Failure and success

I love the story of Nathan Chen, a 18 year old US figure skater.  He fell in the short program, overcome by pressure and expectations of the Olympics.  Due to his failure, he had nothing to lose for the long program.  He scored the highest of all competitors #1 in the long program, raising his combined ranking from 17th to 5th, not enough for a podium finish but enough to make history with 6 quad jumps in his long program.  He would not have the audacity to take a chance on his competitive long program if he had not failed his short program.  I love that he changed his perspective of failure into motivation to succeed.  All of us can be so luckily to have that perspective.

I felt like a failure this week, doubting myself if I belong in this nursing program, questioning if I can pass all my exams, my classes and Boards at the end of the year.  I say this – not for sympathy but to know that not every day is a success and not every week is amazing – that I need to know failure is a chance to succeed tomorrow.

This week was rough – we had ATI maternity exam (which is like a national comparison exam on all things maternity, a predictor if you will pass Boards on this section of your learning), a midterm in Pharm/Pathology, quiz in Community Health, quiz in Professional Nursing, pop quiz in maternity and an Exam #2 in maternity the previous week – which ended poorly with some problems in administration and then a fix, which leads to more pressure for #3/final to compensate for fairness.

At some point in studying, you feel like something has to give, you cannot retain all this material.  Your eyes are tired.  You feel all of this is not sustainable and you can’t keep up with this pace.  On Monday, after our maternity final, our 6 weeks of maternity end and we transition to Pediatrics.  It has been a challenging 6 weeks of enormous learning.

At our last maternity clinical, I was able to work with a lactation consultant (LC) and it was life changing – at least it felt like that to me.  I could have said the same words to my patient but I would not have the success at delivery like the LC. It was her tone and experience that lead the mom to have confidence in herself and her abilities to breast feed.

I first observed the LC knock on the patient’s door and wait for a response.  When the patient said, come in.  She opened the door and before entering – at the doorway, she said, I’m [insert name], the lactation consultant, may I come in?  Right there, that stopped me.  She asked for permission to come into the room.  Every time, I knock on the door, I don’t wait for a response and just say hello, I’m here for x task.  It is presumed as a nurse, you will walk in to do what you need to do, where as the LC, waited for the invitation to be accepted.  By waiting for permission, she gave autonomy to the patient.

When we were in the room, she talked to the patient and asked about her pain around breast feeding.  The patient said her nipples felt sore, and the LC looked at her nipples and said, see this line – it shows the baby is not feeding correctly/latching and if continuing like that, it would lead to infection and the baby not getting enough feeding.

  • She then demonstrated the patient how to position the baby – that it should be belly to belly with you and on the same plane as your breast – propping a pillow under each arm.  She showed how to put her non dominant hand under her feeding breast like underwire and the other hand behind the baby’s back to help it feed and pull it closer to her.
  • She pointed to acupressure points on the baby – under the shoulder, near the clavicle and in their hand to put pressure in these spots to re-engage the baby’s interest in feeding.
  • She described the baby’s tight arm as still showing interest in feeding, but when the arm becomes floppy – it shows their “tank” is full.
  • The LC shared how colostrum – the new breast milk is thick as honey and will take a few days to flow into breast milk.  The mom had not understood this point with her previous baby, it lead to turning to formula to feed.

The mom failed at breastfeeding with her first baby, but now felt she could exclusively breastfeed and succeed.  She had the education to feel confident in her abilities.  The LC also shared a breastfeeding support group that was nearby and a phone number to call anytime she had questions.  The LC said at her check up with the pediatrician, there are LCs available if she had questions.  She put her phone number on the board so she could come back during the day if she had a question.  It was amazing to watch the LC give this mom confidence in her abilities and the follow up with resources after the visit.  It was so thorough, she walked her through every step and gave her support after her visit.  The LC was patient, gentle, caring and her voice/tone was understanding.

I hope to emulate my patient care like hers, to allow for patient autonomy and help in their learning/education to make them feel empowered in their choices.

Going for gold

Can we talk about Chloe Kim for just a second?  In between studying for Patho/Pharm exam – I can’t get enough and I probably watched her winning victory run a dozen times.  If you have no idea who I am talking about – go google it now.  I’ll wait.

I love that she tweets she’s “hangry” – that’s angry and hungry for not finishing her breakfast sandwich – in between her Olympic runs.  She tweeted about eating churros to calm her nerves.  Her dad is amazing – talk about goals – he quit his engineering job when she was 9 so he could support her by driving to Mammoth to train – almost 5 hours round trip – that’s 8 years of driving.  Talk about dedication!  He made a hand written sign that was laminated that said Go Chloe!  with a heart.  When she finished her first run, she went over to the family area and said to her parents, don’t cry.  Her 75 year old grandmother from Seoul, made a sign that said Go Chloe in Korean.  Her gold metal debut was the first time her grandmother had ever seen her compete.  Makes my heart melt.  I can’t even comprehend the love of a dad/parent to sacrifice all for your child.

Ok – now, I want to share my day.  I met with my patient from the DNP (difficult conversations workshop) – and I think it went well.  In 45 minutes, I connected with my patient and she shared with me things that she hasn’t shared with her physician.  I was really humbled she shared with me her personal experiences – diagnosis, treatment, and story.  She shared some of her regret and wants.  I asked her had she thought about dying?  And, she did, but we didn’t talk about that very much.  I hope to see her again next week.  In my conversation, I was thinking – you have incurable cancer.  I know you are dying, do you know you are dying?  I hope our conversations help her get to a place of acceptance.

Global work – underserved populations

I no longer know where my nursing education stops and life begins.  At my 4 hour orientation on Saturday with Church World Service we talked about how work is a big part of one’s identity in the US and newly displaced people from other countries – work is not necessarily a large part of one’s identity in their home country, as it is here.  When you meet someone new, one of the first questions they ask is, what do you do?  For a while, I didn’t like that question, because my answers never felt like they should define me.  I have worked at a lot of places and I have a lot of identities.  My work should not define who I am but, right now, my life is nothing but nursing.  I cannot see anymore where those boundaries stop.

CWS is an organization that welcomes refugees to the Triangle area (that’s Durham/Raleigh/NC) and assists them with support/tools/resources to begin a new life in the US.  They provide English classes, employment resources, immigration/legal and case management.  Starting in March, I’m teaming up with other nursing students and we’ll take turns working with a family recently arrived.  Below is a map of where the refugees in NC come from:

I look forward to working with a family.  I’m learning in my class that this type of work can be social work/case work, but in terms of our learning it is community public health.

Other orientations: Guatemala in 4 weeks, Tanzania in 8 weeks…

Guatemala: school partners with Curamericas Global.  Curamericas’ local partner in Guatemala is Casas Materna.  I’m traveling with 8 students and one clinical instructor.  We are going a very long way to work in rural villages in the mountains region of Huehuetenango (about 10,000 feet above sea level).  This area has one of the highest maternal and child morality rates in the country.  I’ll work alongside local community health workers and midwives to provide support to pregnant women and children under age five.

The CIA overthrew the popular, democratically elected government of Guatemala in 1954, ultimately leading Guatemala to the state that it is now.  (“Bitter Fruit” by Stephen Schleisnger and Stephen Kinzer)  They’ve also had a 36 year Civil War that ended in 1996.  Almost half of Guatemala’s population is under age 19, making it the youngest population in Latin America. Life expectancy is around 72 years of age.  School life expectancy is 11 years. (CIA, Fact book)…. and 51% of the population live below the poverty line, less than $1 a day.

I’m traveling from Raleigh-Miami-Guatemala City… overnight, one tourist day to get acclimated.  We’ll visit a coffee plantation that coincidentally ships to 3 places in the U.S. – one in Durham – Counter Coffee Culture is the shop in Durham.  Next day, we’ll make our way to the northwest (almost bordering Mexico).  I think we stop at Mayan ruins on the way and eventually continue on a 10-12 hour bus ride to our site work at Calhuitz (the isolated mountain region).  I am told there is no wi-fi there.  I’ll only be off the grid for about four days, then we make our way back to Guatemala City and fly home – that’s my spring break.

In 8 weeks – to Tanzania – a 5 am flight to London transferring to Nairobi, Kenya.  We’ll do an overnight in Kenya, then hop on a small charter flight to the border in Tanzania, where we will then take a bus to our site – Teamwork City of Hope.  We’ll be in Tanzania for two weeks working with 100+ orphans giving them health assessments and providing health education.  From what I have learned, we’re staying in guest accommodations at the site which are posh – running water (maybe not heated), flushing toilets (only in the guest housing), and they do have internet.  We have one fun day at a safari and a visit to a local market on our way to visit the big hospital.  I’ll be traveling with 10 other students and 1 clinical instructor.  On Sunday, we also go to church.  I’ve never been to church – like ever, so that’s kind of a new exciting experience too.  I am presuming the service will be in English, but it would be cool if it was in Swahili.  Dress code for both trips – Duke t-shirts and long skirts.  Women dress modestly in both areas we will be visiting.

 

 

 

 

Braving connections – nurse in training

I left the woods for as good a reason as I went there. Perhaps it seemed to me that I had several more lives to love, and could not spare any more time for that one.

Walden

For someone who writes a blog, I think of myself as fairly private person.  I am protective of my stories and decide what and when to share them.  Yesterday at clinical, I was challenged in these moments of sharing my stories.  I was asked to trust and I was not ready to do so.  Trust is choosing to make yourself vulnerable by sharing your stories and seeing the actions of someone else with those stories.

Upon leaving my patient’s room, her guest visitor, her pastor was waiting outside her room to enter.  I said hello, and he looked at my name tag and said, “oh, a nurse in training.”  I smiled and continued on my way.

Later, my nurse and I returned back to her room while the guest was still there and I could feel this intensity of him reflecting on me and my actions.  It made me feel very self conscious.  He was not observing the nurse in the room but me specifically.  It takes a great deal of concentration for me to do the specific task I was doing, since we are beginners and I am not yet confident about anything.  As I was completing my task, I could feel his eyes on me and it made me uncomfortable.  Finally, he asked, “where are you from?”  I took a breath, and answered my regular – I’m from Brooklyn, New York but most recently I moved from San Francisco, to attend Duke.  I now live in Durham.  I was hoping the conversation would end there, but then he continued and asked about what I was doing in San Francisco, and asked several further questions.  I gave brief vague answers and grateful to have completed my task to leave the room. I was uncomfortable sharing about me, when I am in the room to help the patient.  My time in there is about the patient and not me.

In the afternoon, I returned to my patient’s room and our relationship had changed.  She was eager to ask me more questions about me, how I liked San Francisco compared to Durham.  She wanted to know more about my experiences.  She wanted to connect.  I recognized after this moment, I was not doing what I was asking our patients to do with me – to trust me.  Every time I walk into a patient’s room, they are asked to trust me and I am a stranger to them.  I have not yet gained the trust to be a true part of their care team.

My patient was much more willingly to allow me to provide care to her when she trusted me based on what I had shared with her.  It is these small moments that trust is built.  I now know, I need to practice my courage in giving trust.  I need to practice courage over comfort – to make myself vulnerable, just as I am asking of my patients.  I am going to work on thinking the very best in people and making the most generous assumptions so I can treat others with compassion and integrity.

North Carolina Museum of Art

Sharing photos from a visit to the North Carolina Museum of Art.  Each visitor costs $38.  Admission: free.  Recommended donation $3.  I thought that was a great sign.

I was highlighted on a student profile for the school recently:  click link and scroll to the bottom.  You can also read about my inspiring classmates too.

8446-BR_SoN_profiles_final

Spring, Week #3

Nursing school just became real.  I gave meds (narcotics – High risk for addiction and dependence. Can cause respiratory distress and death when taken in high doses or when combined with other substances) to a real patient (supervised) in real time. I am grateful for my clinical instructor who made sure I would not mess up.  I am grateful to my patients who allow my clinical instructor to teach me at bedside, fully aware how novice I look and how they must feel with an inexperienced person providing them care.  I am grateful for their patience and trust in me.

The importance of rights administration was driven home. Last semester it was just practice in the lab and memorization on a test but today – I was very aware of the risks.

First, at the pyxes machine (like a vending machine for meds) you confirm you have the right patient, the right med (route/dose) and right time. The machine double checks you, asking for confirmation before removing each med, but you are ultimately accountable by taking it out of the machine and administering it.  When you get to the bedside, you check the medical record, scan the patient and the meds again, checking for allergies and again that you have all those things right before you give the meds (right patient, right time, dose/route). The computer will tell you if one of those things are wrong but again, you are accountability since you can override it. One final check, telling the patient what you have provided and educating them on dose, route, side effects/benefits.

I also administered less potent drugs today but I worked with an IV route for the first time. The drug was Kertorlac and I memorized this drug last week as the word ket… sounds like cat and a cat has a fever and needs an NSAID like ibuprofen to reduce the fever. This drug is like ibuprofen but in IV form. Postpartum patient is not yet ready to digest oral meds, so it is in the form of IV for the first 24 hrs to reduce pain.

Aside from educating patients on meds, I provided teaching with new parents on swaddling a newborn. It’s just like a burrito and y’all know how much I like burritos. You wrap the newborn like a burrito. I also provided education to another family on taking care of a circumcised newborn too.

Circumcision is the most barbaric thing I have ever witnessed. I can’t quite wrap my head around this cultural and religious practice. I think if everyone saw the newborn procedure, they would think twice about performing it on their child.

I asked the provider performing this elective surgery why people do this practice. she said the American Pediatrics Association recommends it because it has many health benefits like less risk for penile cancer, sti’s, HIV, etc.

I didn’t believe her and looked it up. “Newborn Male Circumcision. After a comprehensive review of the scientific evidence, the American Academy of Pediatrics found the health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision.”

The newborn is tied/strapped down to a semi reclined chair. The newborn is medicated but you can see from facial expressions how painful the procedure is with tears in their eyes and the loud crying. Skin is surgical removed with a scalpel, clamps and other devices.

Things I learned that I wish I had been told: when cleaning up after a newborn poops, you are stimulating them and my newborn was pooping so much it was like a fountain. I was amazed at the amount of fluid and stool that came out of their little body all at once. I was simultaneously unprepared and amazed.

The female anatomy is much more complex than I understood it to be. It takes more force than I thought to separate the labia majora to labia minora to get to the urethra.  The urethra once applied with Betadine also looks like it’s winking at you. That’s how you know you have arrived at the right place to insert the foley catheter to reach the urinary bladder.

uterus

The vagina once open, you can clearly see the cervix, which is like the tunnel to the uterus where the fetus hangs out. The cervix is moldable, flappable in the wind, and can change shape to accommodate the baby. This tunnel stretches for the baby to pass through.

baby in uterus

I also saw other interesting things, like the umbilical cord is really very pretty when it is pulsating.  I liked that the color was a combination of white and lavender.  When it stops pulsating, it is less interesting but when cut, there are typically three vessels that look like a smiley face.  The two “eyes” are arteries and the “smile” is the vein.

One side of the placenta is very pretty.  It really does look like a tree of life with all the veins running through it.  The placenta also is made up of two layers, which was really cool to pull apart.  The body is so intricate and I’m really glad I witnessed a vaginal birth, cesarean birth and a circumcision.

I also came across this very funny new series with Kristen Bell called Momsplaining:

Next week I hope to spend the day with the lactation consultant and learn all about breast feeding.

Practicing difficult conversations

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What I learned thus far in nursing school is practice is what moves you forward.  Practice is the only way to get better at something and today I watched an oncologist give mostly bad news over and over again.  She was so competent at delivering life changing news to her patients.  She did everything I had practiced last semester but to real people in real time.  I spent the morning at the Duke Cancer Clinic (next door to our nursing building).  I love how every day I am presented with opportunities that challenge me.  I love how everyone I meet is willingly to share their experiences and knowledge with me, whether it be watching someone give birth or watching someone tell someone they are dying.

The provider introduced herself with her first name, asked the patient about their hobbies and work, how they were feeling, asked them what they knew about what was going on with them, then she told them what she thinks is going on with them, treatment, options, and recommendations.  She used phrases like, “I worry that…” and “how are you handling…?”  I had never witnessed someone tell another person they were dying, but I watched her do just that all morning, with finesse and grace.

I was impressed with how she did not cry when someone else cried and she was not overly emotional.  I wanted to cry multiple times this morning and I was not even part of the conversation.  I felt heartache when a patient asked “if the treatment does not go as expected, will I have time to do… x?  I have always wanted to do x.  Her reply was absolutely, we can make that happen for you.  It was kind of amazing to grant someone a wish and to know they were thinking about how to use their time they have left.

The common theme for patients was support.  The patient needs someone to help them understand their diagnosis and advocate for their own care.  For example, an MRI might be ordered, but the patient needs to follow through with making sure the appointment is scheduled.  Another common theme I saw with patients who accepted they might die had a much better outlook on their diagnosis.

When I have sat in a doctor’s office, waiting a very long time for a provider to see me – I now understand what takes so long.  She had a very long list on her schedule and she literally just moved down the list.  I asked her if she ever went to the bathroom or ate when at clinic and she said no.  She eats something like a carnation out of can in the morning and waits until the end of day when she has finished seeing all her patients.  She walks quickly and moves from one patient to the next, regardless of the complexity of the situation.  Literally from 9-noon, she walked quickly from one room to the next, but she always sat down and listened intently to the patient.  They had her undivided attention when they were in the room together.  She probably continued her day at that speed, but I left at noon feeling exhausted.  My impression is a provider’s schedule functions the same way as the airport.  You want to get on the first flight to avoid any delays.  Or maybe you want to think of it like going to the spa for a massage, the later in the day, the more mentally and physically tired your provider will be after seeing many clients before them.

Two interesting things happened to me in one of the appointments.  While in the middle of the conversation, a patient asked me if I was Korean?  It caught me off guard because we were talking about treatments and there was no context for the question.  I answered, politely and turned my medical name badge around so the patient could see it.  I said, the origins of my last name are Chinese.  There was some other banter but this conversation ended and moved back to the patient’s treatment.  When they were leaving, the patient’s partner asked me, “do you know if you want to specialize in this type of cancer?”  I said, “no, I am very early in my studies.”  She said, “well, I have a feeling, you’ll be a great doctor.”  I didn’t correct her to say I was a nursing student, but her sharing her thoughts was very kind.

Next up – I get paired with an oncology patient and start to practice my skills on providing support and discussion around these difficult conversations.  With practice, maybe I can be great.