Finals

We are into finals and the library is open 24 hours every day for the week.  Why does the library need to be open 24 hours?  I vaguely remember this being important in undergrad/college because a billion years ago, I did not own a personal computer until my last year at school. I sat at the library writing endless amounts of papers.  Now in this school life, I can’t see why the library needs to be open all the time?  In this new life of studying – there is no cramming for finals, there are no papers to write.  You either know the material or you don’t.  It’s weeks of knowledge built upon a semester of knowledge.

Our Pharm final is on Tuesday and I’m reviewing acid/bases.  As I was rereading my notes for this lecture, here is my personal application on acid/base, fluid balance.

When I competed in my first half ironman, 70.3.  Everything that could go wrong went wrong that day.  First, it was an ocean swim and I had never practiced that distance (1.2 mile swim) in an ocean.  I ended up having a terrible time sighting the shore line because of the sun, and I swallowed horrible amounts of salt water, making me feel nausea when exiting the swim.  When exchanging empty water bottles for full water bottles on the 56 mile bike course, I failed to practice drinking the course provided fluid mix and was repulsed by the flavor.  It made me want to vomit and I ended up only drinking water.  By the run course, the mid day heat had started, and I sweated excessively while only drinking water.  I wanted to finish the race because if I went to a medical station while on the course I would be stamped with a DNF (did not finish).  I figured if I passed out on the course, someone would scoop me up, so I finished the 13.1 run and then went to the medical tent to get IV fluids.  What went wrong – here’s the real life application:

Normally – your cells are isotonic – same amount of intracellular fluid = extracellular fluid, solute to water concentration are the same on both sides of the cell.  In my race, I had a loss of salt from sweat, and taking in too much water without other solutes to balance my water-fluid concentration, which is called hyponatremia.  HYPOTONIC (more solutes inside the cell, water follows solutes inside the cell, and your cells SWELL). Water moves from extracellular to intracellular and your fingers/feet swell.  Serious complications, left untreated can result in coma, seizures, respiratory arrest.  Sodium levels are less than 135 mEq/L.  Admin: (I think is a hypotonic solution of D5W.)

Next application example:  When I biked the U.S., there was one very hot day in the Ozarks (Missouri).  I had 20 miles left in our day, and I had drunk all my water.  I felt dizzy and looked for a shady patch to stop.  I looked up in the tress, and instead of seeing leaves swaying in the wind, I saw people dancing.  Upon closer inspection, there were not people dancing in the trees, but there were leaves.  Clearly, I was on my way to having heat stroke, but some how compelled myself to finish, arrive at camp and replenish my fluids and take a cool shower.  If I did go to the hospital, I think I would have received a (hypertonic) solution of D5 1/2 NS D5NS for fluid replacement.  A nurse would have monitored my BP, pulse rate and quality of lung sounds, as well as NA and urine output.

The opposite of hyponatremia is HYPERnatremia.  It is inadequate water, excessive water excretion usually from dehydration, heat stroke, or too much sodium (kidney failure).  Sodium is greater than 145 mEq/L.  Cells are HYPERTONIC – more solutes are outside than inside the cell, water follows solutes outside of the cell, cell shrinks. Left untreated can result in significant neurological, endocrine, and cardiac problems.

If you have trouble remembering hypotonic vs. hypertonic.  Hypo sounds like hippo – and I think of Fiona, the hippo at the Cincinnati zoo.  She’s made recent headlines.  She’s growing and is huge, therefore SWELL.  And, hyper is just the opposite.

I don’t have any personal application for the other solutes we have to remember so here they are:

When dissolved in water, electrolytes separate into ions and then conduct either a positive (cations: magnesium, potassium, sodium, calcium) or negative (anions: phosphate, sulfate, chloride, bicarbonate) electrical current.

Na – major extracellular fluid cation, regulates osmotic forces and water balance, regulates acid-base fluid balance (buffer), facilitates nerve conduction and neuro-muscular function, active and passive transport across cellular membrane.  Sodium levels 135-145 mEq/L.

Potassium – K (3.5-5 mEq/L) – major intracellular fluid cation, maintains cell electrical neutrality, facilitates neuromuscular transmission of nerve impulses; vital role in cell metabolism; functioning of cardiac, lung, muscle tissues, acid-base balance (leg cramps).  Reciprocal action with sodium.

HYPOkalemia –potassium less than 3.5 mEq/L.  Result of increased loss of K (avocados, dried fruit, cantaloupe, bananas, potatoes, spinach).

HYPERkalemia – potassium greater than 5.0 mEq/L.  results of inadequate renal excretion (kidney function), life-threatening – risk of cardiac arrhythmia/cardiac arrest.

-potential, ECF shift – insufficient insulin/acidosis (diabetic), trauma/surgery, fever, uncontrolled diabetes

Magnesium – Mg (1.5-2.5 mEq/L) – smooth muscle contraction (whole grains, dark vegs)

HYPOmagnesemia – less than 1.5, (malnutrition, alcohol use disorder, laxative use) – increased nerve impulse

HYPERmagnesemia – higher – chronic kidney disease.

Calcium – Ca (4.5-5.5 mEq/L) – cell permeability, bone and teeth formation, cardiac action potential, muscle contraction, blood clotting.

HYPOcalcemia – less than 4.5 mEq/L – Crohn’s disease (malabsorption), Vitamin D deficiency (alcohol use disorder, chronic kidney disease)

HYPERcalcemia – too much – bone cancer…

Here are some questions for you to answer after reading:

  • What are examples of isotonic, hypertonic, and hypotonic iv fluids that a nurse would administer? What would be important to monitor when administering a hypertonic solution?
  • What are the major cations and ions located in the intracellular and extracellular fluids?
  • What is the normal range and role of the following electrolytes: sodium, potassium, calcium, and magnesium?
  • What happens to cells when they are placed in isotonic, hypertonic, hypotonic extracellular fluids?
  • What does isotonic, hypertonic, and hypotonic mean?

Week something

12 days straight of school was not the best idea.  Some how I thought it was important to take the 16 hour doula class last weekend in between my regular class schedule.  The doula workshop normally is a $700 class that was offered to us for free.  I haven’t processed or read all the material that was presented, so I will report back about the experience in a few weeks, after finals when I have more time.

From the training, I did walk away with an incredible admiration for my clinical instructor.  Her life time of work supports the well being of the mom and baby.  She is well respected in the field of women’s health and everyone thinks very highly of her.  When I become “older”, I can only hope to be like her.  She is kind, generous and so willingly to share her knowledge.  Thank you Barbara!

This week was the last week of clinical for the semester and I am glad that things are ending.  I’m not sure how much more emotional work I could keep giving to the oncology patients.  I thought of my mom often these past 5 weeks in oncology.

My patient on Thursday was in the hospital for a variety of things, but what confused me, was that they smoked 1/2 a pack a day, for the last 9 years – that’s like 10 cigarettes a day.  They were in a lot of pain, but as soon as the pain was tolerable (managed by pain medication), they wheeled themselves outside for a smoke break.  I was dumbfounded by this policy at Duke.  Other interesting things I was able to observe a G-tube – a feeding tube directly inserted into a patient’s stomach for feeding and the IV team inserting an IV into a patient using ultrasound to locate the vein.

In one of our classes, we had a panel of previous graduates/alumni talk to us about their jobs and careers.  I learned the ICU is not a place I want to work.  The patients are very sick in the ICU and usually this unit has the highest mortality rate at the hospital.  The nurse who spoke about working in the ICU spoke about compassion fatigue and how emotionally draining it is to work in this unit.  She said some of her patients are there 6 months to a year, while others might not make it through a shift.  She also spoke about how she works night shifts because there is a better support system and it pays more than the day shift.

Another nurse spoke about how he was formerly in the marines, and after graduation he worked for 6 months in Sierra Leone on the Ebola crisis.  After, he spent some time back in the Emergency Department, then worked in research and now he is moving towards a  degree in Global Health/Public Health.  He said it’s best to work on a floor for a minimum of two years before moving on.  You then have the skills to go anywhere.

Another interesting theme that was presented on the panel was the idea that you work 3x a week and have the rest of the week off – you should do something with those days, activities that you enjoy.  I’d like to stay on the East Coast and close to New York, maybe for the first two years to hang out more with my nephew.  By the time, I finish my two years on a hospital floor, he’ll be ready for school and then I’ll too be ready to move on too.  I can be a travel nurse or go abroad.

I recently came across a Glamour article that I thought was interesting:

“What can I do with my time that is important?”

“What unpleasant experiences are you able to handle?”

“What makes you forget to eat and poop?”

“How are you going to save the world?”

“Find a problem you care about and start solving it.”

“If you absolutely had to leave the house all day, every day, where would you want to go and what would you do?”

“If you knew you were going to die one year from today, what would you do and how would you want to be remembered?”

Dying activity and clinical day 5

My iphone news feed thinks I must be pregnant or dying, because that’s all I talk about and read these days.  I’m grateful that our week of lessons on the subject is almost over.

In lab this week, we went over postmortem care.  It is the nurse who cleans and prepares the body before the family sees them.  It is the nurse who puts the body in a bag to take to the morgue.  We practiced putting a mannequin in a white body bag.

In another class this week, the topic was bereavement counseling, and the grieving process.  We did an exercise on what it feels like to be terminally ill.  It left me feeling weighted with a heavy heart.  If you want to try the exercise, I found a few samples online (link below).  For the exercise, when you are down to the final 3 pieces of paper, nurses help the patient obtain them.

Activity: Take out 9 pieces of post it size paper (for example, 3 green, 3 yellow, 3 orange).  Write 3 things you like about yourself on the green paper.  Write the names of 3 living people you care about on the yellow paper.  Write 3 activities or things you enjoy doing on the orange paper.  Lay all of the 9 pieces of paper in front of you.

Follow the instructions in the exercise, but one modification, I think there is a powerful impact if someone collects the papers after each reading.

More things for your toolbox on grief:

How to Support Someone in Grief (I liked page 7 the most)

Some excerpts I liked from page 7:
  • Do reach out. Offer specific practical help like childcare, groceries, yardwork, meals or cleaning.
  • Do give permission to do what feels right for them at this time.
  • Don’t compare their grief to yours or anyone else’s
  • Do say: I’ve been thinking about you. I am here to listen.

Allow time to grieve and treat yourself as you would a friend, be kind to yourself.

Day #5 Clinical – A nurse mentioned to me the night shift and night shift on weekends get paid $14/hr more than the day shift.  Some nurses in other units work 10 hour shifts and do not have a night shift but are on call.  Some other units are considered part of the hospital and not a clinic/floor and get paid less.  One nurse said Duke has a better benefits package than UNC but UNC pays better.  Interesting things to think about.

Today, I observed an upper GI endoscopy (a procedure in which a doctor uses an endoscope – a flexible tube with a camera to see the linking of your upper GI tract.  This procedure allows you to look inside the body to potentially identify unexplained symptoms, such as bleeding, ulcers, cancers, etc

There were several people in the room: the surgeon, a tech (who was a nurse) – helped with suctioning, the CRNA Certified Registered Nurse Anesthetist (a advanced practice registered nurse who administers anesthesia), a GI nurse (responsible for monitoring the patient), and MD anesthesia overseeing the CRNA – I’m not sure if the person who was performing the procedure was an attending, because what I think was the expert gastroenterlogist was standing behind him, with maybe a MD fellow next to him, and then there appeared to be another nurse who was standing behind me, singing along to the music in the room – she did nothing and I feel might have been the backup in case something went wrong.  The GI nurse told me the music helps the patient, and MD but it is a distraction for the CRNA.  Seems kind of important for the CRNA to not be distracted to me.

I liked how the GI nurse called the shots.  They said TIME OUT at the beginning, to confirm the patient’s name and DOB – this was another confirmation they had the right patient before they began the procedure.  This nurse then confirmed the allergies to this patient and said we will not be using any of these medications.  Although the doctors in the room were talking and (to me) being disrespectful when the nurse was calling the timeout, but maybe they were listening while talking.  This nurse also said on the intercom, ready in Rm. 1 – this is when the other people (MD’s) entered.  This nurse declared the time at the beginning and at the end of the procedure.  They told me, sometimes there is not a tech nurse and they sometimes assume both roles.  I was written in the chart as attending this procedure as a student nurse (SN).  I felt legit to be present in the room instead of blending into the wall.

The procedure went smoothly and was very quick.  It was only 15-20 minutes.  It was very cool to see all the organs of the body from the inside on a TV screen.  I liked seeing the fluids in the organs, identifying body parts like the stomach and small intestine.  The GI nurse pointed out to me when we arrived at the pyloric sphincter.  Yay, anatomy!  It is the band of smooth muscle at the junction between the pylorus of the stomach and the duodenum of the small intestine. The pylorus is an important part of digestion, acting as a valve to control digested food from the stomach to the small intestine.

I saw the patient sallow some pills a few hours earlier and saw it on the video in their stomach (undigested).  At the end of the procedure, the issue was not found or identified so the patient will later swallow a special pill containing a small camera.  This pill will go through the rest of their GI tract.  I think the camera is wi-fi capable.  I loved spending the day with my patient.  I loved learning about their lives, their children, their grandchildren, and their dogs.  We talked about so many subjects together.  I happily said goodbye to them in the same way I said goodbye to my patient last week.  The spouse said thank you to me and said they received great care from me.  I count that as a good day.

Today, aside from the procedure, we had a stress management meeting and learned a technique to help calm the mind, body and spirit in ten minutes for patients.  Stress is a change – whether a move, a job loss, entering school, graduating, a diagnosis, or a result of something, etc.  It is a change that effects your mind, body and spirit in real, physical, and tangible ways.  Our facilitator and founder of this principle/program said to be sure to take care of yourself so you can be a service to others.  If you have the courage to touch pain, then you must make sure to have compassion for yourself.  You can only give quality care to others if you care for yourself.  It reminded me of the safety film on planes.  In the event of cabin pressure loss, put an air mask on yourself before assisting someone else.

The technique works something like this:

Part 1 – put your hand on your stomach and take a breath, feeling the rise and fall of your belly.  This focus allows you to take in air and not hold your muscles/body tightly.
Part 2 – feel the support of the chair, or the support of the bed, or where ever you are sitting and allow fully, your weight to fall into it.  Let your body be heavy.
Part 3 – say a short positive thought on repeat – like, I can do this…  or if spiritual, say a prayer.
Part 4 – when your mind wanders, return back to your positive thought.

Natural birth

I think I just became a little more granola. I didn’t actually think that was possible.  After this past weekend’s class on childbirth, I am now 100% for a natural birth.  A natural birth is a woman’s choice in how she wants to have a birth, listening to her body and having a birth without unnecessary medical interventions.  I am all for a home birth or birth in whatever environment she can move freely and listen to the movements of her baby.

I can’t say I knew much about child birth, but what I learned over weekend completely blew my mind. I had no idea birth could be pleasurable. Could you imagine birth can be organismic instead of painful? The same feelings and body’s responses can happen while giving birth. You just need to have the same elements. A supportive space that is private, comfortable and loving. The woman should have the freedom to move her body, standing or kneeling in a pool of water, as opposed to lying down (like traditionally in a hospital).  It makes complete sense to stand and work with gravity.

I love the idea of giving birth the way you want to, in the elements that make you feel happy. It’s such a simple idea but revolutionary to listen to your body and move the way it wants to move. This weekend’s childbirth education made me look forward to the spring semester of maternity and peds.  I am especially happy to learn about midwifery in Guatemala (thanks to your donations).  I have little interest in becoming a midwife but childbirth is such an important time in many women’s lives and it is important to learn to advocate for them.

The video we saw is called Organic Birth. It is 52 minutes that will change your world.

Also, we did an exercise with a ping pong ball and a balloon, which I highly recommend.  It’ll give you an example of what contractions are like with a growing cervix.

 

Clinical days

I go to bed around 10 pm, to wake up by 5 am to get ready for clinical.  I spend an hour eating breakfast, reviewing notes for the day, and getting dressed.  I practice in my head how to give a head to toe assessment and think about what questions to ask around pain and an illness.  Around 6:15 am I bike to the hospital.  Continue reading →

Chase experiences

Every time I look up and see a helicopter flying into Duke hospital, I know it is carrying a critically ill patient.  I look up to the sky, in awe of the brave men and women doing their job.  Did you know a flight nurse is not eligible for life insurance because the job is considered too risky?  I wonder if firefighters are eligible for life insurance? Continue reading →