Synthesis!!!

I feel like this is the aha moment of the quarter. What did we learn, what did we achieve... But fist I would love to say thank you for the opportunity to have this blog. I was always intrigued by people that had blogs and blogged, and now I can say I have a blog too. My blogosphere real estate is secured.

How did my initial goals turn out and how did they relate to each other? Lets take a look...

Travel nursing will probably always be somewhere in my brain throughout my whole life. Being able to combine work and travel sounds somewhat ideal to me. I enjoyed the opportunity to spend time looking at nursing positions literally around the globe. I think this search taught me a handful of things, 1. That is takes a lot of organizing to get yourself an international position. 2. To keep an open mind about countries that accept travel RN's. 3. Don't discount travel nurse volunteering. The thing I learned that was the most interesting to me is that I was looking the opposite direction of most international travel nurses. I am curious what lies outside the United States, while most people are trying to claw their way into a United States Registered Nurse job. However, I did find a very nice compilation of websites that deal with non-US international nurse placement.
Travel is always fun because you get to see how other people live. I feel like travel nursing would be fun because you get to see how other countries nurse. What are the other attitudes and responsibilities held by nurses around the globe. I always love coming home after being away. I feel like I always incorporate one new thing into my home life. So we'll see what happens and how it goes, but at least I investigated and gave some light into what interests me!

                                                             How can you resist!!

Self care was especially nice to call attention to. I think it gets shuffled away and can easily be forgotten. Blogging about it though really calls to importance the beauty of self care. Whatever you think self care entails, is what self care is for you. It is incredibly subjective. Putting on your own oxygen mask first is an important life lesson. I don't think I learned any new ways to self care, but what I really took away was the importance of the self care. As we care for others for so long, it is important to care just as much for ourselves. For me I think self care involves: warm showers, cooking, relaxing with friends, grocery shopping (I really enjoy it?), going for walks, good coffee, drawing, thinking about dreams for the future... In fact I think I could spend my whole life doing those 8 things and be happy. Recently my self care got even better because we added a little wood burning stove to our family! We looked at them in the showroom and they were $2,600, then we looked on Craigslist and got the same stove used for $450! I love the heat a cast iron stove produces and it is beautiful to sit working in front of a fire (like I'm doing right now). Whatever it is that you enjoy and replenishes you is self care. I'm sure as life goes on my list will grow but for now those are what they are. I hope to truly take away the importance of self care and NOT FORGET it!!

          You are all welcome to come over and sit by the fire, but bring a book and expect tea

Sheath's... so I got to vent about the situation as a way to express my feelings. While I don't have any immediate change in circumstances, I feel like I have a better grasp going forward. I will try to educate myself as much as possible. I also feel like I have a game plan to step up and try being resource nurse aka "Sheath nurse" after we finish school. Beth had a great comment that sometimes realizing you don't like something is enough. I could say to myself, yes I don't like it and that is fine. Knowing that is an option takes the pressure off. I want to tackle this issue as a way to feel like a fully rounded cardiac nurse. There is so much to know as nurses that it keeps us smart engaging in the world around us. I think I am still ready to learn more things and tackle new challenges. I'll get there in due time and that is just fine. I remember when I first started working as a nurse for some reason giving blood transfusions really scared me. Recently I did four transfusions on a shift and it was no problem. I look forward to that same transition with sheath pulling.

                                                               The measly little sheath

I also really enjoyed our post on beauty. Especially because I got to see what everyone else thinks is beautiful. The simplicity of sitting in my backyard and taking it all in was fun. I feel like I do that out of curiosity or because I am working in the yard. But I really enjoyed just sitting there with the intention of soaking up it's beauty. In a few months I will be out there all the time. Once the sun starts shining I sit on our picnic table under the cedar tree and enjoy the day. Or I'll put a sun chair in the middle of the lawn and read a book. Or I'll plant more things in our garden, or I'll... ok I digress...

                           Front yard paradise, complete with hammock (not visible in this picture)

Thank you all for a great quarter. It was really fun writing about a variety of things. I especially liked reading all your responses to my posts. It is interesting as nurses, that we all work in the same field (and all have the same license) but we do different things and encounter different stressors. Yet we all need to take care of ourselves, find beauty in the world around us, and make meaning of the crazy situations we encounter. Thanks for being such good sharers and listeners, this was truly a joy!

Empathy

I have, as long as I can remember, believed that we all learn to be empathetic. I don't think that we are born empathetic people or not. I think that this belief makes me hopeful for the future. I like thinking that humanity has the capacity to become more caring. Especially our role as nurses, requires a deep understanding of this skill.

I'm always reminded of this when bad things happen to me. Recently our cat has twice passed out and appeared to be dead. The first time this happen he spontaneously woke up a few minutes later after I thought he was definitely a goner. Then when I was at work in January he did the same thing, except Marcus was home with him. He appeared to have died, so Marcus rushed him to the Emergency Vet around the corner. They put him on a heart monitor, which showed he was severely bradycardic for a cat. He was completely non-responsive and they prepared us to have to put him down in the morning. It had to have been one of the saddest things I have gone through. We cried and cried and cried. He proceeded to wake up the following morning and has been fine ever since. However, this experience with our cat has made me so much more empathetic to my sick patients and their families. If I felt grief stricken and helpless with our cat, I can only imagine how it must feel if it was your spouse or parent. Even though it is so easy in our field to get burnt out from always caring and giving to others, I think it is a highly respectable position in life.

Another instance that reminded me to be empathetic recently as well was getting quasi food poisoning. We went to a friends house for a holiday dinner. I made a spiral ham, everything was going great until we got home. I puked and puked and puked for hours. Luckily I had the next day off work. Sitting next to the toilet feeling nauseous for hours is enough to make you go running for Zofran when your patient tells you they are feeling nauseous. Being reminded of how much suffering sucks in your own life, makes your a more empathetic person to your own patients. Not that I am recommending going through every painful experience in life just to make you a more caring individual. Instead when something bad happens then you can take it into your own practice.

I think a large part of not loosing our empathetic edge as nurses is not over working and taking good care of ourselves on our days off. We should be just as empathetic towards ourselves as we are to our patients. So the various goals for this quarter come together in an interesting way. That taking care of ourselves makes us able to be more caring and empathetic towards our own patients. The airlines really do have it right, when they tell you to secure your own oxygen mask before assisting those around you:)

Maybe I am just optimistic, but I really do aspire to continue becoming more empathetic towards others as my life goes on and as my nursing career goes on. I think you are never too old or young to get better at this. And if you need a reminder, you can always think of a sick pet or yourself getting nauseous.

Translating Nursing Self-Care to the Rest of Our Life

So, I tell myself I'm not super-nurse and I can't do it all. I think that is a healthy mantra to carry over to our real lives as well. I never thought that I'd be applying my nursing self care to my personal self care. I feel like my personal self care pre-dates my nursing career and is usually more developed. However, I really like thinking that it is a two way street. So just as I am not a super-nurse, I am also not super-woman or super-human.

Sometimes, just realizing something and being ok with it is the beginning. I like to think that I am kind to myself and I am doing the best that I can do. So having realistic work expectations, means I should really have realistic out-of-work expectations too. I do not want to come home from work and start my homework but it has to happen sometime. So I am not super-student, but I am doing the best I can do, when I can do it and that is just fine.

What other work self cares can I translate to my personal life. Building strong relationships I find to be a work self care, that I am good at in my personal life as well. However, this year it has been hard to give the same amount of energy to my friendships as I have much less free available time. So maybe prioritizing this will give me the extra nudge to not leave my friends out in the cold.

I had a funny practice in not getting really frustrated at work recently. A patient on our floor gave their nurse a $60 gift card to Tully's and told her to buy the whole floor coffee on her. This was really sweet, so the nurse gathered everyone's orders. She asked me what I wanted and I told her I was actually just about to head to Tully's downstairs. I had a student with me so she asked if the two of us wouldn't mind to fill the orders and carry them back upstairs. I told her I didn't mind at all. So me and Alex, the student head downstairs. We start filling the orders at Tully's, there were 13 coffees to be precise. It took awhile for each order to be written on each cup, so by the time we got to the end of the ordering, half of the coffees were already made. The cashier then rang up the order and I gave her the gift card. She proceeded to tell me that the gift card had no money on it! What was I supposed to do? They were mostly made and there was no gift money. So I paid for all 13 coffees with my own money. I was first really frustrated at the nurse who asked me to fill the order, I felt like it should be her going through this scenario, as it wasn't even my idea in the first place. Then I got annoyed at myself for not checking the gift card first. In the end we carried all 13 coffees upstairs and I explained to everyone what happened. I now have 13 people who want to buy me coffee, we'll see if it really happens. But, it was great practice in letting go of a situation that is kind of out of your control.

Navigating crazy situations is a skill I feel I have learned at work. Whether I am now a more patient or less patient person I think is debatable. This is a self-care skill that I think I have perfected at work and hopefully translates into my personal life as well.

Australia, US Virgin Islands, France?

So my international travel nursing quest continues. To be honest I'm glad that I'm not in a rush to go anywhere because it is not easy. I have come across more websites with more options and I am starting to think that going through an agency is easier than trying to set up an actual job placement on my own.

Premier Healthcare Professionals is another website I found that does placement in Australia, the UK and South Africa- all English speaking countries. The contracts are all for 1 year... Which begs the question of how long do I want to live abroad for in one country. I was thinking a 6 month contract would be ideal. So the quest continues.

World Wide Staffing- Not exactly living up to its name has a handful of international placement options including the US Virgin Islands, which could be tempting and I honestly never thought of going to a US Island Territory?! Would one go stir crazy living on an island, these are all important things to think about when contemplating the future.

Then I found a place called the English Clinic in Southern France. It is run by a handful of UK staff that provide English language care. I am very intrigued. Their website is http://theenglishclinic.fr/ Even if I could not work there for money, I would still love to perhaps try volunteer? I have a fair number of relatives that live in Southern France, in Nice specifically. Maybe they could also be helpful in identifying any English speaking options that they know of?!

Like I said earlier, I am really glad I am not going anywhere anytime soon! I am starting to see why people volunteer on mission trips. Coordinating work visas and taxes sounds complicated. I am up for all of it, but it sounds like a lot of personal investigation work is necessary. There is not one clear agency and not one easy country to travel to.

Has anyone heard of Medecins Sans Frontiers (Doctors without Borders), I assume you all have as they seem to be pretty prominent. This is yet I suppose another option of working/volunteering as a nurse in a foreign country. While a different vein than working in an international hospital, it is another aspect of international nursing that shouldn't be forgotten!

Thanks for listening to my rant. It is interesting, yet not particularly straight-forward. I'm sensing lots of time researching and creativity could lead to some very interesting adventures.  

Backyard Beauty

Over the past year we have put in a lot of effort to our front and backyard. So, I thought what better place to spend my peaceful outdoor time than sitting in my own backyard. As I step outside it is a pleasant crisp, yet sunny day. There are birds chirping all around me. I love hearing the many different types of bird calls. Even though I can not see them, I know they are sitting up in the trees around me.

First I take it all in, and then I get curious to wander around. Last Spring we tore up the moss that covered all our flat yard space and planted grass seed. It rains so much in Seattle that I don't feel bad having a lawn (growing up in California with droughts, lawns are a unnecessary sucking of water resources). The grass is nice and fresh green color and smells sweet. First I peek at our garden boxes.

In the fall I covered the boxes with leaves and mulched them into the dirt. I am curious if anything is growing back. I always find it peaceful seeing the garden boxes resting, full of potential for the summer planting. I like the symbolism in that image. I like thinking that I am resting and rejuvenating all winter long as well (fewer leaves were required in my winterization). I look close and I see little glimmers of growth peeking out of the dirt and leaves.

   

Can you see the little shoots coming back! Pictured from the left to right is flat leaf parsley, thyme, and chives. I love being in the fresh air, seeing the sun peeking out behind the clouds. As it is 11am on a weekday while I'm outside, there is no one else really around. My neighbor's kids are at school and my neighbor's themselves are at work, so I feel like the world around me is all mine.

And finally as I walk around the corner, I notice our Camelia tree is budding. There is so much beauty present in the few hundred square feet of our backyard it reminds you how much beauty there is in the world in general. Sometimes you have to look closer and then it becomes clear. I am grateful to be able to be able to immerse myself in all this fresh air and plant life. I love being able to plant flowers and veggies and see their progress over the years and seasons. These are reflections of what I think is beautiful!

The sheath

Ok, so I'll vent a little bit...

I think the reason I have this deep seated dislike of sheath pulls is once you're in, you're in. Here's what I mean. If you are able to pull the sheath (out of the femoral artery after stent placement) you are then responsible to do it for the entire hospital. The time that I would need to do this role is only when I am charge nurse and there is no one else available to do it- and I just don't like that.

Our floor has the cardiac resource nurse, that is their main responsibility it pulling these sheaths around the hospital- they are some of my favorite people. However, they are currently not staffed on Sunday's, work 8 hr shifts, and can call in sick too. Therefore, there are many times when the charge nurse has to pull the sheath. I do not like being charge nurse and having to go to the ICU pulling a sheath there, then having to go the the Med-Tele unit and pull a sheath there... I find it to be draining as well as doing all the other responsibilities of charge.

If you look at the nurses who have left our floor for outside jobs or other units at Virginia Mason, lots of them have been prior charge nurses- responsible for pulling sheaths. I don't want to wear out my patience with my floor. Therefore, I generally try to avoid being in this situation.

The other way that stents are placed is through the radial artery, these I actually enjoy managing. Most of the new Interventionalist's that VM hires prefer the radial approach. However, in time of STEMI the groin is always used. And... as we are a cardiac floor we are no strangers to the STEMI.

Since I really do like thinking of myself as a totally competent cardiac nurse and have every opportunity to learn how to be a good sheath puller- in the future I want to tackle this topic. Maybe once we finish our BSN then I will try embracing the role of sheath pull. Because I want to keep learning new things and expanding my role as an RN, I suppose I could some day step and volunteer as a resource nurse. I feel like I would have a lot of respect for myself the day that happens. In the meantime, I will kind of side step and kind of mentally prepare.

I think one other reason I dislike sheath pulls is there are so many variables and sometimes I worry about keeping them all straight. So maybe I need a good old-fashioned chart and a refresher day with the anti-coagulation machine. Depending which anti-coagulant the patient got in the cath lab we have to check their ACT- activated clotting time. But in order to check the ACT you have to put three- no more and no less, drops of blood in this little piece of plastic and enter all the various data into the machine.... But every few days the machine has to be recalibrated so there is another step I need a refresher class on too:)

Long story short that it the honest answer of why I do not like pulling sheaths. I look forward to someday embracing it head on, in the mean time I'll keep slowly trying to come around.

Framework II

I'll use the Gibbs Model to analyze a second incident at work...

Recently I had a patient transferred to our floor from an outside hospital for pre-bypass surgery. He came to us with a heparin drip running, but it was the medics bag, with tubing that is incompatible with our IV pumps, and at a different concentration than we stock. This is always a sticky situation, and there is not a lot of guidelines that we have for this. I was charge nurse, so the patient's nurse and I turn off the heparin drip and page the accepting doctor listed. He is not a usual heart surgeon that we work with instead he is part of a cover team if one of our regulars is out of town. 

So I page the doctor listed asking for heparin orders. He calls the floor back and tells our unit secretary for me to page the "210". "210" means nothing to me, it is not part of our usual language. So I am forced to re-page him and ask for clarification, since he will not put in the heparin orders. He calls back again this time frustrated and tells me this always happens. I have enough insight to realize this situation is a little bit bigger than just me if it happens each time. I ask him if he means for me to page the heart surgery resident, he states no the 210! Again, I'm like well that isn't anyone we use here. He then comes to floor to belittle me and ask why I am paging him so many times. Meanwhile it has been over two hours the patient has been on our floor without the heparin drip running. Heparin has a really short half life, so I know most of it is out of his system by now.

Finally, the accepting doctor finds the person he wants to work with- who is the heart surgery resident, that he also thinks should be called the 210. She puts in heparin drip orders and then asks me why we haven't checked his anti-coagulation levels? I tell her we can't do any of that until there is a doctor's orders, which is why I have been paging him. The whole situation felt very circuitous and frustrating, when it did not need to. 

I was thinking I am doing the right thing for this patient by requesting repeatedly for the heparin drip to be ordered, but I can't figure out where the resistance is coming from. I know that the short half life of heparin exists so I'm feeling like there is a ticking clock involved in this situation. I also cannot figure out why the doctor just will not put in the order himself?   

The good thing about this situation is I emailed my manager that night explaining the situation, because I did not want it coming back poorly on me. I then asked her what we should do in that kind of situation. She told me we should call a MET which is like a rapid response call if it has been over an hour of a patient being on our floor who needs heparin and doesn't have an order. That way there is a doctor at the bedside who has to put in the order. The bad part of this experience is that it did not need to happen, and I felt like the doctor was mad at me for looking out for our patient.

The sense that I make of this situation is that this covering doctor felt out of place (even though he routinely covers at VM). I could have called our house supervisor involved, I felt like it was not the role of the hospital supervisor to deal with one specific patient concern but they might have had some insight. I also could have called our rapid response RN to come assist the floor nurse caring for this man, so she wasn't so busy trying to smooth out the situation.

If anything similar was to happen again and involved a pre-CABG patient, I would page the covering resident even if the MD thought it shouldn't be them. I will let the surgery resident tell me they are not working with that patient, rather than sit and wait for hours. And, now I know what is our floor policy as well if this situation of no heparin order arose again. I always let my manager and assistant nurse manager know if something out of the ordinary happens on my shift, that way they are pre-informed and there are no surprise issues showing up on their desks.