for people when they are at their most vulnerable. The best moments in nursing for me aren’t in the critical moments when I’m making tough decisions about patient care or trying to keep a patient from the brink of medical disaster. The best moments for me come when I’m taking a patient history, helping someone with their medication, rocking a scared child. I feel joy when I know a connection has been made between myself and a patient. Despite the fact that nursing is such an intimate profession, it’s not very common to make a profound connection with patients because there is just so much to do in a shift. Most of my time is usually focused on just maintaining the status quo. Sometimes, though, I recognize a kindred spirit, or someone opens themselves up enough to trust in my care, or I get a “thank you” and that sustains me.

My mot joyful ordinary moment this year occurred during the days I got to care for infant A. at The Children’s Hospital of Philadelphia. He arrived on our unit at about 9 days of age – so new to the world. I took such delight in seeing him grow and achieve developmental milestones over the months that I cared for him that the other nurses teased me. There is just something so magical about seeing a human being develop that it is hard not to be mystified. I knew that I wasn’t his mother but I felt such elation the first time he made purposeful eye-contact with me. I enjoyed being his cheerleader – encouraging him during feedings, quieting him after procedures, updating the medical team on his progress. I never once saw or met his parents in the 14 weeks I was on that unit. Their absence – complicated reasons I won’t go into – ignited a little fire within me that kept my anger on a low boil for weeks. I eventually got tired of wondering who these individuals were and speculating about their parenting abilities. Instead I focused on providing A. with lots of positive energy in the time I could give him. Just because I wasn’t his mother didn’t mean that I couldn’t love him in a way, too. My nursing care improved when I focused on communicating to this little babe that he was loved and cared for and going to do just fine in the world. Once I let go of the anger, I found there was certainly a whole lot more room for the joy.

Baby Lust

One of the most difficult things about nursing in the pediatric setting is realizing that your patients are not your children. At 25, I didn’t think that that would be too difficult considering that I still feel light years away from taking a few laps around the “mommy track”. With the current epidemic of babies having babies, though, I realize that I could certainly have birthed any one of my infant charges. It never fails to astonish me that I regularly have to “parent” parents who are ages 16-21, usually with another child or three already at home. It also never fails to slightly offend me when people ask if I have children.

What? Are you crazy! Who has kids at 25 while they’re in school, unwed, and still living with their mother!?

Oh right…you!

Inevitably, many of these babies do not come to us from stable, nuclear families that provide three square meals a day let alone access to a pediatrician and regular primary care. I’m lucky if I can untangle whatever complicated and contentious relationship mommy and daddy might have long enough to figure out who actually plans to take care of the child. I have cared for one particular infant for months now and have yet to see one of his parents or another caregiver.

Caring for small children who are patients is often like bringing home that stray dog you saw on your way to work – you’ll let it into your heart just long enough to find it a good home elsewhere. But that’s it! You’re certainly not keeping this little creature. And then you spend whole days with this loveable being – feeding and swaddling and bathing and soothing. Your maternal instincts are out of control; your ovaries seem to have taken over your brain. Then, one day, it returns the affection with those big, bright, dark eyes and that smile like a perfect little “O”. Your heart swells and you know you’ve been suckered. Except this little pup isn’t for keeps.

Today, I met this little pup’s dad and felt such sparks of possessiveness that I had to restrain myself from asking “And just where have you been all this time!?” I had really wanted to dislike the guy, but he didn’t look like the evil villain I had conjured in my head. Mostly, he looked bewildered sitting far from the crib in a hospital-issue rocking chair, staring at the television while his son recovered from surgery not 5 feet from him.

When caring for children, it can be hard for me to check my judgment at the door. As nurses, we are fierce advocates for our tiny human patients and it is never pleasant when you have to coordinate all sorts of complicated care and medication regimens with barely involved parents. There are always reasons and excuses and extenuating circumstances that seem to preclude even those with the best of intentions from being the mother or father that they want to be, but sometimes I just want them to tow the damn line, step up, be accountable, and get the job done because it’s time for me to stop doing it for you.

I give each child all the love and support and compassion and empathy that I can within reason within the confines of the limits I impose on myself in order to keep my sanity and avoid emotional meltdowns after a shift. At the end of the day, despite this phenomenon I like to think of as “baby lust”, I’m still not the parent. I’m just the nurse.

 

 

Hubris: Not Just a Problem for Hercules

The more time I spend in hospitals, the more I am convinced that there is a certain amount of hubris required to be a surgeon. When mother nature stamps out doctors, she most certainly must have a different cookie cutter for “the surgeon”. I realize I run the risk of making one of those overly general, wet-blanket statements here, but I think you’ll be hard pressed to find other nurses who disagree.

In case your desire to be an open-minded, non-judgmental, compassionate human being should try to sway you to side with the surgeon, let me present a brief recounting of a recent interlude between me and him that occurred last week:

I’m standing outside a patient room in the early afternoon writing the most epic of progress notes on a rather medically complex child when I feel a presence behind me. I turn to find a tow-headed man in scrubs, chest hair bared for all to see through the v-neck of his top. He is loudly chewing gum in the most obnoxious manner, a manner neither professional nor appropriate for a hospital setting. Before I can react he’s reaching for the bedside chart to check on my patient’s fluid output from the two chest tubes he had inserted.

I defensively slap my hand on the binder. Hello, HIPAA!? My face clearly says “Who the hell are you?”

“I’m surgery,” comes the reply with a smirk. I’m surgery? Not, I’m from surgery or I’m the surgical resident. Who died and left the profession to you?

I provide a brief update on the progress of our patient. I’m concerned about the chest tube outputs. I have the patient to water seal rather than wall suction.

[Side Bar: For you non-medical folks, water seal is just a technical term we use when we no longer use pressurized suction to remove fluid from a patient's body. Water seal essentially means the tubes are draining via gravity and the patient is getting ever closer to have the tubes removed. Keep in mind these tubes are about the diameter of a quarter. Yikes!]

Instead of the daily total for each tube being closer to our goal of 200ml, the left side had dumped out a whopping 1060ml of pinkish-yellow fluid. Of course, it could always be worse. The fluid could be frank, bright red blood instead, but as a nurse, you shouldn’t allow yourself to think that thought lest it become a self-fulfilling prophecy.

“Surgery” seems to have left his math skills in the OR and, despite my careful documentation over the past 8 hours, he can’t seem to understand how the hourly totals add up to the cumulative 8 hour total. I have awesome, extremely legible handwriting so I know that this is not my fault.

This is the point in the conversation where he gives me a look that suggest that I am the real moron here.

“Is it putting out chylas?” he asks. Come again? What kind of question is that!? [Side Bar: First of all, it's "chyle". Secondly, chyle is lymphatic fluid]

“No,” I say, “it’s sero-sanguinous.”

“But is it chylas?” he asks again.

I am tempted to utter a Meredith Grey “seriously!?” here. How should I know if the chest tube is draining lymphatic fluid versus interstitial fluid? I’m not a micro lab. I observe output, color, consistency, odor…I don’t test to see where the fluid came from. But what do I know? I’m just the nurse.

With an air of exasperation, “surgery” whisks by me and into the patient’s room without a protective gown, completely ignoring the CONTACT PRECAUTIONS sign on the door.

I think about following him in, but then I think “oh well, let the jerk get MRSA”.

 

Philosophy of Nursing: An Assignment

I wanted to be a doctor until I didn’t. That is to say that I had always planned on becoming a doctor.  It seemed the most natural way for me to emulate my father, whom I have always idolized. That was the plan until, one day, the whole idea seemed completely wrong. When my father was diagnosed with cancer, my view of the health care profession radically shifted as I found myself occupying, or rather coping with, this new caretaker role. I experienced a rather fervent conversion: Nursing is for me. Just like that – no more medical school.

Some say I “settled” for Nursing. Settled! What kind of egregious accusation is that? Do they know how hard this is? I could cry every day for the rest of my life doing this job. I didn’t settle; I stepped up to accept awesome responsibility and privilege – the privilege of being able to lay hands on another human being, to become a participant-observer in their most intimate and excruciating moments, to navigate them, like a wayward ship, through the complexities of illness and wellness. Nursing is not about virtue or piety or maternal instincts or whatever Johnson&Johnson claims in their commercials. These characteristics don’t keep people alive; don’t keep people happy and healthy. Nursing is so continually sentimentalized and trivialized that it has become a veritable Hallmark Card in the health care industry. Somehow, Nursing is about “all the ways you care” and not about highly complex and skilled knowledge work.

Nursing is what results when a highly educated and motivated young woman, like myself, says, “I want to be present in another person’s life. I want to participate collaboratively in that life in order to effect changes. I refuse to merely view another human being as a disease model. I will recognize that people are not just the sum of their parts but complex individuals situated within ever-changing environments. I will take risks for the sake of a greater good, allowing myself to become open to criticism.” I imagine that such a philosophy was most important to my father in his practice of medicine – his primary goal being to relate to a patient human to human, not doctor to patient. So, really, my desire to emulate my father has nothing to do with my becoming a doctor, but it has everything to do with my becoming a good person. Nursing is my opportunity to achieve such a goal. It is social justice.

An Essay for UPenn Nursing

I am not a fan of March. It is my least favorite month of the year. The air continues to have a noticeable chill to it, the streets are often lined with the blackened remnants of a February snowfall, and people are still feeling sluggish from the winter holidays. 

This particular year in March, however, was partly the same, but mostly different from the 21 instances of March that I had previously experienced. As usual, I was on a spring holiday from school and the weather was just beginning to show hints of change from one season to the next. Instead of wandering through the wind-whipped, gritty streets of Manhattan, though, I was midway through a trip along the Eastern coast of South Africa. Instead of being at the center of everything, I found myself on the outskirts of nowhere in a town called Storms River that is known only for two things: having the world’s oldest tree in one of the world’s oldest forests and having the world’s highest commercial bungee jump site.

On this particular day in March I learned a very important lesson about myself: fear is least often the hindrance in life that I assumed it to be. Rather, fear is most often a catalyst for change and growth. Let me preface anything further by saying that, since childhood, I had been a feet-firmly-planted-on-the-ground, levelheaded, ridiculously cautious kind of girl. I cross the street with the light and I color inside the lines. Most importantly, I don’t throw myself off of bridges in foreign countries. Except until now…

On the outskirts of nowhere, in a small town called Storms River that is known only for two things, I decided that the world’s oldest tree in one of the world’s oldest forests wasn’t going anywhere. I opted, instead, to wait atop the arch of the Bloukrans Bridge, between the shallow river below and the N2 highway above, until it was my turn.

I like to imagine that this decision was the result of a moment of temporary insanity or the Scottish tourists who plied me with the hackneyed “you only live once”. Most likely though, this particular March day was a breaking point; a day for breaking the rules, breaking out of the mold, breaking out of my shell. Always making the “safe” choice just wasn’t cutting it for me anymore. I felt that I wasn’t carving my own path in life by continuing to follow the proverbial road most traveled.

The view from the Bloukrans Bridge when 708 feet in the air is spectacular and every other compelling adjective one can think of. On one side the India Ocean spreads itself out; a watery blue blanket that both hugs the rocky shoreline and stretches far beyond the horizon. On the other side, Nature’s Valley is a lush spread of peaked mountains, verdant trees and grasses, and the steady babbling of the Bloukrans River. The image is so postcard-perfect that I almost don’t realize that I am hurtling downwards at 50 mph with nothing but elastic attached to my ankles. When I come to rest after the bouncing and jostling and sway whichever way the wind dictates, I convince myself that I am still alive and open my eyes. Everything, even the fear I feel, is upside down and it rushes towards my head from the pit of my stomach as I wait for a tiny Zulu man – my rescue – to lower himself towards me on what looks like a window washing seat?! The ascent is actually worse than the throwing-yourself-off-a-bridge part – it is painfully slow and there is plenty of time for me to take in every inch of those 708 feet. Nothing, not even the feel of solid ground beneath my feet, is sweeter than the thrill of knowing I survived my first-ever daredevil stunt.

I have since come to look at a lot of things through the lens of my bungee jump experience. When I face something particularly challenging or frightening, I remember falling 708 feet off of a bridge in South Africa. I remember that I survived. I remember the rush of adrenaline and exhilaration afterwards. These thoughts push me through tunnels, up hills, around obstacles and inspire me to attempt feats in my life that I may not have tried before: learning a new skill, taking a class, meeting new people, traveling to new places, or deciding on a career path. I can’t say that I’ve bungee jumped since that day in March, but I can say that I have learned to take careful, calculated risks, to hurdle the hard parts in life. I am much less fearful and much more resilient than I ever gave myself credit for, and taking that oft quoted “road less traveled” really has made all the difference.