epic fail

So this week I had a full day of chemotherapy class, in addition to my three twelve hour shifts, which means I qualify for overtime. And I will get overtime for the next three weeks because I have class every Monday morning from 7 to 4. Although I'm happy for the overtime that I'll get paid I don't know that it's worth it given how tired I am all the time. And I'm going to have a test on the many cancer drugs after these four classes and all this learning is making me really really dumb, it could be the exhaustion too. I think my IQ has been halved. I survived my two night shifts this week, thankful for that, I'm working the AM shift this weekend and then class on Monday and then back to an overnight shift on Tuesday, that circadian yo-yo is going to put me over the edge.

The nights this week weren't too bad though and it was my first time working since completing orientation. I'm now officially on my own, which is stressful but I've just accepted this whole first year is going to be super stressful and I'll probably need a facelift by the end of it. Being exhausted on so many levels is a great ager. BUT, all caps means is my blogspeak for tangent, I had people staying with me this week, I didn't even see them until last night due to my hours working. I haven't seen the one fellow in over a decade and the other, who I wasn't as close to, in who knows, maybe seventeen years or so? How can I put this delicately, the one I haven't seen in seventeen years, he looks bad. He looks easily ten years older than he actually is, he's missing teeth, he looks like an alcoholic, which I strongly suspect that he is. He crashed in my son's bed, which meant that last night my kids both slept in bed with me and I got next to no sleep. But as soon as they left this morning I put everything from Owen's bed in the wash and burned an oakmoss candle in his room because it reeked so heavily of smoke. The room reeked of smoke even though he had been smoking outside on my porch. Oh my, I really don't mean to sound judgmental or bitchy with this but it's sort of stunning how greatly your paths can veer with those you knew in your twenties. I feel like I have nothing in common with them anymore. I'm compulsively neat, cannot tolerate the smell of smoke at all (I hold my breath passing smokers), drink maybe a dozen times a year, have few friends and rarely go out, I'm fucking boring as all hell. I mean these guys are living a booze heavy lifestyle and when I see that now it just makes me sad (did I find this romantic in my twenties, was I really that stupid?) because I know where that goes, having seen how, for all my father's intelligence he amounted to nothing but a half million dollar mountain of debt with his death. Although, my father did have many friends, which is more than I can say and that always makes me think of the quote from It's a Wonderful Life 'remember no man is a failure who has friends.'  This man that looks like he's been on a bender since I saw him last seventeen odd years ago, he was very polite and thankful to me for my hospitality. And the thing that struck me the most, aside from his appearance, is that he drove from upstate NY to Pittsburgh, his face swollen from an abscessed tooth (I can only imagine how brutally painful that must have been) to help his friend cope with his father's death. I mean from a medical perspective I assess him and think, this guy's days are numbered given his lifestyle, but I don't know it's sort of touching he'd go to such lengths to help an old friend.  My friend whose father died came by train with his wife, who's pregnant and would have plenty of totally justifiable reasons to bitch or complain but she struck me as calm, cool, collected and infinitely patient. I was only on the periphery of their even staying here, having only saw them from like 9:30 to 11:30 last night and then briefly this morning but although I know I don't fit that lifestyle, have no desire to fit that lifestyle, I would like to have people I could count on being there for me to the extent his friend was.

The nights I worked this week I had the same patients both nights, one being a person who was recently diagnosed with HIV and then received a diagnosis of a certain blood cancer, I can't really think of two worse diagnoses to receive. Of course, when I first learned I would have this patient I got nervous and was thinking I'm gonna contract HIV. I know this is very silly and as long as I'm safe withdrawing blood samples for labs, which I always am, and avoid an accidental fingerstick, I'll be fine. And I was. Fine. But I feel like I have to be honest that when I initially learn a patient I'm caring for is Hep C positive or HIV positive I do a little freak inside. Until I meet the patient and then I exhale and realize I can handle this. Especially this patient, who was sweet and unbelievably appreciative and the patient's parents, completely adorable. There's certain specifics I'd love to note but I don't want to violate HIPPA. But I think when you see a person in this state and hear their parents mentioning things never said, I just see so much guilt and pain and lost opportunities that could have been avoided. Everybody means well but no one wants to hurt the other so years of stuff goes unsaid. I totally get that having been raised with repressed WASPs but I hope to God that I foster an environment of honesty and transparency with my children, if they feel they can come to me and discuss anything then I think that would be one of the biggest rewards and give me a feeling that I've done my job in being a good parent.

This job truly sucks the marrow out of me physically and emotionally but it is unbelievably rewarding in ways no other job I've had even comes close to. The only thing that drives me crazy is I want to know more. I read the patient's charts (like this patient) and I have so many questions why is the patient considered to be HIV positive and not have AIDS, the CD4 counts puts them in HIV positive territory but the lymphoma diagnosis could swing them to AIDS and how do you treat the lymphoma and not kill them by completely immunocompromising someone already immunocompromised? I'm confused. This is where I get antsy to be a nurse practitioner, to be able to talk and learn from the doctors more, because the hospital nursing, there's no time to really do that, you're so inundated with tasks, at least I feel that way. And I just have so many questions that go unanswered. But I'll look things up on my own and try to talk to residents or fellows when it seems like they're receptive  to questions and the cool thing is that some of the stuff I try to deduce on my own, through researching online, well it winds up being the right answer, which is cool. I want to learn more I just wish healthcare wasn't so maddeningly hierarchical. Okay I've got to go to bed now. Hope whomever reads this enjoys their weekend, please enjoy it on my behalf, the nurse who will run herself ragged this weekend. Have a drink or six for me.

not work related

Well work is still kicking my ass, I go through my night rotation this week and next so I'll be particularly logy but I'm not writing anything work related in this post. No I've been reading guilty pleasure books, my reward for stuffing so much oncology related information into my brain it will surely herniate from amount of information I'm trying to understand. So I decided to read Hunger Games, devoured that in a night, and then Catching Fire. I've got Mockingjay on my nightstand and started that but it's a bit slow going. And then I kept hearing about this Fifty Shades of Grey book. When I first heard about it I thought it was yet another young adult novel that had taken off with older adults. Oh how wrong I was. I finished it in a couple of days and I'm just so confused. I don't understand what all the hype is about (and there is a lot of hype, Newsweek has a cover basically related to the popularity of this book) because it's supposed to be a book about this guy being all into dominant/submissive relationships but, I don't know, it seemed really tame to me. And frankly insipid. I mean the writing is at that Danielle Steel level of perfect people although, to be fair, the author does make reference to Tess of the d'Urbervilles numerous times and I'm sure if you graded it on the Flesch-Kinkaid reading index it would be a level or two above Steel and Sidney Sheldon. But the protagonist in the book is named Anastasia Steele, honestly could you be more cliche you've got Danielle Steel's last name with an e added to it, why not pick a protagonist with a name like Ramona Lipschitz just to add some zing. And everyone is too perfect in this book, perfect looking, wealthy, oh and the really pushing the limits of suspension of disbelief, not only is Anastasia Steele a virgin, she has never touched herself. I think if I had read this in seventh grade it would have blown my mind with the sex stuff, but even back then I would have questioned the virgin who has never touched herself. And now I'm middle aged, divorced and I read Dan Savage every week. I guess I thought that this book would be racier, more of a book equivalent of a David Cronenberg film or the movie Secretary but for all the BDSM implied it's really pretty vanilla. I kept waiting for it to get to a really steamy passage and it never did and the main character is so fucking sanctimonious. The dominant lead, who is falling for her so he's falling short on his dominance and power play stuff, quickly doing these all these firsts for him, like sleeping, just sleeping with Anastasia, and letting her use his first name, blah blah blah. And this protagonist is such an annoying twenty two year old self righteous twit; she's all I can't take these first addition books that you're giving me, the audi, the clothes. Honestly this is like a completely unrealistic dream come true, you get a hot, young, insanely wealthy and powerful guy that's showering you with gifts, telling you how beautiful you are, that you bewitch him, plus he plays piano, speaks fluent French and can drive a helicopter. Oh yes, and he's great in bed?! I'd let him brand my ass if he wanted to. People settle for much much less. I guess this is what forty-three plus years and two kids turns me into, a pragmatist. If it's mind blowing sex I think I could very quickly become nonjudgmental about this fellow's kinks. Spoiler alert: The main character gets spanked, blindfolded and has her wrists tied (with a tie and cable ties) the climax of the story (oh my God reading about all this girl's many earth shattering orgasms I wanted to scream 'enough already', well that and her constant peppering of interior monologues consisting of 'holy crap' but the I don't know controversial/steamy end is when this girl is spanked with a belt and she ends the relationship because this fellow's way too fucked up for her if that's what he's into. Really? I mean I'm sure it hurt but um this is the shocking end? Okay, truth be told my sex life has been very vanilla so I don't have any idea what a truly dominant/submissive relationship is like. I've never been spanked (I think I would laugh if someone spanked me) or had my hands cabled tied or anything like what this female lead gets. But I'm like what's the big deal? I want to read about characters more flawed, more human and therefore infinitely more relatable and sympathetic. I'd prefer that this main guy was into something really dirty or weird aside from what I'm thinking are probably more pedestrian kinks, at least in the BDSM community. I mean I don't know I'm not a part of that community but I'm sort of curious what they make of the popularity of this book. I'm just confused by what shocks people (this book?) and what doesn't (how many people are unemployed/uninsured yet people watch the Kardashians?).

I tried to watch a porn film with a guy I was seeing once and we both had to stop it fifteen minutes in, it was that bad. There was nothing hot about it, at all. The people were unattractive and fake looking with teeth impossibly white, they were like Ross's teeth in the episode of Friends where he bleaches them and they're so bright they glow in the dark. And yes I get that it's odd that I would watch a porn film and focus on peoples teeth rather than their privates. I just don't find that stuff erotic at all. Nor this book. I find James McAvoy very erotic. And Hugh Laurie, mon dieu, House is ten times more erotic than this book. Oh how fucked am I that I think that? And watching Sigourney Weaver and Mel Gibson make out in The Year of Living Dangerously, that was insanely erotic to me as a teenager, not so much now that Mel Gibson became such a nutter. What else? the INXS video for 'The One Thing' that was a huge turn on to me as a middle schooler, it just seemed to epitomize debauchery. I guess reading the book made me long for those times when the blood courses so quickly through me it makes my whole body hum. For someone that makes me flush so readily (although I talk to anyone with MD after their name and I seem to blush- ugh!), who causes my breath to catch just by seeing them. I would love to have a relationship with someone who makes me physically feel like a teenager, who wouldn't? I think it's why there's so much infidelity, you meet someone who seems to notice and appreciate you and makes you feel young, that's heady stuff. Especially compared to the banalities of the everyday. I guess the real trick is to find someone who makes you feel that good but who you can share the banalities of everyday with. I haven't found that. In the interim, before I become a crazy spinster with cats, I'll lust after my guy at the gym, who I would readily let spank me. And if he bought me an Audi like Christian Grey does for Anastasia Steele (can you believe the names?) who knows what my hard limits would be, or if there would be any.

Ha, I write with much bravado but in reality, I wouldn't even let a man, a very distinguished older gentleman, buy me strawberries when I was in the checkout line at the Giant Eagle and they were some ungodly price when I thought they were on sale and I started turning bright red (like said overpriced strawberries) as the checker took forever to remove the strawberries from my bill and the man was insisting he'd buy them for me, 'Come on, they're good for your health.' And I'm pretty sure he was flirting with me but I'm like Temple Grandin when it comes to flirting, an anthropologist on Mars, and I was mortified taking so much time in the express lane and I kept getting more and more nervous and could not look at this man, who was like sixty but very kind. I just said thank you after declining his many offers to pay for my strawberries and ran to my car.

april fool

So... I'm sort of going back and forth with ending this blog because I think the things I'm writing about most people don't relate to anymore. When I started this blog Oona was one and my Grandmother had just moved here from Cape Cod. I was still married and a stay at home Mom, doing the odd freelance photo retouching job at home. I'm sort of astounded at how much my life has changed since I put that first post up. I've gotten divorced, gone back to school, gotten my RN and am working on a unit where I'm regularly accessing central lines, that burrow into internal jugular veins, tracing a path through the vein to lie in the distal third of the superior vena cava, nestled right above the heart. I've gone from wondering how I could ever manage to give a person a shot to wondering if I'd like to be a nurse practitioner specializing in oncology, because then I would be able to perform bone marrow biopsies, not from a schadenfreude point of view because this sort of looks terrifyingly painful but I've heard in the right hands patients don't really feel a thing. I want hands that sure, attached to a body that feels equally confident in my skills. That will take time, probably a lifetime, but I don't mind passing the years on that quest. I started my ninth week of orientation today. Oh what a difference nine weeks makes. When I say what a difference nine weeks makes, we'll there was one specific episode today that comes to mind but I'm like how do I explain this in a way that those not in healthcare can understand. I'll try.

I had a patient recovering from a MUD transplant, this is a bone marrow transplant where the recipient gets stem cells from a matched unrelated donor. It's really such delicate balance when it comes to bone marrow transplant, when it comes to so much in medicine, weighing the benefits versus the risks. The risks for graft versus host disease are increased with a MUD but some doctors want to see a little bit of GVHD in order to ensure engraftment (that the patient's body has taken on the new stem cells, which decreases the risk of leukemia recurring). The patient had neutropenic fever (spiking a temp when your immune system has basically been obliterated to take on the donor stem cells) and, my God if you saw all the IV medications going in. I was using all three of the central lines, going from antiviral to antibiotic to antifungal. Potassium and magnesium replacements, immunosuppressive therapy. And there were contact precautions so I needed to wash gown and glove every time going in an out. I went in to get vitals at 4 this afternoon and brought along a dinamap (a machine to take vital signs). So I put a pulse oximeter on to get the patient's oxygen saturation and pulse and the dinamap registers the pulse at 250. On seeing that number I think my heart rate and blood pressure quickly spiked. I palpated the patient's pulse and tried to count it. It was quick, definitely tachy (meaning over 100, it was about 126) but I wouldn't be able to palpate 250. There was continuous pulse ox in the room and I turned that on to double check. It started high but then dropped to right around where I palpated it, high 120s. But there was an image going across the screen, it looked like a rhythm strip (which is an EKG reading you look at for heart function). I'd seen it the other day looking like sinus tach but this one kept looking like the patient was throwing PVC's (premature ventricular contractions) and a run of two (bigeminy) and then three in a row and then it looked like a run of V tach - all of these are very bad to see on a rhythm strip and my heart was still in my throat over seeing the heart rate at 250 even if it was erroneous. I ran out and told the resident I thought he should order an EKG and then started saying what I saw. My preceptor is like how do you know what a run of V tach and bigeminy look like? Not meanly, she was impressed but sort of chuckling at me. The resident ran into the room. And then the other nurses are like, you can't get a rhythm strip off the continuous pulse ox - and they were right. You need to be monitored, which entails having five leads (stickers) hooked up to your torso smoke over fire (red lower left quadrant, black upper left quadrant), clouds over grass (green lower right quadrant, white upper right quadrant) and chocolate close to your heart (self explanatory). I had fucked up. Sent the resident, who's first day it was (wonder how he'll view me now) careening into the room. I felt like such a complete idiot and asshole. I was so scared by that impossibly high number (250!) it clouded my thinking. Maybe it was my own heart that was still having trouble calming down. He came back in and canceled the EKG. I was confused. I've used pulse oximeters plenty of times but there was never a faux incredibly similar to EKG looking rhythm strip attached to them. But I was able to laugh at myself and that's where the pivotal difference is in the time that's passed on the floor. I probably would have bawled early on but now, well I made a fool of myself but no one got hurt. And my preceptor is always saying I'm an excellent nurse, I think she's too kind, but her heart's in the right place and I think she sees that mine is too, that I'm trying my hardest to stay on top of things and keep my patient's safe.

There was a young patient that I wrote of earlier. I really liked her and her Mom. I came in one night having had her just the night before and I knew she was off. I can't explain it, it was just a gut feeling I had. I called the resident on call that night, twice. I kept trying to get her help because her heart rate seemed too high and she was breathing too quickly and she just looked bad too me. The resident blew me off, both times. Chalked up the high heart rate to anxiety. Even when I said 'But she got something for sleep and has been sleeping for four hours and just woke up and she's in the 130s?'. The resident walked in, walked out, did no more than an eyeball assessment then left. But I couldn't put the bad feeling away and went in shortly after the resident left, with the dinamap in tow, just to check her vitals again, to reassure myself. Her heart rate was 165 and her pulse ox was 88% (not good for someone who normally was around 97-98%). She was transferred to the ICU and died a week later. It had been the last day of my night shift. I picked up my children after school that day, it was so beautiful and warm, that we went to the park. A nurse anesthetist I know, our sons are friends, came up to me and asked how work was going and I was talking her about my week and I just wound up crying and talking to her and crying, I just couldn't stop crying, for well over an hour, in the center of the other parents, knitting and eating snacks, and the children running around. Angel, that's her name, truly, and she was an angel to me that day, listened. And she gets it because she's a nurse and it was so unbelievably helpful talking to her.

Angel told me to journal about my days on the job because then I can look back and things and see what I've done right and not beat myself up when I feel like I've fucked up. So I'm writing this post from my new macbook air (13 inches and light as a feather). Once I get Word on this I think I'm just going to puzzle this stuff out on my own. My dream is be to be the nurse equivalent of Atul Gawande, to be able to write that well about medicine, but from a nursing perspective. But I don't know that I can write this way on this blog anymore, it hurts my heart too much. I feel displaced in most every role I inhabit; mother, nurse, friend, other. Maybe I'll switch to pictures if I get around to getting an iphone.

If I was really clever I would have shouted, "April Fool's!" once the resident came back to the nursing station after running to the patient's room for the stat EKG I was recommending but I'm too flipping earnest to be a tease.