The New Year
First of all, I have always really loved new year's resolutions and I have always been pretty bad at following through. This year, I do feel an added pressure to start taking better care of myself since I will soon be a health care professional (though that is still kind of unimaginable to me). So, I hereby publicly declare that I will endeavor to do some things differently. I am going to try to start out with baby steps and build from there.

#1 - Some physical activity each day. To start with, I am not setting time or activity requirements. Just something every day. Even if it is only stretching before bed.

#2 - Keeping track of what I eat every day. Not in the calorie-counting, dieting kind of way. I am not writing down specifics. Just a general description, so that I have a rough idea. And I think after a few weeks of doing that, I'm going to make more of a plan of how to eat better. Mostly, I know there need to be more vegetables. Also, drink more water.

#3 - Writing something each day. Again, not saying how long or what. Could be a letter, could be a blog post, could be a nice little note to my boyfriend. I just like taking a little time each day to focus on expressing a thought eloquently or, if not eloquently, coherently.

So, those are the initial goals. Subject to modifications.

On another note, I have been having to read a lot about health care policy lately for class, especially as it relates to public health, and I am finding it difficult not to be incredibly depressed about the state of the American health care "system" which is not actually a system in any coherent sense of that word. So I will probably have some thoughts about all of that at some point. But in the meantime, I hope everyone is feeling happy and healthy. Thanks for reading.

The Days of Richard Simmons with Seniors

Seeing as how I about halfway through the semester, it is a good time to check in and write some stuff down. I think all of us in my program realized that we'd just been hazed when this semester started. The summer semester was much, much harder than this one which made for a nice change, but is also making it difficult to stay as engaged simply because I don't feel like I have to try as hard to keep up in my classes. Sadly, I am feeling like only about half of the time I spend in class is particularly worthwhile right now. There is a lot of review of things that I already know (which is weird, because I don't know very much) and a lot of time spent on concepts like leadership that I don't particularly think you can teach using a lecture format. So, pretty much I want a tuition discount for this semester but I don't think that's really going to work out so I try not to think about it too much. I am just trying to enjoy the free time and make the most of it by doing other things like volunteering with other students to provide some nursing care at a free lunch in a church basement and going to health care conferences and doing storytelling activities with residents with dementia at one of the assisted living facilities near here. And I just got a job as a nursing assistant visiting people in their homes who need help with various activities of daily life. I am really excited about that. It's for an organization that tries to help people stay in their homes as long as possible, so there are several levels of assistance they can offer. I will probably do things ranging from helping to bathe people to helping them clean their homes and go shopping. I wish I'd thought of doing a job like this when I was in high school or college. But that's okay. I seem to realize everything a bit late.

My clinical placements this semester have been pretty interesting. We have three of them. The first one was in a neuropsych floor at a hospital in Iowa City. My current one is at an adult day center in Cedar Rapids. The next one will be back at the hospital in the newborn nursery/mother-baby unit. So, I am getting a pretty brief exposure to a lot of different patient populations. I have been reminded that I really like old people. I've gotten to sing Gene Autry songs with them and do Richard Simmons exercise tapes (Disco Sweat!) and make snowmen out of painted coffee creamer bottles. I am not sure how much I am learning, clinically-speaking, but it is a fun way to spend a day. I liked the neuropsych floor too, though it was hard to feel free to interact with the patients as much because there were locked doors and glass windows surrounding the nursing station. I am not a fan of this arrangement. I think it started because of concerns about nurse safety, but I would be surprised if it actually decreased the number of violent incidents since there are definitely ways to get into the nurses' station if a patient really wanted to. Mostly, I don't like it because it feels weird and the nurses talk about the patients behind their backs a lot more than they would if it was open like a regular unit. But it's a tricky situation with some patients and I could see wanting that boundary if I'd been attacked as a nurse, and it does happen.

There are a lot of tricky things about nursing. There is a movement now for bedside report, which means nurses reporting to each other in front of the patient at the end of a shift, rather than sitting in a room somewhere and giving report to each other without even talking to the patient. I think it's a really good idea because it would include the patient's input which would probably mean much more accurate information and a feeling of empowerment for the patient, both of which can be hard to come by in a hospital. Generally, there just needs to be more communication with patients, especially when it comes to things like discharge plans and long-term care options and living wills. There just seems to be a huge reluctance to really plan for the future with a patient because it's logistically complicated and because it brings up emotionally difficult questions. I would really like to somehow be involved in doing that when I'm a nurse. Managing transitions from hospital to home or from home to assisted living or assisted living to skilled nursing facility or skilled nursing facility to hospice can be very difficult physically and emotionally for patients especially as they get older. I really don't believe enough time is spent helping to get them ready for those changes in the vast majority of cases.

Also, I know I have referred to this before, but did you know that medical students and nursing students typically graduate without having interacted with each other at all? Like, not even for five minutes? This continues to blow my mind. And we act like it is this intractable mystery as to why communication among members of the healthcare "team" continues to suck and continues to result in poor patient outcomes. Could it be because none of us ever EVER has to actually do it before we graduate? There is plenty of fault to go around - physicians don't often respond to pages in a timely manner because they have too many patients and nurses don't often include enough information upfront to give the physicians something to work with - but mostly I blame the institutions of higher learning around this country who can't manage to arrange for one damn class or clinical experience that nursing students and medical students would get to take together. Professionally, we start in completely different places right off the bat. So should everyone really be surprised and dismayed that we don't communicate better and that there is so often tension between doctors and nurses? Ugh. It depresses me. But I know that there are exceptions and there is always potential for change. Besides, if everything was working super well, I'm sure I wouldn't even be interested in being a nurse.

The 5th Anniversary of Katrina

A few not-profound thoughts:
1) my career path and the person I am changed as a direct result of living in post-Katrina New Orleans
2) as a person who still really does try to love America, what happened there is one of the biggest possible disappointments, and for a whole lot of predictable reasons
3) I sometimes miss living there, even though it also made me miserable
4) I wish I could hug all the little old ladies - thinking about them still makes me want to cry

The Summer That Took FOREVER
I tried to post this summer, but it got a little crazy. Turns out that taking 10 credits and spending two days a week working in the hospital is kind of time-consuming. But I must post now before the new semester starts! So, for some context. I was on a general medical-surgical floor where most of the patients have things like chronic organ failure (usually kidneys or liver), or post-surgical infections/complications, or a problem that hasn't been figured out yet and they have to have a lot of testing. Most of the patients I've taken care of have been elderly. I have come to appreciate the difficulty of simple things like putting in someone else's dentures, figuring out the best way to help move them to the commode or chair while not strangling them with their oxygen or IV tubing, how to change the bed linens while they're still in bed, how to bathe them while they're still in bed, and how to do lots of other things while they're still in bed. It's hard. And when you don't know how to do it, it is immediately apparent and really awkward. I have spend a LOT of time being awkward. And all of my patients have been very patient and nice to me. One of them even pronounced at the end of the day on Friday that she'd thought I'd be okay after all!

I guess that my experience so far can be broadly lumped into:
Things and People I Have Come To Appreciate, and
Things and People I Have Been Disenchanted With

The Appreciation List:
#1 - CNAs (certified nursing assistants)
Dear lord, I would have no idea what to do about 95% of the time without the CNAs. I didn't really understand what everybody on a hospital floor actually does until now. It depends on the facility, but CNAs usually take care of most of the immediate, non-medication patient needs. The bathing, the toileting, the moving and repositioning, the ambulating, the linen changes, keeping track of the patient's intake and output, taking them to appointments elsewhere in the hospital, and just generally working to help the patient be more comfortable. And they each have up to 8 patients. Nurses on our floor usually have 4-5. It is a LOT of work. It makes me wish I'd been a CNA before, because there are so many things I would feel more comfortable doing now.

#2 - PTs (physical therapists)
I have not met a PT yet that I didn't love. I guess when your job is to be positive and supportive and motivational but still honest and stubborn, you have to be kind of an amazing person. All of the ones I have met have been funny and helpful and just generally the kind of people you want to be around. They are awesome.

#3 - Nurses
That I'd be lost without the nurses kind of goes without saying. They have all been easy to work with and don't usually hesitate to ask me if I want to try something (or at least watch them do something) whenever there is a learning opportunity. But one of them in particular has gone out of her way to check in with me about how I'm doing, to thank me for my help, and to include me whenever possible. She's so nice, I kind of wanted to cry.

The Disenchantment List
#1 - The discharge/scheduling process
To be fair, I still don't really understand how this works. And clearly, neither do the patients. The physicians are usually in the patient's room for a few minutes each day, but that is pretty much it. Some of them are better than others at spelling out what is the next step in the plan for the patient's care, and what needs to happen before they can be discharged. But this is never written down for the patient as far as I know, and most of the patients aren't updated in a timely manner as to their test results, or changes in their diet, or the scheduling of procedures. Honestly, it would make me crazy if I were a patient. And it makes it really hard to care for them if, for example, you find out that someone is going to be discharged in 45 minutes when you've just given them medication to control their dangerously high blood pressure that requires you to monitor them for at least the next 30 minutes, plus they're nauseous and they have no prescription for an anti-nausea med so you have to spend at least part of the next 45 minutes trying to track down their doctor so you can give them something before they leave so they don't puke in the car on the way to the nursing home. For example.

#2 - Physician/nurse communcation
Honestly, this has been the most depressing part of the whole summer for me. Physician-nurse communication doesn't work as a rule, as far as I can tell. When it does work, it's because a specific individual went out of their way to make it work. There are hardly any systemic incentives or disincentives that make successful communication more likely. And it seems that they've tried several things, like having the nurses and physicians carry cell phones to take out the pager/call-back step. But, for example, there is no way for a nurse to know when the physician will be in a room, so nurses often aren't there for the physician-patient interactions. Which is unfortunate because patients will often have questions later about what their doctor said and if the nurse wasn't in the room and the physician didn't find the nurse at some point, which doesn't happen that often, the nurses can't answer the patient's questions. And I've been surprised how much the basic pathophysiology that even I know can be useful. It's not that I probably wouldn't understand what the physician was saying - it's that I wasn't in the room to hear it. And although the division between nurses and physicians isn't so strictly along gender lines anymore, that seems sometimes like a superficial distinction. I have felt just as invisible and excluded in a room of doctors as I have in a room full of weight-lifting dude wrestlers at the gym. It is weird.

(By the way, after visiting my new local gym, I also think that there should be women-only rooms/times for weight-lifting. Does this make me lame? I don't care - I don't want to fight with the whole stinking wrestling team so that I can lift weights for 10 minutes. Call me a weenie - I am not that assertive or motivated. Plus, I don't really need all the unnecessary grunting that working out with a room full of dudes usually entails.)

Okay, I don't want to end with a bunch of negativity, seeing as how I'm going to start a new semester and I'm generally pretty excited about it. I have reached the conclusion, though, that I want to continue on with the schooling after this and eventually become a nurse practitioner. I'll have more autonomy and I think I'll be more useful in non-hospital settings.

Up for this fall: rotations in neuropsych, geriatric nursing, and neo-natal nursery!

The Week of Summer Break

So, my plan to update regularly every two weeks fell apart during the second half of the semester. The combination of springtime and more tests/papers left me with less to say. Or at least less time to figure out what and how to say it. Having gotten through the semester, pretty much all I've been wanting to do now is sleep and read Anne Lamott's new book and watch episodes of House (and rekindle my dormant crush on Hugh Laurie). I have also managed to plant a garden, embark on yet another stupidly ambitious knitting project that I won't be able to finish for months, see a Local Natives show with some friends, plan a sewing project and (hopefully) before the week is done, bake some bread to take when I go visit friends in Peoria this weekend. I also wanted to take some time to gather my thoughts at this point, one semester into nursing school.

Thought #1 - Nurses do more than you probably think. Unless you're a nurse. My time spent in the hospital has been pretty limited so far, but I have had some. And I have been watching a lot of doctor TV shows recently. And pretty much everything that you see doctors doing in those shows (except for the actual surgery stuff) would be done at least partially by nurses. Nurses have the vast majority of the hands-on time with patients.

Thought #2 - Nursing school is really different from majoring in English and history at a liberal arts college. Different, for me at least, in a nice way. My undergrad experience, though I'm glad I had it, made me a huge stressball for four years. I was reading ridiculous amounts of dense literature and having to come up with essays constantly and rarely ever producing something I was satisfied with. I learned a lot, but I found it extremely difficult. And although it could occasionally be very rewarding, it was not really a sustainable lifestyle for me. Going to grad school for academia, for example, would have made me crazy. Nursing school is easier for me to handle because the skills are so practical, and the interpersonal techniques are usually intuitive. Not that it's easy. There is a lot of information to learn. But the applicability is immediate and rewarding. And I guess as I've gotten older, I've starting placing more value on the things the are concrete. It's very reassuring to me.

Thought #3 - Public health nursing is very interesting to me. I'm still trying to figure out what it means, exactly. My ideal job would entail going to where people live and building relationships with them and helping them to manage and hopefully improve their health. I don't think I want to work in a hospital. I am much more comfortable being in the place where the patients themselves are comfortable. What I want to avoid is providing care in a place where everything is foreign to the patients and the health care providers have all of the control over the environment. I have an internship-like thing in public health this summer/fall where we do monthly (sometimes twice monthly) hour-long clinics for homeless folks and provide things like foot care, blood pressure testing, and vaccines. I've only gone to one of these so far, but I'm looking forward to more.

Thought #4 - I am good at math! There is kind of a lot of basic math in nursing. I forgot that I like math. That is all.

I think those are about all of thoughts in my stuporous vacation brain right now. This time next week, I'll be up to my eyeballs in pharmacology. Woo hoo!

The Last Day of Spring Vacation

Somehow, a month has gone by since I last posted. Oops. There was the week before the last week before break, when we were tested on our catheter-placing ability, and then there was the week before break, when we were tested on the respiratory system and taking a health history and doing a physical assessment of the skin, eyes, ears, nose, throat and probably some other things I forgot, and then it was spring break and time to get out of town. So, it's been busy.

For spring break, Ross and I went back to New Orleans courtesy of our tax refund. It was a good trip. We got to see folks we used to work with and I checked in with a few of the homeowners whose houses we rebuilt. One of them in particular was good to visit because when I talk about the things in New Orleans I saw that made me want to be a nurse, I'm often talking about her. I'm still not exactly sure what her specific health problems are, though I'm fairly sure she had a stroke and at least one heart operation not long before I met her. She is extremely medicated and has trouble staying awake or sleeping when she's supposed to. She once took out all 13 of her prescriptions from her purse and dumped them on the coffee table in front of us and said, basically, that she had no idea what they were all for. I can tell that in her former life, she was a feisty and capable woman and it irritates me that she is so clearly not in charge of her own health or informed about her treatments. I say that knowing that there are a lot of things that make it difficult to communicate with patients and to form a really collaborative and trusting relationship with them. But I didn't get the feeling that most people working with her had even tried.

She was very excited when I told her, before I left New Orleans, that I was going to nursing school. She sent me a Christmas card saying that she wanted me to deliver her next baby. My lack of qualifications for that particular task aside, I doubt this woman has been fertile in 30 years. This time when I visited (along with Tommy, who took over lots of my job responsibilities when I left and is now a bonafide old lady whisperer), she had been feeling sick and was in bed and all curled up when her grandson let me in. It was a surprise visit, so I suppose I should have been worried about accidentally giving her a heart attack. But she was fine. Her little head popped right up out of bed and she gave me a big hug. She was actually looking pretty good. Since I've gotten to know her, she has started freely telling me about her health, so this time I got a full update on her recent vaginal discharge and her lack of bowel movements. This is the kind of thing that makes me think that if someone wanted to really have an open and thorough dialogue with this woman about her health and how to improve it, she would be all for it. She is totally happy to talk about it - she wants me to know about her vaginal discharge. She actually called after Tommy and I had left to tell us that in the intervening half hour, she had both vomited and had a bowel movement. So I got to leave New Orleans knowing that her digestive system had been thoroughly emptied.

Anyway, I just kind of keep coming back to the idea that a person's own health and health care shouldn't be a mystery. Just because it's complicated doesn't mean it can't be explained if you just take the time to do it. I know that everything in health care now is about efficiency and that nurses and doctors are probably spending less time than ever with their patients. In the end, though, I would guess that whatever gains you get in "efficiency" are off-set by more medical errors and the patient confusion and lack of compliance that result when people don't feel empowered and invested in their own care. For now, all of this is mostly speculation. But each day I'm learning more and it is exciting, if daunting, to think that someday soon I'll know enough that I'll actually get to try this out for myself.

The Day of Talking About Dying

It has been a month since school started! This week we had a mini-conference at the U of I about hospice. There were four presentations that covered the basics of hospice, hospice for children, palliative care, and the spiritual needs of hospice patients. One of the presenters mentioned about the work of Dr. Ira Byock, whose book, "Dying Well," I read last summer and really appreciated. Experiencing hospice first hand was definitely one of the reasons I decided to go to nursing school. What I loved about Dr. Byock's book, and what draws me to hospice, is that the end of life holds such potential for emotional fulfillment, for peace, for coming to the end of your life on your terms. I think it is an opportunity that is denied to a lot of people. I have a hard time thinking about all of the people who die alone, in the middle of confusion, or after a violent and unsuccessful attempt at resuscitation, without knowing what is happening to them. Obviously, some deaths are unavoidably sudden. But the vast majority of deaths in this country are the result of chronic illness, and can be managed and can happen painlessly and with the active participation of the patient and their family, with the right planning and support.

The somewhat recent "death panel" debates made me furious and really sad, precisely because it ended up denying people the opportunity to do the kind of planning and have the kind of support that I'm talking about. In essence, there was a proposal in the now-stalled health care reform bill that would have included a measure to cover the cost of appointments for any patients who wanted to discuss end-of-life options with their doctors. It was pretty much the most innocuous proposal in the world: hey, wouldn't it be nice to make it free for people to talk to their doctors about how they wanted their end-of-life care to go? That was it. And, as anyone who has had to deal with a family member's death knows, these are the kinds of conversations that have the potential to save an infinite amount of guilt and uncertainty for the family members left to make decisions about their loved one once they become incapacitated. That measure ended up being removed from the bill after the "death panel" debacle, incited in large part by Sarah Palin, about whom I have nothing nice to say. At all. At. All.

Moving on. I am heartened when I hear about stories like this one about successful end-of-life planning. The idea behind hospice and this kind of planning is to make sure that everyone has the opportunity to make choices about how they die. Because, and our entire culture does not seem to want to acknowledge this, we will all die. You. Me. All going to die. But we are luckier than the vast majority of people who have ever lived because we have the chance not to die in pain, and to die with some amount of awareness of and control over our last days. It boggles my mind to think that some people would want to deny us this choice for their own political gain - I can't think about it without feeling a little horrible about the world. So I won't! Suffice it to say that I was really glad to get some more information about hospice this week, and to think about being involved in hospice in the future.

P.S. - The *only* good thing to come of Sarah Palin is Tina Fey's Sarah Palin impression.