Liar, Liar Pants on Fire

I have started to think that my friends and fellow nursing students don't really believe this whole circus shtick of mine. Frankly, since nursing school started I don't really believe it anymore either. Well, there's photographic evidence. (I know, I know -- I'm faceless. But there is HIPAA to contend with here, so enough already.)

I have been for a long time at your side

"I see them! Over there against the stormy sky. They are all there..." ~ Det sjunde inseglet




"By this time I'd had the experience of dying patients at the hospital and I was becoming interested in dying and death and resenting the way I'd been deprived of experience of death almost as I would have resented being deprived of love...By the beginning of the next academic year I switched my studies from embryology to death."
~ Daughter Buffalo

I, Antonius Block, play chess with Death.

Most close friends, loved ones, understand my fascination with death and dying. Well, maybe they don't understand, per se, but they are accepting of it. It's the Norse blood, some say.

After dedicating years to the folkloric study of death rituals and legends, cryonics, anthropology da morte, being deprived of death both by exclusion and by default* I have been reacquainted with it in the clinical setting. What an experience.

*In case you haven't noticed, sans the Veteran's Memorial in the Presidio, there are no cemeteries in San Francisco. I won't say what my mind conjures about the implication of that absence, but when in need, one can always visit Colma, California -- the city which has "inherited [our] hundreds of thousands of bodies." The story goes that the San Francisco board of supervisors "evicted" all of its cemeteries in 1912; by 1937, all the bodies were removed, making us San Francisco the city of the living. The city without the dead. Weird.

Sunlit

"Once one's said it, that one must act, one must ask oneself, shall I act within the cultural order I do not believe in but with which I am engaged by times of love or anyway ties of of fellow-feeling, or shall I act within the cosmic order I do believe in, at least in principle, an order indifferent to man? And then again, shall I act by standing indecisive between the two orders -- not striking out for the cosmic order because of my human commitment, not striking out for the cultural order because of my divine commitment? Which shall I renounce, my body -- of which ethical intellect is a function -- or my soul?"

Pedagogical Brilliance

In order to teach proper medication administration and instill confidence, many weeks must be dedicated to scaring the s**t out of nursing students. Brilliant.

The Disappearing Circus

You may have noticed a paucity of circus news here lately... the amazing Xiao Hong is in Beijing for the Olympics and I have abandoned Daniela and her single point trapeze for the sad excuse of clinical exhaustion. But, never fear, one super-circus-motivated nursing student has recruited me to join her for a morning of flying trapeze -- August 16th. Stay tuned.

Miriam & Emma flying at this year's Circus Center showcase. Image, again, courtesy of Seth.

Geri

“Geri is ideal for preparing students for working with real-life geriatric patients, since it features an elderly appearance with skin wrinkles and folds. No other manikin on the market is so realistic and true-to-life.”

Geri has a lot of parts to try to comprehend. And a few anatomical extras, if you see what I mean.

General Medicine

Tuberculosis, methicillin-resistant staphylococcus aureus, acute colitis, cystic fibrosis, cancer, renal failure, necrotizing fasciitis, acute lymphatic leukemia, pneumonia, paralysis secondary to lumbar laminectomy, abscessed abdominal incision with wound vac, inflammation of the terminal ileum secondary to Chron’s disease, herniated intestine causing malnutrition, muscular sclerosis with secondary decubitus ulceration of the bony prominences, dementia, liver failure, more TB, more cancer, more CF, staph infection secondary to hip replacement accompanied by cirrhosis, undiagnosed, undiagnosed, undiagnosed…welcome to general medicine, week 5!

The Foley Zone

Maybe it's like the erotic zone and/or the Twilight Zone, but I am still trying to figure out why the men in our cohort felt compelled to don the female genitalia for catheter insertion* in clinical skills lab on Tuesday.
And while I am flummoxed, I am not-so-secretly jealous that John-Paul caught it on film.

*Each colleague that I saw do this, did so independent of the other... that is, without knowledge that someone had tired the vagina on for size before him. Hmm.

Clinical Sequelae of Infarction

Studying for the last pathophysiology exam I read this: MI --> reduced CO --> dilation of heart --> increased pathway length for conduction --> allow impulse to re-enter muscle that is recovering refractoriness --> increased potential for circus movements --> VT

Two days after the test, I have still been trying to figure out what "circus movements" are and what they have to do with infarction. Here is what I found:

"If a ring of excitable tissue is stimulated at a single point, the subsequent waves of depolarisation pass around the ring. The waves eventually meet and cancel each other out, but, if an area of transient block occurred with a refractory period that blocked one wavefront and subsequently allowed the other to proceed retrogradely over the other path, then a self-sustaining circus movement phenomenon would result." Mines and Garrey

Anyway, it's a form of arrhythmia associated with ventricular fibrillation and one more bit of minutiae that I don't need to know about the heart. Alas.

Front Mullet

The Kid thinks I have cut his hair into what he calls a "front mullet". Not to be confused with the "top mullet" he accuses many thirty- something hipsters of sporting these days.

Miss You

I say sorry
I say bye bye
I say miss you
I say cry cry

Hypochondria & the Student Nurse

Do all student nurses become mysophobic hypochondriacs
or is it just me?

Contraception as Abortion

Interesting. I'm not totally sure what exactly what HHS-45-CFR* entails. From my reading we're dealing with the federal government withholding funding from any organization that "discriminates" against a healthcare professional that refuses to administer an abortificant. The part that's causing bristling is that HHS has expanded the latter terminology to include emergency contraception (bka "the morning after pill"). Most of us know that EC does nothing but provide, ahem, emergency contraception (imagine that) with higher doses of the same hormones (estrogens and/or progestins) found in typical contraceptives. Taken after unprotected sex, high hormonal doses can prevent pregnancy. But, basically, they're powerless against pregnancy that has already occurred. So, that's disturbing -- using an umbrella to define abortion in order to make it inclusive of contraception. It's also disturbing that there are funds out there potentially withheld from important reproductive services, impinging on certain critical women's rights.

With our broad lens, it looks to be a way to protect individuals with certain moral positions on abortion from discrimination; namely those with personal or religious stances against it. This puts the rest of us in a pretty tricky position -- because fighting for the right is exactly the same ideological battle. Do we think that those individuals who have an ethical stance against abortion should not be allowed to work in clinics where abortions are performed? (Remember, this could also very easily be the very clinic where babies are born.) I don't think so. It would be the same as saying we can't work in L&D because we support and are willing to participate in termination or for that matter, contraception. We don't want such divisions.

I want to acknowledge that defining abortion by conscience absolutely sets a dangerous precedent for policy: when we start defining "life" as implantation, there are some very real consequences that darken our horizon. It's a slippery slope, for sure. I just worry about accepting all of the hullabaloo caused by commentary without going back to the source and making critical and thoughtful statements of our own. We need to remember that sometimes "critical" commentary isn't critical (as in thinking outside of the box), but critical, (as in reactionary). I encourage everyone to read the HHS statement before running off, pitchforks raised, for the lynching.

~ If you want a really straight-forward women's right issue to be pissed about, look at this.
Thanks to slight of hand by Senator David Vitter (R-La.) the Indian Health Care Improvement Act, initially meant to provide "new programs, improved facilities and funding for the Indian Health Services system which serves about 1.9 million people nationwide," now explicitly restricts abortions under IHS programs. That's a huge problem. Apparently, Vitter's handiwork is nothing more than a reiteration of the Hyde Amendment which has been under scrutiny and re-evaluated and fiddled with practically every year for the past thirty + years. (That's the one that bars the use of federal funds to pay for abortions for low-income women.)

*Thanks to fellow MEPN, the lovely and brilliant Nicole, for alerting CN to this development.

Disease vs Patient

The third week of clinicals was amazing, fascinating, humbling and exhausting. Working in medicine in a very busy unit has proved challenging. Being trained at a tertiary hospital means that some -- most -- of the patients that we see are very, very sick. For example, Thursday I saw and cared for a patient with necrotizing fasciitis. Friday, with seven patients, we saw everything from TB, HIV, CF, MS, colitis, renal failure, all the way to palliative care for a very young cancer patient.

While the diseases are interesting, and processes hold a fascination all their own, I came away with the feeling that there is a real necessity to make nursing about the patient and not just about the disease and its management. Friday revealed two nurses out of six on the unit who had the ability and the drive to understand the patients and their disease, and to understand the patients despite their disease.

Friday I also had to fly home unexpectedly to be with a critically ill family member. I've been feeling out my own reaction to it. I found that I immediately wanted to understand the disease. I wanted a prognosis. When I laid eyes on the situation for myself, I found that "nurse eyes" (assess, assess, assess) were ready, doing their job, second nature. Then, of course, I became emotional. So the next thing I tried to focus on was the care being provided. I watched the nursing process. I wanted to learn about the drugs, the reactions, the process of healing. But more, I watched the way the nurses interacted with both the patient and my family. There was a glaring absence of compassion. Many processes took place without explanation or apparent reason. I saw this on Friday as well, with my palliative care patient. The family wanted their father, brother, cousin, uncle, husband, son to be treated like our own. And in large part, sadly, he wasn't. He was in pain. He was dying and we were disrupting that death, his experience of it and his family's for lack of protocol and lack of differentiation of the man from his illness. In fact, he seemed to have become his illness in the eyes of the medical professionals and therefore his death became a symptom of it, instead of the inevitable human experience. He was lost in there somewhere.

I want to preserve this, the way I feel about this person, my patient, his family, my family, our "patient" -- before I am a nurse -- so that when I am a nurse, I will never forget.

While the disease is of the patient, the patient is not necessarily of the disease. As we treat both the patient and disease we need to remember, foremost, not treat them as if they are one.

Heart Sounds

Because yesterday I learned
that the heart is a beautiful thing
and today I learned that
it is sometimes
not.

Montana Diving Board

Old Steele Bridge. Kalispell, MT

Burden of Dreams

"Today was a good day.
I hated today.
I don't know why,
but I hated today."

-Werner Herzog

PhDoctor?

An interesting discussion came up at lunch yesterday regarding the previously mentioned Doctorate of Nursing Practice. Someone in the program posted an AMA resolution on the use of the titles "Doctor" and "Resident" in clinical practice*, which led to a deluge of negative comments directed at the docs, whether they support the position or not. (Weirdly, a lot of people also seem to think that the AMA is still only comprised of stodgy old white men. While I’m no Milton Freidman, I see the problems with the organization. Still, there’s a little denialism going on if we actually believe that it hasn’t diversified and made some important changes, and contributions, over the years.) In any event, I’m sure the position of this organization on the DNP goes without saying. But it’s hardly the point. The argument from the master’s entry students has largely been that the DNP is a great coup for nurses, that it seeks to put the advanced practice nurse on par with those they see as their medical doppelgangers. To me, both of these positions are misdirected and fairly uncritical, but my saying so led to some definite winking and spitting in my direction. Though I'm cursed, I'd like to clarify.

First, I recognize that the DNP provides the opportunity for APNs to seek higher level education and to complete a residency in his or her chosen specialty. This is a very good thing. It is also a good thing that we have the chance to earn a degree beyond the terminal master's that isn't specific to research or policy. It's important that we can further our clinical practice in order to teach the next generation of nurses. My fear, however, is the requirement for the APN to seek out a clinically-based PhD. And I believe I doubt with sound mind. We’re not doctors and we don’t treat under the medical model. Physicians and physician’s assistants treat under this model, and both practices are distinct from nursing.

The more critical point, however, is a glaring one that can be demonstrated in the master’s entry program, and that is to whom this advanced practice is available. It’s not necessarily the best nurses, nor, as we’ve been repeatedly told since we were admitted to UCSF, the best and brightest individuals, but those who have and have had the resources to pursue an advanced practice degree.

Let’s expand our practice to make the most of those who are best for the practice and best for the patient – not turn advanced practice nursing into another place to demonstrate privilege. Seriously.

* I'm just going to be frank here. We're not doctors; even with a PhD we're not MDs. The whole "Dr" title for the PhD recipient has always made me a little woozy. Just remember, if I go into cardiac arrest on some form of public transit, don't ask if there's a doctor on board. I don't want some anthropologist hovering over me as I die.

Ode to the NA

Unofficially, I began clinical rotations last week. Yesterday I began working, officially. I'm at a tertiary hospital for eight hour shifts. At the moment, all of the MEPNs are shadowing nurse's aids, arguably the hardest working people in the hospital. The NA that I shadowed yesterday not only works an 8 hour day shift on one of the busiest floors of the hospital, but travels 30 miles to a skilled nursing facility where she works another 8 hour shift, 5 days per week. She was humble, informative, hard working, compassionate. As we were charting at the end of the day, we were looking through the chart at patient diagnoses. "Read this," she said of the doctor's notes, "you'll need to know it." If I had a diagnostic question, she'd answer it. As it turns out, she was licensed and practiced as an RN in Manila. She's now practicing at home (in her spare time, whenever that can possibly be) to take the NCLEX here in California. And that, my friends, is much, much harder work than MEPN.