Sundays

Sunday is my one day off from work and school but somehow it manages to be the most stressful day of my week. Because my schedule's otherwise full, Sunday's the day to get everything done. Such as: clean the house, resuscitate a plant, go for a bike ride, change five lightbulbs, read 50 pages on cardiovascular disease, shop, return phone calls, go on a long walk with the dog, catch up on work, take a nap, go on a date, read 100 pages of the novel I need to return to the library on Tuesday. And that's just today. Last Sunday I had to sleep in, do the dishes, take all the trash out, walk the dog, attend the opera, finish a book, catch up on email, make 100 flashcards, watch a football game, wish D a happy birthday, study for a midterm, and collate notes about OB meds. I'm starting to dread Sundays but it does makes me feel better about the work and school that fill my not-so-busy days.

Sidewalk

On our walk this morning, B and I passed a man on the sidewalk. He was walking the other way, dressed for work, shaving his head. I swear to god, he was moving an electric razor back and forth over his noggin.

Bird flu

After a bit of a dry spell, work has suddenly ramped up full force. In fact, I'm still on a conference call (my fourth of the day) as I type this. I'm still paying attention; at the moment the discussion is about whether a porta-potty is a resouce or an asset. I'm multitasking. And what, you ask, has prompted this flurry of activity?

Oprah.

That's right. Oprah had the expert generally referred to (though not always nicely) as "The King of Public Health" on her show today to talk about bird flu. Suddenly my company is talking about new funding streams, products, tasks, and so on and it looks like I'll be spending my free time working. If it seems a little strange that Oprah could have such an impact on the company's plans and the public health priorities for the next few months then you don't know public health. It's one of the special little quirks of this business that you swim with the current and there's a new current every other day, all leading to...well, I don't know where. Perhaps because it's the government. Perhaps because it's the business of prevention. When I worked for the state, I prevented bioterrorism one week and prevented SARS the next and guess what? There was no BT nor SARS either week.

Midterm

I way overstudied for the test today. And by overstudied, I mean that I was anticipating questions like: If a patient has a blood pressure of 142/80 and an intercranial pressure of 18, what is the cerebral perfusion pressure and does this indicate that their brain is adequately perfused? At this point, is the brain still capable of autoregulation?

And an actual question was: a patient has increased intercranial pressure. What should you check? Answer: level of consciousness. Duh.

According to one of my classmates, we'll be able to pass all of our tests if we remember three things:
1. Don't think too much
2. Raise the head of the bed
3. Tell the patient to tuck their chin when they swallow.

$#*@%#^&!!

I couldn't relax yesterday and when I finally did close my eyes to go to sleep I saw all sorts of gross things from the operating room. I think I got about four hours of sleep. I bought coffee this morning for the zillionth time this quarter. My budget's blown again. I sipped my grande nonfat latte all the way to clinical this morning and through report. I left it in the breakroom and in between giving my little old lady her meds and a bed bath and about a quart of applesauce I would pop in for another sip. Until the 10th time, around 11:15 am, when I walked in and no coffee. That #&&@*!&* nurse must have followed me from the hospital yesterday to this hospital today for the express purpose of throwing away my coffee.

Bad outcome

I didn't start shaking until I was walking down the hall toward my clinical seminar. It was after I'd left the operating room where the patient was quietly crying and the doctors were counting instruments before sewing up her stomach. After the father had followed the perinatologist and his child to the NICU. After I'd run into the family, anxiously waiting outside for any information I could give them. After I changed out of my blood-splattered scrubs.

I entered seminar, forty minutes late, and the instructor immediately stopped talking about tocolytic drugs and asked for my report. I gave my classmates the long version of this: woman laboring with twins, premature, normal vaginal birth for baby A, complications, lots of worry, blood, emergency, nurses questioning the doctor's methods, baby B born but not breathing, no heartbeat, mom: "why isn't he crying," more emergency, there's the heartbeat. When seminar ended and my classmates left, the instructor told me that I'd seen "about the worst thing that can happen." She warned me I might have some trauma and could be called in to give a deposition. Call her if I need to talk.

The adrenaline that I hadn't noticed until I was walking down the hall was starting to wane and I noticed that my shoulders were sore from being tense for four hours. I was cold and hungry and wanted to talk and talk about what I'd seen, but also didn't want to tell anyone else about it. I returned to the break room to grab my bag and coffee, coffee I hadn't had a chance to drink all morning, to discover that some well-meaning nurse had thrown out my cold 3/4 of a grande nonfat mocha. What a jerk.

The odd thing about OB work is that the patients aren't actually sick, yet two people could suffer lifelong disability or death if things don't happen the way they should. It's so easy to get overcomplacent or alternatively treat the event as some sort of critical emergency. And neither response is appropriate.

Quote of the day

"I can accept failure, but I can't accept not trying. " Michael Jordan

Infections

It's no secret that I'm interested in infectious disease to the exclusion of everything else. In some ways, this is a liability - I'm not going to be very astute in diagnosing signs and symptoms of noninfectious diseases. On the other hand, I plan to spend the rest of my life in an infectious disease specialty clinic and that's what referrals are for. So in my clinical experiences, I consider a day a success if I can find some connection to an infection in my patient.

My patient today had a pneumothorax (see description below) and nothing to indicate that little creepy crawlies might be involved. I was a little bummed - especially since one of my classmates got a patient with MRSA (methicillin resistant Staphylococcus aureus) in his lungs...she was so lucky! But in the course of the day I discovered that my patient's lung x-rays showed evidence of granulocytes which the diagnostician noted were probably due to a past tuberculosis infection. And guess what? A TB infection can cause lung changes that lead to a pneumothrorax. SUCCESS! There wasn't anything in the patient's chart to indicate that they had ever been tested or treated for TB infection, which means they may still have a latent infection. I discussed all of this with my clinical instructor and we came to the conclusion that the patient should get a ppd test and, if positive, be treated for latent TB.

See? It's all about the microorganisms.

Looking up my patient

On Fridays my classmates and I wrap things up at one clinical and drive 15 miles to the next site to get our clinical assignments for Saturday. We're expected to go to the hospital, find the name and diagnosis of our patient and then review their chart for things like medications, diagnoses, vital signs, health history, lab results, interventions, etc. We take that info back home to look up things we don't know and fill out three different forms that we need for Saturday. It's a bit brutal and takes hours to do...lots of fun on a Friday night.

So today I finished my shift at the high-risk prenatal clinic (AKA the "Scare the Shit Out of Pregnant Women" clinic) and headed north. I didn't see any patients with infectious diseases, so I picked out one with a pneumothorax (lung collapse due to air in the pleural cavity) and went to look over their chart. One of the first things I noted was that the patient was a nonsmoker - important because smoking is a risk factor for pneumothorax and for recurrences after recovery. I flipped through the chart, taking notes, and got to the medical administration record (MAR). There were ten different drugs and I started copying the names but then noticed that one of the ordered drugs was a nicotine patch. Why would a nonsmoker have a nicotine patch? I looked more closely at the form and realized that the MAR for a different patient had wound up in my chart. I pointed out the mistake and the unit secretary corrected it.

I just took the trash to the curb

Another day of OB clinical today, this time following the lactation consultant. I learned lots of interesting factoids and tips and saw a lot of painful-looking nipples. Youch.

I made coffee at home this morning for the first time this week (excuses for not making coffee at home: not at home, out of milk, ran out of time). I took my first sip while I was driving to Roosevelt to catch my carpool and just about spit it out. It tasted like soap. So I had to stop and buy coffee.

I bought new purple scrubs last weekend. I'm not sure which is more depressing: spending money on ugly purple scrubs or spending time in the ugly purple scrubs store. But the new ones fit like a dream and every time I realized that the crotch of my pants was not around my knees for a change, I was happy. Which is good because I'll be wearing them the next two days.

My can

I missed my alarm last Friday but miraculously woke up anyway at 5:27. With 33 minutes to meet my carpool, I threw on my scrubs from the previous day, took Bennet for a spin, and ran to the carpool stop. I made it with enough time to grab a cup of coffee, but almost immediately found that I'd forgotten some paperwork and my stethoscope. On the drive home I was congratulating myself for faking it through the day despite the late start. I turned the corner into my neighborhood and found that I'd missed something else: trash day.

Sometimes when I don't put my trash to the curb, someone else in the neighborhood does it for me. I kept my fingers crossed that that was the case that day, but alas, my can was full and leaning against my house, right where I left it.

I have to wait another week for my can to be emptied, but the thing's full now. There's just enough room for a few more bags of dog poo, but that's about it. In the meantime, trash is collecting within my house. The can in my bedroom is full. the bathroom trash is full. The desk trash is full. And the kitchen's a mess. I've stopped throwing things away altogether and now there's an empty container of milk in the fridge. Things are out of control.

I had to hire someone to walk B on my long clinical days. If this trash situation goes on much longer, I may need to consider hiring someone to take my can to the curb on Fridays.

Faculty support

The study guide for my illness class was particularly confusing so I emailed the professor to ask for clarification. Here's her answer - in part:

"We covered SAH today and will do CVA (all types) on Wed. The concepts for ICP will be important for all pt with CVA but the lecture will focus less on the intensive period where ICP is the main issue and more nonfunctional deficits and ways to manage them."

What the hell? I need another six months of nursing class to figure out that email. Here's how the email ended:

"We want to support your learning and not create unnecessary frustration."

Two notes on my personal life

So far so good, but I'm expecting my personal life to all but cease to exist in the near future due to the disappearance of my free time (I spent three and a half hours today printing things from various course websites. Not reading, not learning, not filling out forms, but just printing all of the things I'm required to print. Just one week's worth of printing and I'd burned through a quarter of my waking hours). Before it's gone I wanted to record two items.

Item 1: Remember the guy with the pho? Or more accurately, the not-paying-for-the-pho? He got back into town from his holiday vacation and actually called to ask me for another date. I wasn't near my phone and listened to his voicemail with more than a little surprise. I guess I wasn't as obvious as I thought about how badly I wanted that date to be over. I sent him a nice little email ("you're a catch, but there's just no chemistry") and don't expect to hear from him again. I love how vague and yet final the phrase "no chemistry" can be.

Item 2: I went on another date at Lincoln Center. Different guy, better circumstances - it was half way between our places and we were going to see a movie. But still, twice at Lincoln Center in less than a month? I blame this on the fact that I've been dating people from the Eastside and I'm really bothered by that. What does this mean? Have I lowered (raised?) my standards? Am I destined by fate to live in Bellevue (or Kirkland or Issaquah or Redmond)? Have I dated absolutely every eligible man in Seattle and now have to go across the lake for a new pool? This is a really disturbing development.

Birth

Today I had the most amazing clinical experience to date: attending a birth. It was my first day on the floor and my fellow students spent the day in lecture learning about stages of labor and fetal heart monitors (I took the class last quarter), so I was going solo. I walked into the patient's room around hour 16 of labor and the second hour of active pushing. It was mom's first baby so things were bound to take a bit longer and to complicate matters, the baby boy was not making a lot of progress down the birth canal. I did a lot of waiting, occasionally pushing a button to stop random beeping and after a couple of hours the doc came in and decided to try using the vacuum. Suddenly the room was in a bustle of activity. I followed the nurse to grab the baby blankets and hats and watched as they took down part of the bed and readied a plastic bag at a strategic location. A cart rolled out with clamps and needles and the doc put on a gown, stuck on the vacuum, and about a minute later there was another person in the room! As the babies head emerged I heard a funny little sound. Sure enough, poor mom had a fourth degree laceration (her tissue was torn all the way from the vagina to the rectum). I watched the doc suturing and watched the nurse dry off the baby and tried to remember that if I were the nurse in the situation, there would be a lot of things for me to do at this point. I just wanted to stop everyone in the room and shout "hey, something incredible just happened here! Let's take a moment to marvel." But of course, torn tissue and cold babies can't wait. I got to give the baby his first bath and diaper and feel the mom's fundus (the top of her uterus). And later in the day I got to stick my fingers into a laboring woman's vagina to feel the baby's head and her dilating cervix.

What a wonderful job it must be to work in OB. Although my experience today really did reinforce my decision to become a nurse. As the patient this morning labored, her nurse was monitoring her, making decisions about med rates and progress, getting to know mom and dad, teaching them how to get through labor and care for their new baby. The doctors - two wonderful women who I'm sure are very competant and caring - came in three times in as many hours, spent a total of 25 minutes delivering the baby and suturing the lac and were gone again. I'm glad I chose a health profession that allows a bit more hands-on, comprehensive, nonhurried care.

I just had such an amazing day and am so excited to go back next week - although I only get one more day in labor. But I'm not too worried that I'm losing the love for infectious diseases... While the birth of a brand new human tops my list of clinical experiences, the unroofing of a herpes lesion in the summer is a close second, so I think I'm still good with my microorganisms.

OB

Today was our OB clinical orientation. I'm pretty excited about this one for some weird reason. Even though I had to get up at 5. And didn't take a shower. And wore those ghastly purple scrubs all day. Maybe because I've already had the class and I want to get the clinical experience done before all of the information trickles out of my brain. The instructor asked me an easy/important question today in front of the rest of my clinical group and I got it wrong! I have this remarkable skill of knowing what I have to know only for as long as I think I need it. I don't think it's a good thing.

My group in this clinical is exactly the same as the one for my med/surg rotation which means the 10 of us are spending 30 hours a week together. It's not the easiest group of people to get along with - this is the creme de la creme of Type A personalities here - plus there was big drama within this same group last quarter (we were also all together for psych), so it should be entertaining. Half of us all carpool together and I'm curious if we're going to be speaking in the car on the rides to/from our site by the end of the quarter.

Everyone wants us wearing our purple scrubs which are the absolute worst articles of "clothing" known to man. In addition to making us look like large dinosaurs, they are very polyester and so very uncomfortable. The pants particularly are built like a barrel. The crotch hits around my knees and the waist is around my ribcage and it's a straight shot from one to the other. But my body is not particularly cylindrical and there is a curve or two between knees and rib which is not at all accomodated by the pants. So in addition to having to wear these terrible things at all, we are supposed to wear them three days in a row - two OB followed immediately by a day of med/surg. First of all, I just have to say: spreading disease. And they're going to get gross. According to our OB instructor, during labor there's amniotic fluid and blood spraying everywhere and "you don't know where it's going to come from". So I have this picture in my head of...well, I'll spare you. My scrubs are going to be gross.

Day 1

My first day of class this quarter and I feel like I've learned more in 8 hours than in the entirety of the fall quarter. I now know how to classify spinal cord injuries. I can define autonomic dysreflexia. I learned - unfortunately - what an "anal wink" is.

In addition to two hours of med/surg lecture, we got to race on up to the hospital where our med/surg clinical will be. I feel a bit bad for our instructor...most of my clinical cohort's been in the same string of bad clinicals that I've had and we're all a bit jaded and pessimistic. She got us back though - she's a smart one - by giving us enough information, assignments and requirements to seriously freak the crap out of us.

Snip

I cut my fingernails down to the bed today. I guess this means it's time to go back to school.

Resolutions

New Year's resolutions are for schmoes. If you really care to make a change in your life, you'll start on September 21st or July 9th or February 16th or any other old day in the calendar. There's nothing magical about January 1st and if anything, it gives people license to fail and having done so, put off the changes until the new year rolls around again.

That said, I do feel like the New Year provides opportunity to reflect on the good and bad of the past, and to project the "hopes and fears" upon the coming year. Often, events around January 1st seem to frame or anticipate the course of life in the next 365 days and it seems no mistake that this January first, finally finishing the 800 page behemoth, I should pick up Mountains Beyond Mountains. This biography describes the life and career of a truly dedicated infectious disease doc and the work he's done to bring health to the poor in Haiti and elsewhere. It's awe-inspriring and makes me feel inadequate, uncaring, clumsy. But it also gives me a little bit of hope, a slight nudge of encouragement to think that I could accomplish even a teeny fraction of the things this great man has done. I hope this kernal of empowerment will stick with me throughout the stupid clinicals and dull lectures and other mundanities of nursing school and help me grasp all of the opportunities I have this year to become a compassionate and talented health practitioner.

Paul Farmer:

"The only noncompliant people are physicians. If the patient doesn't get better, it's your own fault. Fix it."

Regarding the treatment of a poor TB patient. "When she received [the antibiotics] she soon began to respond - almost as if she had a treatable infectious disease."

"I'm still looking for something in the sacred texts that says 'Thou shalt not use condoms.'"

"We want to treat his ass. ID says treat. Love, ID."

He had "faith [in God]. I also have faith in penicillin, rifampin, isoniazid, and the good absorption of the fluroquinolones, in bench science, clinical trials, scientific progress, that HIV is the cause of every case of AIDS, that the rich oppress the poor, that wealth is flowing in the wrong direction, that this will cause more epidemics and kill millions. I have faith that those things are true, too. So if I had to choose between lib theo, or any ology, I would go with science as long as service to the poor went along with it. But I don't have to make that choice, do I?"

"I feel ambivalent about selling my services in a world where some can't buy them. You can feel ambivalent about that, because you should feel ambivalent."