Okay, so you've been a nurse for a year or so....now what?

Julie and I were sitting in the monitoring room the other morning before report, just enjoying the glamorous and exciting life of the nurse, when she made a comment that I remember making:

"I've been a nurse for a year, and I am so burned out. I can't wait until I actually know something."

(Now, before any of you older nurses snicker over the "burned out" part, think back: remember how it felt to be overwhelmed all the time? Yeah. Like that.)

I think everybody feels that way after the first year, and then again after the second. Not to give you false hope, or anything, but after the second year of practice, nursing gets a whole lot easier. The question of *why* it's so hard the first two years, though, is something that it might help to understand. Heck, it might keep you from flinging yourself in front of a fast-moving laundry cart, even.

The first year of nursing is a combination of one part sheer terror and two parts cluelessness. It doesn't matter how well you did in class with pathophysiology or nursing diagnosis; things are much, much different when seen in 3D. Looking at a lab report with wonky numbers and figuring out what's going on in the classroom is miles away from looking at the same numbers at the nurses' station as call bells are going off, doctors are rounding, and your patient has sixteen other things going on that distract you from those numbers. I like the simile that another colleague of mine came up with: Nursing school is like learning to put together a jigsaw puzzle of a cathedral, while practice is like being handed a bunch of stone blocks and being told to build that church.

"Burned out" isn't really the right term for it. Most of us still want to come to work, and most of us aren't especially depressed by our choice of career. It's more like your brain feels full all the time, and you never really get a chance to integrate things. You *know* you're learning stuff, but it's either not really sticking (even though it is), or things are happening so fast that you have a hard time with recall (even though you don't).

Plus, you keep feeling like you're totally ignorant. (You're not.) Again, it's that jigsaw puzzle versus cathedral-building thing: you have all the information you need, but it's hard to put it together on the fly.

And, if all of that weren't enough, you're refining your routine and your time management and the way you deal with people and doctors and other staff members and learning who to call in the pharmacy when the dadratted drug machine won't dispense and what to eat and what to stay away from in the cafeteria and where the best bathrooms are and.....*whew*.

The good news is that the feeling of being constantly overwhelmed goes away. The bad news is that it's replaced, during the second year, with "is this all there is?"

There's a good reason for *that*, too. During the second year of practice--and keep in mind that these timetables are fairly arbitrary and mostly based on my own experience--you've got the basics covered. You can make a bed with a person in it, you can lever a body up off the floor without hurting yourself or them. A crazy-low potassium or calcium level won't make you panic, and you know who to call at 3 am for those problems.

The trouble is that you're....well, you're kind of disappointed. Things seem a little dull.

That feeling passes, too. It's there because you've absorbed all the things you need to do your job *efficiently*, but you're not quite to the comprehensive detail-management, weird-complication-anticipating point. That comes during the middle or end of the second year, and things therefore suddenly get much more interesting.

The biggest change in my practice between years two and three was this: I began to be able to see, sometimes even days in advance, what might go wrong with a patient. My care up to that point had been competent, but shallow. After two-and-a-half years, it deepened, as everything that I knew and everything that I could imagine anticipating came together in a cohesive whole.

The human brain recognizes patterns. Part of the brain's development is the ability to recognize patterns *as part of a whole picture*. That's what happens during years two and three: the big stone blocks you've piled up begin to resemble a cathedral, because you're able to stand back and see the whole damn thing.

So hang in there. Don't feel like you're the Lone Ranger on this one--believe me, going from expert in one part of nursing to novice in another brings those feelings right back. If you're feeling overwhelmed still, remind yourself to look back in a year more and see how things have changed.

Because your brain will catch up and your practice *will* change. The stuff you need to avoid in the cafeteria, though? That stays the same.

OMG WTF AM I DOING HERE? A guide to your first months as a nurse (with special thanks to Pip)

When I was a new-new nurse, like my first six months on the job, I would show up way early for work every morning and pray in the hospital chapel that I wouldn't kill somebody. I was scared--constantly terrified--of all the mistakes I could make, of how little I knew, of how easy it was to screw up and do damage.

Slowly, those feelings went away. It took about a year and a half before I could say "I'm a nurse" without feeling like a fraud. Watching other new nurses go through orientation after me really helped--it showed me exactly how many people are watching your every move as an RN.

So, and with full thanks to Faithful Minon Pip, who said, "Yo, dude, you need to write a 'surviving as a nurse' post", here are tips for Surviving As A New Nurse, Dude. Yo:

1. Pee.

This is the single most important piece of advice I have for new nurses. Right after report, but before you hit the floor, pee. Emptying your bladder will clear your mind and take one small worry away. With any luck, it'll be hours before you need to pee again (unless you're me) and you'll have a chance to get things done before then.

2. You are not going to kill anybody. No, really, you're not.

There are three reasons for this, so I will subset them under the main point:

A. Humans can take an unbelievable amount of damage before they keel over.

You're unlikely to do the sort of damage it would take to kill somebody yourself; it generally takes a fair number of tiny mistakes that add up. At every stage of the way, there's the chance to ask questions, to catch problems, and to stop bad things from happening. Your job, therefore, is to be The Elephant's Child and ask questions about anything you don't completely understand and feel comfortable with.

B. Everybody is looking over your shoulder.

Yeah, you as the RN have ultimate accountability and responsibility for what happens, but remember: you have other nurses, pharmacists, and docs checking you all the time. Lean on them. See "asking questions", above.

C. Humans can take an unbelievable amount of damage before they keel over.

This is exactly the first point, but I'd like to take a different tack on it: I have had patients with potassium or magnesium or calcium or pH levels that were totally incompatible with life, and those patients weren't even all that sick. I have had patients with blood pressures that would make your eyes bug out and others with pressures that made me wonder if they were perfusing everything. I have had patients missing legs, arms, and (once) half of a body. All of those folks lived, and they all did mostly fine. It's all about what that person is used to. For some people, walking around with a calcium of 5.3 is totally legit.

3. The First Rule Of Nursing Is: If You Have To Fuck With It, It's Wrong*.

There was a story years ago about a new nurse in my orientation class who ran oral contrast through a central line, thus injuring (but not killing) her patient (see, we really can take a lot!). In order to do that, she had to set up a Rube Goldbergian series of tubes and connectors, find a certain type of syringe that would fit the end of it, and then administer the oral contrast bit by bit, because it's very thick stuff.

Think of how much she had to fuck with that to make it work. If you're having to force something to make sense or work, STOP. Look around. Ask if you're doing it right. Medical equipment, med-administration rules, and protocols are so bulletproof these days that it's work to screw them up.

4. Find somebody whose shoulder you can cry on.

This might be a preceptor, a fellow orientee, a more experienced nurse, or your mom. Whoever it is, find that person and use them as a sounding board for when you do something really stoopid. You *will* do stoopid things now and again--all nurses do, all through their careers--and it's important that you find someone who understands and can make you feel like less of a donkey.

5. Remember that things will get easier.

It's hard at first to get your skills and time-management and organization down. You might miss lunch or end up with a bladder infection, but that will change. Eventually, some things will become so second-nature that you'll have to double-check to make sure you did them. Eventually, changing a bed with a patient in it will be simple. And eventually, you'll have time for lunch. Don't despair.

6. Don't be afraid to ask for help.

Delegation is a beautiful thing. Find the people who are willing to help you and lean on them.

7. Don't be afraid to ask questions, even stupid ones.

I ask questions all the time, sometimes the same ones over and over in a shift. Nobody thinks I'm an idiot. Obsessive-compulsive, yes, and perhaps with a little short-term memory deficit, but not stupid. They do it too. Questions are good.

8. Be kind to the techs and the unit secretary, for they will save your ass someday.

This one needs no explanation.

9. Likewise, be kind to the doctors, for mostly they love to teach and are fairly nice people.

If you find one who's a jerk, avoid him or her at all costs until you feel more confident. Nothing will make you fade faster than being yelled at by an asshole with "MD" after his/her name.

10. And do find time to be kind to yourself.

You didn't spring fully-fledged from some god's forehead, and neither did any other nurse currently in existence. Even Cherry Ames screwed up now and then, and she learned things every day of her career. You will, too. Be easy on yourself: you've taken on a very tough job, in a challenging, rapidly-changing profession, and the whole of it is something that nobody but another nurse could really understand.

*Funny story about Jo's First Rule Of Nursing: I had a student precepting with me the other week in the CCU, and I told her as we started, "Remember: the first rule of nursing is, 'if you have to fuck with it, it's wrong'." She immediately said, "Oh, my gosh! You read Head Nurse, too! I love that blog!" I concurred solemnly that the writer was a damn genius, the crafter of elegant and spare prose without equal in the world today, and then we went on with our day.

When What's For Lunch Is You: Dealing With Workplace Bullies.

Nurses eat their young.

Bullshit.

Nurses don't eat their young any more than electricians do, or bookstore clerks do, or lifeguards do. There are bullies in every profession; the thing about nursing is that we're expected to be all warm and cuddly and friendly and healing angels of peace yadda yadda. So when "horizontal violence", or bullying, happens, everyone clutches their pearls and has a little crinoline-lifting moment.

Still, if you have to deal with a bully at work, things can suck hard. I deal with three on a regular basis. Two I've dealt with fairly successfully up to now and the other I've ignored. Here, therefore, are the three types of bullies you'll encounter most frequently and the ways I've come up with to handle these people. More suggestions in the comments would be welcome.

(Nota Bene to new nurses: If your manager is the one who's determined to clean your bones, get a new job. There is no winning with a bullying boss, unless you're willing to spend a whole lot of time and effort to get them reprimanded repeatedly and then fired. If you're new, quite frankly, you have better ways to spend your time. Get the hell out and leave the crusade to older nurses who don't have to worry about ruining their future careers through one bad apple. Seriously.)

Bully Number One: The Know-It-All.

This person just wants to help you. Yeah, right. They know more than you do (debatable) and are better at their job than you are (extremely debatable), and are determined to let you know it every single time you two work together. It's wearing and exhausting to have to listen to unsolicited advice when you're trying to get something done, and a lot of what the Know-It-All does involves criticizing (ever so subtly!) the people who taught you how to do those things in the first place.

How To Deal With Bully Number One: Speak Up.

This is the hardest sort of bully to work with, though he's often the least damaging to you personally and professionally. Bullies in general are easily recognized by other people that you work with; it's likely that this guy has a reputation that preceeds him. Still, he can make you (meaning me) freeze up and screw little things up when he's got you under the microscope, no matter how much experience you've got.

Therefore, the only way to handle such a person is to be frank. You have to tell them--sometimes repeatedly, in a variety of situations--that you're doing fine, thanks, that yes, you understand that X, Y, and Z lead to Q, and that the way you're running that line is just fine with your preceptor, manager, and the attending.

Doing it respectfully is the key. Doing it without losing your temper is critical.

Oh, and by the way: Never, ever, ever ask this type of person for help. They'll likely defer to the patient care aid, the charge nurse, or Santa Claus before actually being useful.

Bully Number Two: It's a bird! It's a plane! No, it's Off-The-Handle Man (or Woman)!!

This sort of person can be nurse, doctor, or aid. Or respiratory therapist or X-ray person or whatever. The thing that distinguishes this sort of bully is that everything will be fine for some time.....when suddenly, they'll blow up at you over a situation or problem over which you either have no control or weren't involved in in the first place.

There's usually shouting involved. There's also usually hand-flapping, eye-rolling, and perhaps some loose spittle here and there. It's scary and can be enraging, but like the Know-It-All, the actions of OTHM, while disturbing, really don't make much of a lasting difference to anybody.

How To Deal With Bully Number Two: Employ Heavy Weaponry.

This is another sort of situation you gotta deal with immediately. It's fresh in my mind because I just had a mild, drama-free showdown with our local OTHW the other day, and here's what I did:

I waited as calmly as possible until she finished screeching, and then I said, "There's obviously a problem here. Let's take it to Boss Lady as soon as she gets in."

OTHW backed down immediately, saying that oh, no, that's not necessary, but--and here's where the heavy weaponry part kicks in--I would not let her off the hook. She'd yelled at me for something completely beyond my control, made some remarks about my parentage and my personality into the bargain, and scared hell out of a student I was precepting.

So in the morning, off we went to see Boss Lady. As we walked into her office, I said, "OTHW got very upset with me this morning, and so we need a mediator. I'll let her talk first." And then I sat down and made myself comfortable while she ranted.

This is, again, crucial: you must let the nutjob spew gaskets and bolts all over before you respond in a reasoned, logical manner. Not only will it make you look like a fair person, but it's golden for getting your point across in such a way that showcases the other person's wackiness.

Not only, then, do you show your boss where the problem is, but you do something equally important: you let OTHperson know that you are on it, you are down with it, and you are not afraid to bring it to their doorstep (as the kids say). Not being intimidated is what makes these bullies leave you alone.

And finally, Bully Number Three: She Who Must Not Be Named.

I have no good name for this person. If there's a nurse that eats her young, this is the one: passive-aggressive, condescending, subtly critical, and prone to complain about other nurses to residents and attendings. This is the bully that you have to watch out for, as she can be damaging to your reputation as a nurse and your standing with your boss and the people who aren't there all day (like doctors).

How To Deal With Bully Number Three: Get Ready For The Long Haul

Unfortunately, like all things toxic and explosive, this person is the hardest sort of workplace bully to handle. You can go about it two ways: ignore what's happening and just keep your head down, or write everything down and make a near-Federal case of it when you have enough evidence.

You know how everybody always tells you, "Write everything down", right? Well, it's true: it does give you ammunition when and if you want to confront SWMNBN in the boss's office. (Don't ever do it alone, without a senior person there. That way lieth disaster, verily.) You'll need to be as careful at recording what she says or does as you would be in documenting the care of a very ill patient with litigation-happy family: that's the only way to keep yourself from becoming mired in she-said/he-said Hell.

Try to mitigate this person's actions and words by forging close relationships with the doctors and nurses (and everybody else) you work with. In dealing with our unit's SWMNBN, the reputation that I've developed--carefully and consciously--over the last eight years has been invaluable. You may not have that depth of experience, but it's never a bad time to start building respectful, open relationships with your peers.

And, if it comes to the point that you have to say something to your boss (it might not; often this bully's teeth are pulled when you ignore her or him), it's usually best to meet alone with the boss and show them the evidence you've compiled, then let him or her take it from there. The more ammunition you have, the better--and the higher quality ammo you've got, the better. If a doc reports that SWMNBN told her that you'd not done some vital thing, ask the doc to write that down for you, and keep it with your other documentation.

I wish you luck in dealing with this particular bully. I was fortunate that, when my unit's bully complained to an attending about the care I supposedly hadn't given a patient, she chose an attending with whom I'd just discussed that care, and with whom I have an excellent working relationship. The doc basically nipped that particular bitch in the bud, and I've had no problems since, but it was pure chance that it happened that way.

Tell your fellow Faithful Minions and any new Minions out there how you deal with bullies in the comments, please. And thank you.

Advice needed: current and former nursing students, this one's for you!

A particularly intelligent Faithful Minion and I have been shooting emails back and forth for a week or so. She's having a problem staying motivated through her first semester of nursing school, and I've hit a wall in the advice-giving department. I'm turning it over to you guys.

The problem, as far as we've worked it out, is threefold:

1. Nursing school, and its methods of evaluating knowledge, bears no resemblance to anything else on the planet. Even if you've done well in school before, you're unlikely to do well on the first one or three or six quizzes or tests you take, simply because the testing format is so strange. By "strange" I mean "all the questions come in an NCLEX format and that's freaky as hell."

Query one for Faithful Minions: How do you work out the correct answer when faced with NCLEX-style questions? How is this process different than it was in, say, English class or Biology 101?

2. Screwing up tests and quizzes makes one fearful and anxious of doing it again. This leads to test anxiety, which is a true black, shaggy bitch on your shoulder.

Query two for Faithful Minions: How do you get rid of test anxiety?

3. Screwing up tests and quizzes makes one feel idiotic and unmotivated. Never mind that nursing school is like unto nothing else on the planet except maybe a bad Surrealist novel; it's still happening.

Query three for Faithful Minions: How do you get your mojo back and stay motivated in the face of fuckups?

I have to confess: as my memories of nursing school get foggier, my ability to say anything sensible on this subject dwindles. I'm putting it out there for you guys with the certainty that somebody else will be able to deliver in the brilliance department.

Git to it.

This may be the first time I've ever written a song in honor of a patient.

To the tune of "Mister Sandman":

Mister Dickwad,

Please get well soon;

Can't wait to see a diff'rent face in your room.

You drove me crazy for thirty-six hours,

You pushed the limits of my nursing powers!

Dickwad, I'm at the end

Of any rope I had: I am not your friend.

Please, please get out of your behh-heeed,

Mister Dickwad, heal up your head!

(Backup singers: fuck fuck fuck fuck fuck fuck fuck fuck fuck fuck fuck fuck)

Mister Dickwad, please don't you say,

That sterile fields make no difference each way;

Please don't imply that my training ain't real

Get meningitis: we'll see how you feel!

Dickwad, I've had enough

Of condescension and of your acting tough,

Please, please get out of your bed:

Mister Dickwad, heal up your head!

(Backup singers: dumb dumb dumb dumb dumb dumb dumb dumb...)

Mister Dickwad, can't you shut up?

I need some Scotch, yes, at least half a cup.

I'm tired of your ass-grabbing behavior

Your weakened state here will not be your savior!

Dickwad, when the cops find

Your charred remains, I will be on their mind.

But you know I'll be acquitted:

Mister Dickwad, you are half-witted!

Sadly, this particular patient was alert, oriented in all spheres, and totally intact. Also sadly, he was just a bit too big for me to strangle efficiently.

Sometimes I just want to go back to waiting tables.

Saturday Seriousness: for nursing students.

It's not often that I'm really, really serious, but today I think I might as well go 'head and be.

I got to thinking today about what five things I could tell nursing students that would make them feel better--or at least a little less bad--about clinical rotations and classes. Here, then, with a special shout out to my fellow Texan Rob, currently kickin' ass and diggin' shallow graves (see his blog in the listing to the right!), is my list of Five Things You Must Know About Nursing School:

1. Nobody Wants You To Fail. They Just Want You Not To Be Stupid.

Even the toughest professor I had (Pediatrics, booyah!) would forgive stupidity if it was followed by a fast "Oh, duh, I wasn't thinking." Trust me. I had plenty of those moments and still graduated. The professors who seem most intent on weeding out students are those who are also excited and stimulated by people who want to be challenged.

2. The Nurses You're Paired With During Rotations Don't Hate You; They're Just Nurses.

We say things once and expect you to get them. We want you to conform your schedule to ours; after all, you're usually leaving halfway through the shift, and we're there all day. We double- and triple-check everything that you do not just because you're newbies, but because we care about you not learning something wrong. But we (well, most of us; there are some toxic weirdos out there) really like nursing students. We want you to do well, and we like teaching.

3. That Said, Someday You Will Be Just Like Us.

I used to swear that I would never be the brash, outspoken, cynical, irreverent, bitter person that I saw over and over and over during rotations. I'm not as bitter as a lot of those nurses, but everything else, I am. I have become incredibly tough-minded and efficient, with a short-term and mid-term memory that would put most Mensa members to shame. You will be that person, too--it's part of becoming a nurse. Just make sure the bitterness comes last in the list rather than first and you'll do fine.

4. Doctors Don't Hate You Either; They're Just Busy.

Learn to say it in the fewest words possible. Never apologize for paging someone, or forget to thank them for returning your call. Have the chart with you before they call back. If you must interrupt rounds, be sure it's for something major, like the patient's stopped breathing and you can't intubate them. Doctors like efficiency, and they love nurses who are one step ahead of them.

If these skills don't come immediately, don't fret. They take practice.

5. Eventually, This Will Be Over.

Everybody has a breakdown in nursing school, and everybody has a crisis when they're a new nurse. It's okay. You're riding the steepest learning curve known to man. In time, it'll smooth out and you'll feel finally like you're swimming with the current rather than fighting to stay afloat.

In the meantime: sharp pencils, extra pens, and notecards never hurt anybody. And have some fun learning this stuff, okay? It's actually really, really cool to be a nurse.

An excellent question

we are not so dissimilar, new nurses and new doctors. so why the disconnect? if we can all acknowledge that we're all here for the same reason - to learn how to do our jobs, and to do as much good as possible, with as little harm - can't we meet in the middle? with the greater good as our goal?

That particular question came from the comments on the post before last, and it's a hell of a poser. Why can't we, in the immortal words of R. King, all just get along?

Ego. Fear. Exhaustion. Territorialness (well, it's a word *now*). Bad examples set by other people. 

I have heard, oh my friends, horror stories from residents and nurses alike about how they're treated by each other. I read once, on another blog, of how an older nurse told the new nurses in her charge to treat residents badly so they'd know their place. I once witnessed an attending telling a resident that nurses tended to get hysterical over nothing. That was the same guy who swept an entire counter full of charts off into the face of a charge nurse, so consider the source--but it goes to show you that there are bad, bad examples on both sides.

There's also the issue of turfing, or of being territorial. We all want what's best for the people in our care, and sometimes we disagree on how to accomplish what's best for those people. If two people have equally compelling arguments on two sides of an issue, and they're both convinced they're right, you tend to get discord. Sometimes it's hard to admit that, even though you have a good plan, somebody else might have a *better* one. We tend to fall a little in love with both our patients and our treatment ideas; getting over that posessiveness can be difficult. So we fight.

And exhaustion. Imagine, if you're a new nurse, doing everything you're doing now, but with increased power and no sleep for the last 48 hours. (Yeah, yeah, I know there are work-week limits now, but they're honored more in the breach.) Imagine that everything that you do will be gone over with a fine-toothed comb by people whose job it is to teach you hard lessons quickly and sharply. Imagine that, if you screw up, it could easily kill somebody--and you feel like there's nobody checking your work.

Contrariwise, residents, imagine being a new nurse: you're dropped onto the floor after a couple of years of school and told--and it's really true--that you are ultimately responsible for every single thing that happens to your patient. Doc writes a bad order? Pharmacy doesn't catch it? Charge nurse and second nurse go ahead and sign it off, and you give that drug or perform that treatment and it hurts that patient? That is, ultimately, the nurse's responsibility. You're also expected to supervise other people, play peacemaker with family members, coordinate getting the person to radiology/ultrasound/CT/whatever, and still find time to make sure they're not lying in their own shit.

Ego and fear go hand in hand. Everybody's afraid of screwing up and looking stupid. Everybody's afraid of losing some perceived power they have in any situation. And that tends to make people jerky at best and assholish at worst. 

The thing is, though, that doctors and nurses have the same feelings and the same reactions to situations. We all get frustrated, we all remind ourselves that you can't medicate crazy, and sometimes we all just need a cup of caffeine and a shower. 

My advice? If you want to work with people who aren't jerks, find a facility that fosters respect among colleagues. If you're unlucky enough to have an attending who shoves charts off of counters and yells at his residents and nurses in common areas, try to be the opposite of that person. Likewise, if you're a new nurse with a preceptor or mentor who views residents and interns with disdain, ask for another preceptor or find another person to hang out with.

Most of all, when you get angry or frustrated, try to remember that the other person is likely just as angry, frustrated, and frightened as you are. If you yell, apologize. If you break down in tears of frustration, that's okay. If you need to, you can take a deep breath, give the issue a rest for two minutes, and return to it in a calmer state of mind.

All of us are in the same boat. Rather than smacking each other with the oars, we ought to dig in and start rowing. Forgiveness, a sense of humor, and keeping hold of your self-respect helps a lot.

Everybody has it that bad. I promise.

A colleague-shaped blur went past me this week and resolved itself, once I caught up to it, as Marcia, one of the new nurses on our floor. She just got out of her internship and has been looking a bit white around the eyeballs lately.

"What's up?" I asked. "D'you need any help with anything?" 

"No..." she replied, "It's just one of those learning experience kind of days."

Ooooohhhh yeah. I remember those days. Sometimes (meaning about three shifts out of five) I still have them. There is nothing worse than being a new nurse and having Learning Experiences every. damn. day. you work.

Because, no matter how hard you try, you still feel like either an asshole or an idiot (or both) by about noon. This is common, and it's caused by the fact that you think you've actually learned something in nursing school. 

Not that I'm bagging on nursing school. It's like this: You learn all this very useful information, and all these valuable facts, but you don't--you *can't*--learn how to put them into practice until you've been, well, *practicing* for a while. Coming out of nursing school and expecting to have a handle on being a nurse is a lot like taking driver's ed without ever getting into a car, then expecting to be able to handle rush-hour traffic. On a different planet. With totally different physical laws.

Part of the problem, I think, is that you're trying to put things that you learned in a static fashion into practice in motion. I know that's a weird way to look at it, but bear with me. When you're in nursing school, you get a case study or a scenario to work with, and you can go through it step by step in a logical fashion.  You're sitting down, what you're working on is the only thing you have to deal with. Once you get out onto the floor, though, you have that scenario *and* about fourteen other things--literally--happening at the same time, and you have to keep track of all of them, and call bells are going off, and people are falling over in the bathroom, and you're running down the hall. 

Not only does your brain have to get good at sorting, discarding, and shoving things into medium-term memory, but you have to do it all on the run and while paranoid. 

This is why new nurses have breakdowns, start drinking, and think about going back to banking.

The good news is that things do get better. I don't know how it happens, but somehow your brain gets good at remembering five or six things for an hour or two, ranking those things in order of importance automatically, and then (most important) discarding them once you've dealt with whatever they are. Thinking back, it took about six months for that to start happening for me, and another year for it to get really good. Now I can go to the grocery store without a list and not forget anything. It's a good skill to have.

Also, you get used to thinking on your feet. It'll get to the point eventually that it'll be hard for you to really grasp a new concept without being in motion as you learn it. There's some neurological basis for that, but I'm down two Hop Head Reds at the moment and can't remember what it is. Anyway, you'll get so used to learning and coping while on the fly that it'll seem weird to discuss a problem with a doc if you're standing still.

And finally, you'll lose your pride. I don't mean that in a negative way: you don't turn into some sort of snivelling creature who winces any time anybody corrects you. I mean that you realize that mistakes happen multiple times a day, and catching and correcting them before they do harm is the important thing. You'll also learn that nobody knows everything, and even experienced nurses screw up in impressive, mind-boggling ways. Your ego learns to lie down and take a nap while you're at work, and mistakes quit seeming so damn personal.

Listen: I screw up at least six times in a shift, every shift. Most of the time, thanks to experience, I catch those screwups before they head out the door. Sometimes, I manage something so amazing that it qualifies as a Learning Experience, Nuclear Grade--and I've been doing this full-time, in one specialty, since 2002. Thankfully, my pride doesn't take a hit (or not much of one) every time that happens, because I've learned that I'm not the only one.

There are also things that I still do not know. Some of them are very basic; others are kind of arcane. I ask a lot of questions (one of the docs has nicknamed me the Elephant's Child) and do a lot of reading and try to get in on cool bedside procedures when I can. Those habits are among the most valuable you can develop as a new nurse. Not only do they mean you'll never stop learning, but an honest curiosity about things will put you in good stead with doctors and other nurses who like to teach and learn themselves.

Eventually it will all come together. You'll look up one day and realize you've filled out your chart's checkboxes in three minutes, your patients are all medicated and comfortable, and you actually have time to pee. Six months later you'll have time for lunch. Two years later you'll have enough downtime to fill in a couple of boxes on a crossword. More than that, you'll be able to form a synthesis with speed and accuracy and keep a dozen metaphorical balls in the air without flipping out.

Getting there sucks. The nightmares suck, the fear that you're going to hurt somebody really sucks, and the anxiety is awful. But it all does ease out over time. 

New nurses, listen up: Cut yourself some slack. Be easy on yourself when you look stupid, as you most certainly will. Don't expect to be an instant expert, or even instantly competent at everything. Recognize that you have strengths and play to those. Recognize your weaknesses, too, and learn how to hedge around them and how to compensate.

And for God's sake, don't go back to banking. We need you here with us. I am glad and proud and tickled to death to be working with you, because you teach me so much. You also remind me why the heck I got into this business. So thank you.

And if you need some help, don't hesitate to ask. We've got twelve hours, after all.

In which Head Nurse turns back into a nursing blog, at least temporarily....

I'm back at work. That means I'm too tired to blog at the moment, but trust me: big things are coming.

And it won't just be about siding, windows, doors, bedroom paint, my choice of Roman shades for the new windows, and deck building. It'll be sexy, exciting posts about OMG GONNA KILL US ALL HOLY SHIT WHADDA WE DO RUN RUN RUN AWAY SWINE FLU FROM MEXICO!!

More later. I promise. Meanwhile, keep washing your hands, and keep tuned to this channel. Here at HN we're more committed to the truth than, say, Lou Dobbs.

PS: Cover your nose when you sneeze.

Do Not Want: The brain edition.

Yeah, yeah, I know. I'm a lazy blogger, posting videos from YouTube and graphics from National Geographic. Tra friggin' la; I have the day off.

Which leads, of course, to what I've been doing recently. 

Which is dealing with encephalomalacia. 

Not my own, thankfully; the brain softening of other people.

See, your brain isn't supposed to be soft. It's kinda firm and resillient (in vivo, that is), with its own lovely network of venous sinuses and arteries and linings and ventricles. It's a thing of beauty, whether you're watching it live through a dissecting scope in the OR or on video.

Except when it gets soft. Then it's not so beautiful. Worse, though, than the aesthetic considerations is what encephalomalacia does to a person. Basically, it takes a productive, happy, loving member of society and turns them into a nonresponsive, snoring shell of a person who's getting fed through a tube.

And sometimes we simply don't know what causes it. We can take biopsies galore, we can run every single test on blood and CSF and urine and what-have-you that the most specialized specialists can think up, we can scan and X-ray and poke and prod...and we still don't know why you've all of a sudden become a lump in the bed.

It's frustrating. More than that, it enrages me. Bad enough that somebody that I grew to know a little and like a lot is dying; why on earth can't we figure out why?

The last time this happened, the diagnosis came back primary leptomeningeal melanoma. That happened years and years ago, when I was first starting out in neuroscience. That particular diagnosis was obtained on autopsy. This one probably will be, too.

*sigh*

This, my friends, is the bad thing about nursing: seeing somebody you thought was getting better suddenly get worse and having no hope of an explanation in time to fix them. The only bright spot is that, since we're hip-deep in researchers, maybe the *next* person won't be so badly off. If we can catch whatever-it-is in time. If they have the same thing. If we can figure out what this is in the first place.

Five by Five

It's been a while since I've done a meme, so here's one:

1. Five posts from the blog which I particularly like:

This is the coin

Dear Joey

A Chrissolstikah Story

Nursing Students: A Love Letter

The Nurse's Guide To Specialists

2. Five things of which I am proud:

a. That I work out three to four times a week and thus can lift heavy things

b. That I started the prerequisites for nursing school at 30, despite feeling quite old

c. That of all my colleagues at the hospital, I only really have problems personally with one

d. That my dog likes me

e. That I can get pretty much anything to grow--outside.

3. Five things I'm a bit ashamed of:

a. My temper

b. My foul mouth

c. That I'm a beer snob

d. That I have a terrible weakness for beauty products

e. That every present I wrap looks like a mentally-deficient orangutan went at it with a chop saw.

4. Five things you'll never find in my house:

a. Miracle Whip

b. Far-right periodicals

c. Coors Light

d. A non-dusty surface

e. Anything you can't touch, use, or sit on.

5. Five things you'll always find in my house:

a. Coffee

b. Toilet paper (I have a morbid fear of running out)

c. Brain drugs (ibid)

d. Lots of books

e. Dog and cat hair

What're yours?

The following communication will not be therapeutic.

If you have a patient-controlled pain relief pump that is giving you thirty micrograms of fentanyl every five minutes with an optional bolus of one hundred micrograms of the same drug every hour, and you've been taking advantage of that bolus every hour on the hour for the past twelve hours, and you've also been taking more than one hundred milligrams of baclofen and more than one hundred and twenty milligrams of oxycontin and various other milligrammage of narcotics twice or three times daily, please do not try to get me to believe that you are going into withdrawal because I have removed your fentanyl patch, which expired three days ago.

Because I will look at you and say, "Really?"

Then, when you do not respond, I will say, "Really?"

And when you tell me that you're feeling queasy and you want Phenergan, because ondansetron doesn't work for you, I will say, "Of course it doesn't."

It has been a long week.

What to Expect When You're Expecting A Ventriculostomy!

Back to work, kids! Today, we'll learn about (cue music) Tubes In Your Brain!

(I really wish I could hire James Earl Jones to say "tubes in your brain". That would be cool.)

What's a ventriculostomy, anyway?

Simply put, a ventriculostomy is a tube that goes into a ventricle in your brain to drain off CSF.

Simply put into English, it's a tube that a surgeon runs through your skull and into one of the big, fluid-filled spaces on the inside of your brain (yes, your brain has big fluid-filled spaces on the inside) in order to drain off what's called cerebrospinal fluid. Cerebrospinal fluid surrounds your brain, penetrates it...oh, sorry. *ahem* It does surround your brain, though, and it cushions it and provides a number of different benefits.

So why the hell would I need a tube in my brain?

The reasons aren't good reasons. That is, you're obviously not doing all that well if we're needing to stick a tube in your brain.

The three big reasons to get a ventriculostomy (or "ventric", for those who sling the lingo) are head trauma, including brain bleeds; hydrocephalus that happens really fast, or an infection inside the brain itself that needs to be dosed directly with drugs. We also sometimes put them in during or before surgery, or use them for chemotherapy, though those are less common, at least that I've seen.

Okay, great. What's in this for me?

Well, if you remember your anatomy, you'll remember that there's only room for your brain inside your skull. If you should add more stuff there, like extra CSF or extra blood, your brain gets squished. A ventric can help your brain not get squished by giving it more elbow room. Not that your brain has elbows, mind you.

If you stayed awake during the second hour of anatomy, you might remember that there's something called the blood-brain barrier. Normally, this nifty anatomical trick keeps your brain safe by filtering out all the harmful stuff that could get into your bloodstream, thus keeping it away from the delicate and mostly-defenseless brain. Unfortunately for us, the blood-brain barrier also keeps things like chemotherapy drugs and antibiotics out of the brain. We occasionally have to stick 'em into the brain directly to see an effect.

How do you get one of those ventriculowhatevers?

Sit down. You're gonna love this.

A neurosurgeon drills a hole in your skull at the crown of your head (roughly speaking) and sticks a tube in, aiming for your nose.

Best part? At our facility, it's done at the bedside. With a nurse holding your head and speaking soothing words of comfort (unless it's me, in which case the nurse is humming a little tune and trying to block out what's happening). It's done with a hand drill, usually, unless it's in the operating room, in which case it's done with a power drill. Oh, and lidocaine. Lots of lidocaine.

Yikes. What happens next?

Well, a ventriculostomy, unlike a lumbar drain, is open all the time. It's connected (as with a lumbar drain) to a sterile, closed system. It's also connected to a leveling apparatus that in some cases is kind of fancy and in others involves, like, an old radio antenna* and a marked pole. 

What happens next is "not a lot, really". In other words, if you're the recipient of a ventric, you should begin to feel better fairly quickly (if you're in a state to feel much of anything at all). You might have a dull headache for a while, given that somebody's punched a hole in your brainbox, but that's it. 

Your nurse will watch you like a hawk, making sure that the ventriculostomy drain stays at a particular level, ordered by the doctor, and that there's not too much or too little fluid draining out. If you need drugs administered through the ventric, you'll get those administered by a doctor, through a syringe connected to the tube setup.

What can go wrong?

The biggest threats are infection and overdraining.

See, whenever you penetrate into the brain, you're opening that box of troubles right up. Ventriculostomies are done in a sterile field, of course, and we're paranoid about making sure nothing horrible gets in to the hole. Sometimes, though, things can happen that mean you end up with an infection in the ventricle. In that case, we treat it with stuff instilled--you guessed it--through that ventric.

If your brain is overdrained of CSF, it sags. Sometimes it can herniate (bulge through) the hole in the bottom of your skull. This normally leads to death. That's why the nurse who'll be taking care of you is hopped up on caffeine and hovering over you like a hen with one chick: it's her responsibility to make sure nothing happens (like a sudden position change) that could cause you to overdrain CSF.

The whole infection threat is why she's drawing blood and constantly checking your temperature and asking if your neck is stiff, too. 

What happens when you guys are done with tubes in my brain?

Well, we take it out. The ventric tubing gets pulled out by a doctor, and that's it.

No, really. Sometimes you might get a stitch to close the hole in your scalp, but usually we just slap a piece of sterile gauze or a bandaid on there and let it be.

Holy shit! You're kidding, right?

Nope. Not in the least. The skull itself might take a while to heal, but your scalp heals really quickly--and your brain just sort of squooshes shut around where the tubing used to be.

Uh...so...then what?

Well, presumably, if we've taken out the tube, we've solved the problem.

If your problem is hydrocephalus, we've probably put a shunt in (more about that in a week or so) to help keep your CSF pressures normal. If the problem is an infection, we're done with instilling drugs into your brain. If the problem is a tumor in your brain, we've installed something called an Ommaya reservoir to pump little doses of chemo toward that tumor on a continuous basis. Whatever it is, we're done with tubes in your brain.

That's all, folks! Now you can be happy you've never had to have a ventriculostomy!

*No, really. I had a confused patient once who kept fiddling with and breaking off the leveling arms on his ventric setup, so I had to replace the leveling arm with an old radio antenna I scavenged from the surgeon's lounge. Just call me MacGyver.

I love you guys, but please.

Cut your damn nails.

I *mean*.

A couple weeks ago, while I was at the Doc-In-A-Box, waiting to be diagnosed with "viral syndrome" (what you get when you get the flu after having a flu shot), my vitals and history were taken by a very nice LPN with NAILS.

Now, nails on women bug me. Nails on men are worse. Dirty, too-long nails on men are the absolute worst of all, but long nails are almost as bad. This poor guy had long, broken, filthy nails. 

I dunno--maybe he worked on cars in his spare time. I know that after I've gardened or pulled up bushes or worked on the Honda, my nails are a sight--but I scrub the everloving hell out of them prior to going to work, and have been known to use white nail polish in moderation so I don't scare my patients.

Most importantly, my nails are short. I do not keep my fingernails long so they click when I play the piano. As the firefighter from Islington observed, "You keep your hair short. You keep your nails short. Not terribly feminine, are you?" No, not really; but I'm clean. 

Please, guys--and this includes two guys in particular with whom I work--keep those nails trimmed. Unless you're a professional classical guitarist, there's really no excuse.

And gals--don't get me started on the acrylics, okay? We've been over acrylics, too-tight scrub tops and visible whale tails/tramp stamps before. 

Thank you. I have to go back to work again tomorrow, and I'd really like to see this issue resolved by then.

In which Jo answers questions posed by a semi-anonymous reader.

A couple of weeks ago (or a little more), I got a very nice email from a young man (God, I love being able to say that) who had some questions about nursing and about the blog. He'd read a bit and was interested in learning about stuff I don't necessarily mention here. With his permission (Hi, Chris!), I have excerpted some of his questions and my answers. I think this might be for a class of some sort; Chris, I hope you get a decent grade on your paper.*

You sound sometimes like you really hate your job.

Honey, *everybody* sounds like they hate their job sometimes. I don't. I get frustrated and angry sometimes--not with patients, but with manglement and doctors and sometimes family members--but I love what I do. It's like a cocktail party, but with more blood.

What's the thing that pisses you off about nursing the most?

On a micro level, it's the lack of positive reinforcement I get from my bosses. Yes, I have more than one, and yes, they all suck at telling you you're doing a good job. Fuck up on your charting and you get an immediate email and a correctional meeting; manage to get a hostile family member to calm the hell down and get on board with a plan of care and you hear nothing. My bosses, for the most part, suck rocks. That's discouraging, but not enough that I'm gonna find another job. (I originally typed "mob" for "job", and that's about right.)

On a macro level, it's the "Dare To Care" stereotype of nurses and nursing. If you've read back over the last year or so, you've seen how I yammer on about being a scientist first and a warm, fuzzy person second. One interesting thing that illustrates what I mean: we had a doc write for QID (four-times daily) massages for a patient. Uh...I can't *do* QID, thirty-minute massages. Leaving out that I don't have the training, I have four or five other patients who are, you know, in varying stages of critical. We had to do some hasty education with that doc.

What's the one thing about your job you like best?

Making a difference, as hokey as that sounds. If I'm able to touch a patient with my bare hands when I know they haven't been touched by anybody without gloves in a week, I know it'll make both of us feel better. I love being able to relieve pain and alleviate fear. I love being able to educate. I love being able to learn, most of all--and I learn things from my patients every day. I know more now about structural engineering, how to manage Crohn's disease, Asian art, nonstochastic physics, politics, and being a rodeo clown than I ever imagined I would know.

The patients are the absolute best part of my job, hands and spines and brain pans down.

You sound like you work for Dr. House. Is everything always so complex at your job?

No. I write about the cool stuff; the stuff people might not have heard about before. Lumbar surgery and neck surgery aren't all that interesting. Lumbar surgery on an 800-pound patient is more interesting. Brain worms are *way* more interesting even than that. 

Plus, I do work at a research hospital. We see shit every day that most nurses never see in a lifetime. I Googled a diagnosis that a patient of mine had once and got 35 results. So the stories about CJD or crazy-ass neuroleptic syndromes or conversion disorder might make it on to the blog most often, but they're probably only about 40% of what I do. The other 60% is plain old boring ordinary craniotomies and lumbar laminectomies.

LVN or RN?

Based on my experience, I'd have to say go for the RN. That'll differ from place to place, of course, but Texas is moving away from using LVNs as primary caregivers. Big County Hospital now, in fact, requires that all entry-level nurses have a BSN. 

There's a joke: "What's the difference between an LVN and an RN? About ten thousand dollars a year." That's *kinda* true, and *kinda* not. A lot of the things I do an LVN could do as well or better. Some things, though, LVNs can't do because of the guidelines set out by our state board. For instance, while they can intervene to fix a problem, they can't assess the patient--either baseline or in response to their fix. Now, most places you'll find LVNs acting basically as an RN, doing assessments and whatnot, but they're not *technically* supposed to. 

It's a silly distinction on a lot of levels. Unfortunately, the way things are here, you're pretty much locked into working either at a long-term-care place or overnights with shitty staffing in a hospital if you're an LVN. You have a lot more freedom as an RN.

So, yeah: RN. The choice between a two-year and a four-year degree is a whole 'nother ball of brain worms, though.

What one piece of advice would you give somebody starting nursing school or starting a nursing career?

Find a mentor. Do it as fast as you can, and lean on that person for support throughout your schooling or the first few years of your career. It makes a huge difference.

My mentor in nursing school was one of my instructors. She was, hands down, the best teacher I have ever had in any subject in any school I've attended. Luckily, she was both an active nurse and my clinical instructor, so I got to see a real pro in action during clinicals.

The thing that impressed me most about her, and what made me want to be like her, was her combination of dignity and warmth. When she dealt with doctors, she had their respect. She stood very straight and was extremely professional--almost like something out of an old movie, but without the "Yes, Doctor" subservience. She knew her worth and the worth of her work.

And with patients, she was amazing. She was the person who taught me how to approach people first thing during the shift. She would walk into the room, introduce herself before she approached the bed, and then make the person in the bed or the chair her *total* focus for five or six or ten minutes. Sometimes she'd just rest a hand on their arm while they talked to her; other times, she'd fix some seemingly-minor (but huge to the patient) problem right away, without waiting. In that small space of time, she established a rapport with the patient that let her give really good care, because the patient knew she wasn't going to get distracted or screw them over by being in a hurry.

I learned more from just watching her in one semester than I did the first three years I was nursing. She was the best.

Hm. Maybe I ought to drop her an email and let her know all this. I doubt she'd remember me, but it's nice to hear when you've made a difference.

Any other questions you want answered? Post 'em here or drop me a line.

*Dude: Edit out the word "fuck", okay?

Jo Muses: The Love/Hate Edition

I'm reading Heat by Bill Buford right now, partly because I mistook "Buford" for "Bryson" and thought, "Wow! Bill Bryson's written a book on learning to cook?" and partly because it sounded interesting--a blow-by-blow account of learning to be a chef by doing, rather than by schooling.

One of the most interesting bits in the book describes the process of learning to use a knife as though it's an extension of your fingers rather than something you pick up and put down. ChefBoy has, of course, this talent. I have the same talent--all nurses do--but in a different way.

Think of how you learned to start an IV. (New nurses and students, listen up! This will be heartening, I promise.) At first, you had to think about every step in the process, and things like tape felt foreign--getting stuck to every conceivable surface except the one you were aiming for; flushes went on the floor, gloves seemed too thick or too loose. Then, one day, it all came together, and what's more, the IV needle itself suddenly became something you could feel *through*--you could tell when you hit the vein dead on or when you'd scooted to the side of it.

Buford describes this as analogous to the process of learning to throw a ball--learning like a child, he calls it--and that's exactly what you're doing when you learn how exactly to juggle IV bags, tubing, medications, piggyback setups, needles, flushes, and everything else as though you've grown a third hand. It's visual and physical rather than primarily about reading and memorizing, and it uses a totally different part of your brain. 

I love that explanation.

Something I hate: Being tossed--lobbed, really--gently under the bus by somebody who's made an amazing, stellar, incredible, obvious, historical, unbelievable screwup. I won't go into detail, but suffice to say: Doctor ResidentBoy, if you fuck up and expect to blame me for your fuckup, not only will my boss not believe you, but *your* boss won't believe you. I know what you did was embarrassing, but it's not nearly as embarrassing as knowing that I know what you tried to do. 

I know what you did last weekend. And I will continue to smile and be helpful and pleasant and take care of your patients the best way I know how, but if you dance too close to the cliff again, I will not haul your ass back from the precipice. Have a nice day!

The first rule of nursing, after "If you have to jack with it, it's wrong" is If You Screw Up, Admit It And Move On. People screw up, okay? Nobody's going to remember that particular screwup in a year--or if they do, they'll remember it in a hazy, amusing, gosh-wasn't-that-funny kind of way. 

That is also the first rule of medicine, right after "Do no harm."

Another thing I love: Waking up in the morning on the first really cool day of fall, with all the windows open, and dogs and cats sprawled everywhere on and off the bed, and realizing that I do not have to get out from under the covers and work out or go to work. It's totally different from checking in the mirror to see exactly how far down the tire tracks from that bus go.