Monday, January 04, 2010

Off the leash

Well, I'm done with my internship, off the chain, on my own, riding without training wheels, a danger to myself and society.

Six weeks ago, I felt like every day at work was like trying to climb up an escalator covered with bacon grease while somebody yanked on my shirt-tails at random moments. Now I feel like a barely-adequate skiier slaloming down a slope rated for Olympians. If I just go with what's happening, don't think about it, and don't try to look too far ahead, I do just fine. It's just a matter of not relaxing, of doing things right when I get the chance, and of being as efficient as possible.

Which is frustrating. It's hard to go from an area where you've been able to know without thinking what needs to be done, where the synthesis is second nature, to an environment where you have to stop, think, and double-check that you're even asking the right questions.

The head of the CCU internship program for Sunnydale and I had a conversation about that the other week. She wasn't exactly encouraging about my progress (though I thought I had done pretty well), and she expressed some serious doubts about my ability to form a comprehensive picture about my patients and anticipate/prevent problems. I left that interview feeling about three inches tall, until two things happened:

1. I realized that I cannot possibly be expected to think like an experienced CCU nurse yet. Fourteen weeks is barely enough time to review the things you have to review to keep from hurting somebody in the unit, let alone learn how to integrate all of those things into a cohesive whole. Everything right now is going to be task-based, and I'm going to feel like a complete idiot for a while, and that's just part of the learning curve.

2. The other interns in the program said that they'd had the exact same meeting with the head. The upshot of everybody's discussions with her was that she felt we're all safe nurses, but she's encouraging everyone to ask lots of questions and get help when they need to (collective "Duh"). In her defense, she's been a CCU nurse for about twenty years, so I think the thought processes involved have become so second-nature for her that she can't get into the headspace of a new nurse/new CCU nurse. Anyway, I felt better about the whole thing after we all got together and looked blankly at one another.

After the last couple of days on the floor, during which I had two not-really-critical patients who quickly turned critical, I feel more confident about my ability to at least keep people alive. Right now it's more a matter of being fast on my feet (as my Sainted Mother says) than of being a really good CCU nurse, but I'll settle for that for the moment. One patient yesterday shook off the propofol and Versed and tried to extubate herself in a particularly creative manner while shooting liquid stool all over the place, and the other had a fistula between an abscess and an artery break loose near the end of the shift, but I still got out on time and gave a good report.

As I was leaving work, passing the very last computer monitor on the very last computer cart near the furthest edge of the station, the monitor on that cart suddenly caught fire. I did not stop, I did not look back, I merely kept walking. That, my friends, is what the CCU is like.


Crabby McSlacker said...

Hmm, sounds like the CCU head who expressed doubts about every single intern in the program has an interesting teaching style--make everyone feel inadequate, so they won't make mistakes? Not sure that's the most effective way to train...

Sounds like you've learned a hell of lot very quickly, and are already saving lives on a regular basis. Bet it won't be long before it's all second nature.

bobbie said...

Yet another case of nurses eating their young... what a witch!
Give yourself (minimum) 3-6 months to really settle in... and remember to breathe!!

My favorite 'rule' from "The House of God" has always been "In case of cardiac arrest, the first procedure is to take your own pulse."!!!

woolywoman said...

Remember that if you restrain one arm down, (in the usual position, around waist height), and the other UP, over their head, from the top corner of the bed frame, then they cannot do a sit up and reach their tube. As an added bonus, their arm pit airs out, preventing yeast, and you prevent their shoulder from getting frozen. At Q2H, you switch arm positions. Now you are half way through your shift, and they have not extubated unexpectedly. Always worked great for me.

Your DON is an ass. Luckily for you, she showed her behind to all of you, so now you know. Never schedule a review with her while you are PMSing. Oh well, maybe she is fair in how she gives out vacation, or something?

Carolyn said...

Dearest Jo-

I second Crabby wholeheartedly. I had 20 weeks of orientation as a new grad, a constantly changing roster of preceptors (including one who spent the whole night shift looking at telescopes online while I monitored the pt. on the balloon pump!), in a unit with an overall atmosphere of dissatisfaction and back-biting. My first day off internship I had a pt on two pressors and an insulin drip, and another pt getting pegged and trached at the bedside who went into bronchospasm and ended up being vecked in order to ventilate her. I was afraid to ask for help because the nurse manager had told me some of the preceptors thought I was "marginal." Not one of the nurses around me, nor the charge nurse offered to help. So much for pt safety.
But I did it. And the patients all did fine. And when I think about it now, the utter insanity of it, I marvel I ever came to work the next day. Or that I am, and continue to become a good ICU nurse.
You have WAY more under your belt than I will ever have. Please do not let the poor structural properties of ICU culture get you down or shake your confidence. You will be awesome! And you will live to change the way people are trained and treated.

Penny Mitchell said...

The management style of, "Let me shit on you some more, maggot," utterly astounds me. Don't let it get to you.

Gert said...

Walking past the burning computer reminds me of my first clinical day on the cardiac floor....when it was over, as my friend and I walked away, our steps got faster and faster...we simultaneously broke into a run as we turned the corner. We couldn't shake that place fast enough! Then, we laughed. And returned the next week, of course!

I wish everyone would finally learn that positive reinforcement kindles the motivation to improve/succeed. Negative comments undermine confidence and leads to mistakes.

GingerJar said...

When I was a newby (12 month LVN, 6 month RN all on Tele) just off preceptor, I was begged to stay 1/2 shift more until they could call somebody in for my patient's. I had a pt with dementia, her hubby stayed w/her. She was s/p heart cath w/stent, but had some bp problems, so in CCU. She had a little back pain, not unusual for her with her arthritis. Her hubby put a tropical creme on it. She went into Afib (new rhythm for her) for less than 5 minutes, which I was unable to catch on EKG< but I had the strips. The charge Nurse reviewed the strips, but didn't see anything different. I called the on-call cardio, not the one who had done her procedure of course (it was 3 a.m.). He wasn't concerned and REFUSED my offer to fax the EKG to him. I was relieved at 4 a.m., and my patient coded and died at 5 a.m. The patient's stent had reoccluded and she had a massive MI. It was considered a sentinel event. I came in to shift with a nurse I had never seen before screaming at me that I had KILLED the patient, and what kind of idiot was I anyway (later found out she was always crazy) and the primary Cardio asking me what had happened. When I went to my Supervisor for review of the case...she was very kind, asked what I thought could be done to prevent a future occurance (duh...have the on-call MD's actually take a faxed EKG if the nurse thought it significant enough to preform!), and the other nurse who yelled at me was written up for unprofessional behavior. So sometimes you do get a Director that will back you up.

I know you will be great, I've been reading your blog since the beginning!