Monday, July 03, 2006

Making a difference

I've missed blogging. I know that sounds lame from someone who hasn't posted in 2 months, but its true.

I can't say nothing has been going on in my life because, well, I'm 35 weeks (or more) pregnant, I'm in finals at school, and I just finished my first nursing rotation.

Of course, most of the pregnant updates fall under TMI (who wants to know when my stretchmarks first appeared? right, no one). Most of my school stories are just rant sessions. And most of my nursing stories, if I shared them, could easily be called a violation of patient confidentiality.

However, now that my rotation is over, I can sit back (as far back as my gigantic belly will allow) and take stock of what those 15 weeks meant to me.

When I first got assigned to the General Surgery ward, my first thought was "oh, yuck". My still somewhat queasy stomach would be checking open surgery wounds, with somewhat yuckier patients. I was hoping for Orthopedics, or Internal Medicine which would be less yucky.

We spent almost the first 10 weeks of the rotation simply talking to patients. We were not allowed to do anything to them (makes sense, since we didn't really, even after 2 years of nursing school, know how to do anything). We took lots of patient histories, learned how to interpret their charts, how to interact with patients, and how to make nursing diagnoses - which are very different from medical diagnoses.

For example, let's say a patient comes in with high fever, problems breathing etc. A medical diagnosis would be "Pneumonia" and the treatment plan would easily be "antibiotics".

In nursing, the diagnosis and treatment completely depend on the patient. You could have 2 patients with identical medical diagnoses, identical medical histories, and totally different nursing plans. the same patient with pneumonia could have a diagnosis of "Decreased functioning in the family home, secondary to pneumonia, expressed by failure to work". And the treatment would either be to educate the family or the patient. If however, the patient lives alone, there would be a completely separate diagnosis and treatment plan.

Although I began to get bored of taking these long histories, and feeling like all I was doing was invading the patient's privacy, eventually it all started to make sense. When I started admitting patients before their surgeries, I began to pay attention to little cues I would have missed earlier. I had a patient in for a relatively small surgery, who seemed overly anxious, with a very high blood pressure and pulse (sign of stress). She told me she took antidepressives and that she was a widow. And that none of her adult children knew about her surgery. Eventually I worked out that her husband had committed suicide a year earlier, hence the depression and extreme anxiety.

One of the things that bothered me about my rotation was that it seemed pats on the back were few and far between, but criticism was available in abundance. Students got kicked out of the program for relatively minor infractions, but when someone did something really noteworthy - nothing was done.

When I first started doing admissions before surgeries, one of the first patients I got was in for a thyroid removal. I had to take the extremely long history, with questions that seemed inane and useless to the patient. Plus, the questions, at least in part, are repeated by the doctors and anesthesiologists. This particular patient was really irritated by me. She'd already met with the doctor, the surgeon and the anesthesiologist, all of whom had asked her the same questions and who had all approved her surgery.

Then I come along. I am required to tell her I'm a student (plus my name tag says so), and then I start asking her all the same questions she already told the real doctors, plus questions that seem useless - such as what floor is her apartment on, how many children does she have.

I ask her what medications she takes. She tells me a few drugs, mostly for high blood pressure. A few minutes later I ask her the same question. I do this because patients often "forget" some of their drugs, but after talking about other things (past illnesses, dietary contraints) they are reminded of more medicines, or things they don't consider to be medicine but really are. She remembers that she also takes aspirin once a day, prophylactically. People often do this because it has been shown to prevent strokes and ischemic heart disease.

I finish my medical history, and go to my teacher to have her review my interview. For liability reasons, before its entered into the computer a real nurse has to sign off on my work. The teacher signs off.

As I am entering the data into the computer, the penny drops. Patients who take any sort of blood thinner (such as Coumadin, Heparin, etc.) have to stop these drugs 10 days before surgery or they risk bleeding out during the surgery. One of the drugs that thins blood is....Asprin. The reason it prevents strokes is because its a blood thinner. I run back to the patient, who is about to go home for the evening (and return at 7 am to have her surgery) and ask her if she stopped her aspirin. She looks me at me like I am nuts and says, "Why would I do a thing like that?" I ask her to wait, and tell her I need to check with the doctor but that there is a possibility her surgery will be postponed.

She's pretty irritated with me now - all of the doctors, surgeons and anesthetists have signed off on her surgery and told her she was good to go. What's a lowly nursing student doing telling her it may be pushed off?

I shared my findings with the doctors (who are also irritated to be "caught" by a student). In my communications class, one of the topics we covered was "How to tell a doctor he's made a mistake without losing your job". I had to tell the head of the surgery department, a somewhat arrogant man who definitely does not like students, that he missed a vital bit of info without making it sound like he did anything wrong. Not to mention tell my teacher, who approved my interview and didn't catch the problem herself.

The surgery was cancelled and rescheduled for 2 weeks later.

I was a little upset that no one, especially my teacher gave me a pat on the back for catching something so important that everyone else missed, which could have really hurt the patient. If I had done something of equal magnitude that would have hurt the patient, you can bet I would have received an automatic failure.

As luck would have it, two weeks later, I was assigned a patient who was just waking up after surgery on her thyroid. The name rang a bell, but I couldn't figure out from where. I introduced myself to her husband, and said that my name was Noa, I was a student, and I'd be caring for his wife. He immediately woke his wife up and said, "Is this the Noa that saved your life and got the whole surgery rescheduled?"

Even though my little catch went totally unnoticed and unrewarded by my teacher, the patient realized what went on - enough that 2 weeks later her husband (who I never met) remembered my name! And that's what nursing is about to me - making a difference to patients, whether they realize it or not.

I have no idea what grade I will get on this rotation - and I am sure that my "save" won't even get factored into my grade - but it doesn't matter to me. The thing that most concerned me about this rotation was that perhaps afterwards, I would decide I really didn't want to be a nurse. I have, after all, been known to change my mind a lot. And the past 2 years of nursing school, while difficult, have been totally hands-off. This was my first time interacting with patients.

I managed through the 15 weeks without getting any truly disgusting patients - I have no idea how that happened. No one vomited on me, I never had to change anyone's poop bag. For some reason, cleaning a patients' penis while his catheter was in didn't disgust me. Everyone else had at least one truly memorable patient in terms of the gross-out factor. Don't let anyone kid you - we may be semi-professionals, but we do still occasionally get yucked out - the professionalism simply requires us not to show it.

But I do think I made a difference in the lives of at least a handful of patients - so I know I am on the right track.


Blogger Fun Joel said...

Welcome back to the Blogosphere!

And consider this a virtual pat on the back. Great job! :-)

6:15 PM  
Anonymous nikki said...

wow -- noa, as i got down to the part where your patient's husband recognized you, i got chills. i think you'll make a fine medical professional.

welcome back!

6:55 PM  
Anonymous Anonymous said...

wait, the world wants to know: how did you break the news to the surgeon (or docs)?

12:13 AM  
Anonymous Anonymous said...

that sounds bad to me now; it wasn't meant sarcastically; more like, so, what did they teach you to say to docs, and did it work?

12:14 AM  
Anonymous essie said...

Wow, I have tears in my eyes from your story. Kol Hakavod to you.

3:26 AM  
Blogger GregoryT said...

Kol haKavod and keep on blogging

6:06 PM  
Blogger lisoosh said...

Welcome back, I was just about to email you to see how things were going.
And to think you did all that work while in your last trimester - now THATS impressive.

5:03 PM  
Blogger Emah S said...

Very impressive! Just remember this in the future.......patients who seem annoyed by you may secretly be thanking you for saving their lives, and you just don't know which ones are thinking that. Think of it as your private pat on the back from them!

B'hatzlacha....with your delivery and the rest of your course!

2:52 AM  
Anonymous Anonymous said...

Wait a sec... When did you get stretch marks? I WANT TO KNOW!!!

7:45 PM  
Anonymous arash said...

Israelian innocent kids are writing some words ----->

9:24 AM  

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