No Good, Very Bad Day

Saturday was my worst day ever at work. Allow me to share with you a partial list of what I did during the course of my 12-hour shift.

• I hung a liter of D5 1/2 NS instead of the ordered D5NS (that's all abbreviations for types of replacement fluids, by the way--water with 5 of dextrose and 0.45% sodium chloride, instead of water with 5 of dextrose and 0.9% of sodium chloride) and didn't notice, but my preceptor did, after 300 mL had already run in. (Incidentally, this was a non-big-deal clinically but went a long way toward making me feel like an incomptent boob.)
• I spilled a patient's ginger ale all over the floor. I wiped it up, and then should have called housekeeping to come mop it to get rid of the stickiness, but I never did.
• I grabbed the sprayer for cleaning out bedpans and somehow depressed the lever prematurely, and got one whole side of the bathroom wet, including the toilet paper.
• I forgot to get morning vital signs on the guy in Room 28, and didn't get any until noon.
• I totally missed the 10am dose of oral Lopressor for the guy in Room 38. Just somehow didn't see it on the med sheet. Fortunately (?) they were deciding to go up on his Lopressor dose, anyway, so he did get the new higher dose around noon.
• I somehow decided that 24 divided by 8 was 4, and so pulled 4 tablets of Zofran to pre-medicate the guy in Room 28 for chemo, instead of the needed 3, and my preceptor noticed it before I did.
• I didn't know that you throw away cyclosporine tubing after each use, and spent 5 minutes trying to get the damned locking adapter off the end of the tube, where it was stuck (because cyclosporine is hellaciously sticky stuff--just another little vastly useful tidbit of knowledge for you).
• I put on the ID bracelet for a new admission too loosely, so it could slip off her wrist, and I had to ask the unit secretary to print me out another one.
• I had a hard time taking an apical pulse on the guy in Room 38. Who can't find a damned apical pulse? (That essentially means I couldn't consistently hear the boomp-boomp, boomp-boomp when I tried to listen to the guy's heart to count the beats in a minute, which I was doing because the pulse in his wrist was all erratic. Gold-standard for pulse, especially when the heartbeat is irregular, is listening to the heart with a stethoscope for a full 60 seconds.)
• I repeatedly forgot to get more saline flushes for Room 28, and he was on MRSA precautions, so I had to keep gowning and gloving and then de-gowning and de-gloving as I went in and out and in and out of his room.
• I started crying in Room 38 while the patient was in the bathroom, and didn't get my face wiped off in time, and he probably noticed.
• As I was leaving around 9:00, 2 hours after my shift was supposedly over, I got all the way downstairs before I remembered that I had left my jacket, with my car keys in the pocket, back up in the break room, and had to go all the way back up and get it.

As you can probably tell, it was one of those days where things start out badly and then just get progressively worse as one loses all faith in one's own abilities, all ability to think clearly, and all concentration for anything but self-recrimination. I am very grateful that none of my little disasters actually had much of an impact on patient care, and shudder to think that they might have.

I've been trying to figure out just what went wrong. I really, really, really don't want to live through another day like that one. Part of it, I think, was that I had been frantic and flustered and rushed the day before. Both at work (a rare 8-hour shift) and then at home, I was running to try to get things done and feeling very frayed pretty much all day. And then I rushed to go to sleep, so I could be rested enough for a 12-hour shift, and then I got up and rushed to work, and so by the time I got there, I was already all jangled. I started out the day without enough calm and attention to sit down and really take in and process a whole bunch of new information about two somewhat complicated patients. I started feeling anxious and overwhelmed almost immediately, and I just never was able to catch up after that.

The other problem was Julie, my preceptor. She's the nice one, the one who always knows just what to say and just how to handle me. Saturday, though, she seemed suddenly to have lost faith in me. Instead of responding to my being scattered and freaked out with her usual relaxed confidence, for some reason she started looking at me like I was really Not Okay. She gave her usual little pep talks about doing what I needed to do to recover, and to try to put things into perspective, and to realize that things were not actually as out of control as they felt like they were. But for some reason, her tone and her facial expression belied her chill-out message. Her nonverbal attitude was one of Grave Concern.

As the day wore on, and I tried to take some opportunities myself to lighten up and get a grip and snap out of my tragic-screw-up mindset, she seemed to make a point of pulling me back down. It was weird. Once I spent a minute, or maybe two, joking around with an old favorite patient, and came back to where she was sitting at a computer with a smilier, more confident manner than I'd had all day. She started in immediately talking very seriously to me, at length, about the things I hadn't done yet (including some that weren't even due for another hour or two). It was the same story after lunch, when I was feeling refreshed and cheered up by sitting around for a few minutes with other nurses in the break room, talking and laughing about dumb things. This time she even managed to mention that it was Week 7 of my orientation, the implication apparently being that I was alarmingly behind where I ought to be. And then, toward the end of the day, I came out of the room of the new admission, having just done the 6-page admission assessment questionnaire (Have you had any changes in your bowel habits? Have you fallen recently? What is your religious affiliation?) as I was supposed to, and remarked to Julie that it was so nice to get to really have a conversation with a patient, that it helped me remember what this was all about, that it was most fundamentally about the people and not about the tasks, and that was the thing about the work that really fed me. She agreed (half-heartedly?), and then a minute or two later gave me another little lecture about how it was very nice to talk with patients and all, but at this stage, I really needed to concentrate on the tasks. As in, I may tell you to try and put things in perspective and that this is just all part of the process, but you need to know that I don't really mean it, and you'd better not think for a moment that you're doing fine and things are okay, because you're not, and they're not, and you sure as hell better wipe that smile off your face, missy.

Sigh. I don't know. We'll see how it goes tomorrow. It's funny. Now I'm even wishing I had Jessica as my preceptor instead of Julie. But maybe we can come to an understanding somehow. If it's bad again, I might even have to say something kind of direct. Bleah.

Further Preschooler Insights

It's Friday, around 6 pm, and Cassie and I are at the (excellent) local produce market / deli / bakery doing some grocery shopping, because it's the only time I could figure out to fit it in. I have a 12-hour shift the next day and am feeling tired and stressed. Apparently I'm not the only one.

Cassie, after we've been there about 20 minutes: There are a lot of people here having bad days.


Later that evening, Cassie has just started supper.

Cassie: I'm getting less cuter.

Mama (had not noticed): You are?

Cassie: Yes. Big kids and grown-ups are not cute.

And she has a point.


Minutes later, Cassie is pretending that the chicken nuggets on her plate are cars, and the dollop of ketchup is the red light at which they're all lined up.

Mama (incredulous): You're eating cars?

Cassie (agreeing): Eating cars would be yucky.

Mama: Yeah, well, yucky and hard to do.

Cassie: Yucky and hard to do and a choking hazard.

Maxim

This morning, a propos of nothing I could discern, Cassie stated the following (a quote from something she heard at school or on television? possibly an original thought?):

A girl is not a girl without her strongness.

Not Only but Also

Oh, and I also have to tell you that I have this great new t-shirt. Even though I got the XL, it kind of won't really fit me until, well, until I'm not pregnant any more (and even then...), and the fabric is thin and flimsy, but I love it and I'm going to wear it anyway.

It reads "are you experienced?" in a 1968 Fillmore West kind of font, and it has a picture of Hello Kitty dressed up as Jimi Hendrix.

Maybe you have to see it.

And while I'm back at the unsolicited testimonials, have you seen Peep and the Big Wide World? It's a kid's show. It has a round yellow chick, and a nondescript red bird who turns out (if you listen closely to the dialog--there aren't really any other clues) to be a robin, and a blue duck wearing a sailor's hat, and it's one of the funniest shows on television, never mind that it's for preschoolers. Joan Cusack narrates. They're just starting a new season, which is a ridiculously exciting event in this house. (We've watched the previously existing episodes into the ground. We can recite whole exchanges by heart. We all sing the theme song together.) Plus it's made by WGBH, and the National Science Foundation has something to do with it, and so I guess it must have--you know--like, protein and fiber and antioxidants in it or something. I mean, it's somehow secretly good for you. Well, they did have moldy bread in it today. That's scientific. Anyway, it's totally excellent, and you should probably watch it, even if your house is preschooler-deprived.

Okay. I think I'm done now. I just can't seem to stop blogging today. Maybe I should go take a shower and give my damned cat (yes, she's still alive) her medicine.

Fallout

You assume it's going to be the sadness of patients dying. That's the obvious emotional burden, the one that people are thinking of when they say things like, "I guess you have to be a special kind of person to work in oncology." And the truth is, I haven't gotten to that part yet.

Some of "our" patients have died, of course, since I've been working on the floor, but I'd only actually even met one of them, and I didn't know her well. I'd never taken care of Mrs. W myself, though on one occasion she did graciously allow me to come watch the process of flushing her double-lumen urinary catheter (she had terrible hemorrhagic cystitis, a bleeding bladder, and required frequent flushing to get the clots out--they caused her great pain). She was clearly a warm and lovely person, but my own sadness at her death felt distant--there were so many nurses who had genuinely been close to her, and I just hadn't been.

I have started to notice, though, occasional surprising flares of anger. Hatred, even. I spend most of my time in a reasonable, therapeutic, compassionate mindset. Here I am, being there for my patients, providing all I can in terms of understanding, comfort, and care. You know. Professional and warm-but-detached. This is not my suffering, and it's almost presumptuous to take it on myself. But. But every so often, this eruption of red-hot feeling comes through. It fortunately lasts only a couple seconds at most, but it tends to catch me off-guard, even though the kinds of things that provoke it are kind of predictable. The dad getting a bone marrow transplant is visited by his two small children, and has to put on a mask and gown and gloves to spend time with his own babies, and then they go away again, and he waves bye-bye to them through the glass window in the door of his positive-pressure hospital room. I stop in to say hi and chat briefly with N, a rebellious and funny 30-year-old with lymphoma in his own mask and gloves, sitting at the computer in the patient lounge, and as I leave, I pass G, a 21-year-old with metastatic osteosarcoma, who measures his time left in months. I hear from J, a woman in her late 20s with newly diagnosed leukemia, about her lack of health insurance. She's smart and thoughtful and incredibly sweet. In her hospital bed, she knits because her chemo has messed with her vision, and it's hard for her to read. She has amazing tattoos on her arms. She's been finishing up her bachelor's, and next year, she would have been moved into a job category with benefits. The people at the school where she works held a big raffle to raise funds for her care.

And then I get this flash of blind rage. For a moment, I just hate cancer with everything I've got. I want to get a torch and rally a bunch of villagers to TAKE THE FUCKER DOWN. And then before I even take another breath, I realize that's ridiculous, and cancer is not a very well defined villain, and I simmer down, and I go on with my day. But for a while, a kind of unsettled feeling lingers. Who knew I had that kind of anger?

And then, yesterday, the tears came for the first time. Pete had taken Cassie to a children's concert, and I had the house to myself for a couple hours. I was picking out some music to put on to clean by, and I noticed my Norah Jones cd. I don't play it very often, but now I wanted to. Julie, my preceptor, had told me a story that her patient Mrs. G had told her. Mrs. G is a lady in late middle-age, built like a fireplug and now also entirely bald from the chemo. She has a fairly thick accent I haven't yet identified, and is warm and funny and outgoing and generally a real character. She has a framed picture of herself mugging with a lollipop because she thinks that without hair, she looks just like Kojak. She's had a long course, and now she's in for a bone marrow transplant, which entails a grueling and somewhat dangerous regimen, with a hospital stay of at least 5 weeks. She told Julie that a couple days before she came in to the hospital to begin the process, her whole big extended family had gathered. The occasion was maybe some grandchild's first communion or something, but because of Mrs. G's situation, the party was more on the scale of a wedding. Everybody was there. And when the dancing was going to start, the floor cleared, and Mrs. G's son came to get her to dance, and the dj put on Norah Jones's "Come Away with Me." There wasn't a dry eye in the place. (This, of course, extended to Julie and me, misting up talking about it in the clean utility room as we got supplies for a dressing change.)

So I decided to put on Norah Jones, in honor of Mrs. G, as I tidied the living room. And when "Come Away with Me" came on, I indulged myself in a good wallow, summoning a cheesy mental montage of Mrs. G being in the hospital and getting chemo, with all the concomitant boredom and discomfort and frank suffering, as her loving son invited her "come away with me," even though he knew she couldn't. And what I found myself thinking, as I sobbed at my own generated pathos, was not just "how sad," but "I'm sorry." I'm sorry, I'm sorry, I'm sorry.

The emotional difficulty in being an oncology nurse is not just in the grief and sadness, I realized. Part of it is that being a person who administers chemotherapy implicates you in the suffering. Chemo sucks. And yes, you can take a step back and think about how it's the best chance, the only chance, for many of these patients. It could buy them months, years, of life--in many cases, symptom-free life. Sometimes it, along with surgery and radiation therapy, even cures. And that the patients have chosen this route as the least of the possible evils; they actively want this treatment.

But still, chemo sucks. And there is fallout from giving people incredibly toxic substances, putting these vile chemicals right into their veins. And then watching their blood counts fall, watching their liver function test numbers rise, watching their electrolytes get out of whack. Watching the nausea, the fatigue, the mouth sores, the diarrhea, the rashes. Administering packed red blood cells when the hematocrit falls below 25 (normal is around 40), platelets when that count falls below 20 (normal is over 150). Bringing in handfuls of pills, giving medications to control the side effects from the medications you gave to control the side effects of the chemo. And even though you know why, there's still something in knowing that you did this to them. You, personally. You hung up that bag, you strung the tube through the pump, you attached it to the catheter or the port leading directly into their bloodstream. Cytoxan, ifosfamide, etoposide, cytarabine, high-dose methotrexate. You punched the numbers on the pump's keypad to administer the carefully calculated number of cc's per hour of the poison.

Meanwhile, at the end of my shift on Friday, I heard two of the older nurses talking. I didn't know who they were talking about at first, because I always call this particular patient by his last name, and they were using a diminutive of his first name. His mother is in the patient lounge now, crying, they said. Of course you can't blame her. He still has blasts in his periphery. There's nothing more the oncologists can do. It finally dawned on me who "he" was. It was N, the 30-year-old at the computer.

Fuck cancer. Fuck. Cancer.

Finesse

I'm back on days now, and worked 7A-7P last Thursday and Friday. As a special surprise bonus, I got to have my beloved Julie as my preceptor on Thursday because Jessica happened to have somebody else to precept that day. So that was awfully nice. But then of course I did have to have Jessica on Friday.

Friday morning on the bus, for the very first time in this job, I found myself dreading (ever so slightly) getting to work. And, as it turned out, I wasn't really wrong. Nearly as soon as I got there, Jessica was on me, micromanaging even the smallest details of my day, "correcting" my decisions about which task to do first, giving me little lectures about time management. I managed not to say "Fine, fine, FINE!" but let slip a sort of understated, "Okay, okay, okay, I'll go get the 8 am meds now." It did have a slight edge to it, but was nonetheless substantially filtered down from the "would you shut your flapping piehole and leave me the hell alone?" that might have more accurately represented my true emotions at that second.

Things did kind of settle down after just an hour or two, but I was feeling pretty chafed, and it really wasn't helping my concentration or my efficiency any. Fortunately, there turned out to be some more substantive, actual patient-care-relevant issues to talk about come late morning, and we were able to warm up to each other again a bit. It occurred to me that one school of thought would be to initiate a frank dialog with Jessica, explaining my frustrations and asking for a change in behavior. The advice columnist solution. I briefly tried to consider it seriously, but gave up on it pretty quickly. It just seemed too ham-handed in the situation, and seemed like it would make things more, not less, tense. Plus I really didn't feel like it.

By noon, Jessica was finally pretty much leaving me alone, since she had a new admission to contend with herself. Around 4:30, we reconvened, and she said, "okay, there are 2 1/2 hours left, and there's still a lot to get done," (subtext: you haven't been taking my time management advice, have you?) and had me list what remained to do. Then she offered to take over Room 16 so I could concentrate on 32A for the rest of the day. That was nice of her, though in context, it did have a little shading of I-told-you-so. So I went and finished up with 32A--changed the caps on her triple-lumen Hickman catheter, belatedly got her 4 pm Benadryl as well as the Zofran she requested, hung her vanco, emptied her urine & tidied the bathroom, changed her bed (finally), took her vital signs again (I'd taken them at 4, but then had not written them down, and uncharacteristically forgot the numbers completely), and charted her Is and Os.

There was one notable Jessica moment, when she poked her head in and noticed that the patient had... an orange! If it had been Julie, I know that whatever she said would have been compassionate and diplomatic, but Jessica blurted out a rather snippy and condescending, "Has anyone explained to you what neutropenic means?" and told the patient she wasn't allowed any fresh fruit (as part of the "low-bacteria" diet that people with severely compromised immune systems have to follow). The patient, a kind of salty working class middle-aged woman with newly diagnosed leukemia, quite reasonably replied that she had been told that oranges and bananas were okay because they had thick, protective skins that you didn't eat. Jessica bustled off to ask the nurse practitioner, and the patient mischievously hurried to peel the orange so that she could eat at least one section before Jessica came back. "They're really good oranges," she said to me. I probably should have stepped in, with a gentle, "why don't we wait for the answer, just to be sure..." That would have been the nursely, responsible thing to do, right? But I couldn't bring myself to. I just stood there and, well, maybe kind of twinkled as the patient peeled her orange. Jessica then came back with the news that the nurse practitioner said it was okay. Oh, whew.

When I was talking to our friend Max on the phone shortly after my shift, I was trying to describe what Jessica was like, and I think I was being a little incoherent. Finally, he said, "oh, does she have her hair pulled back into a very tight ponytail?" "Um, yes," I said. "Yes, actually, she does." And he laughed, because then he got the picture exactly.

What's funny, though, is that for all her uptightness, Jessica also cuts corners that I don't feel comfortable with--and that Julie (my role model and exemplar in all nursing standards) doesn't cut. I guess maybe it's that Jessica's tightly-wound-ness is more about rules and efficiency and less about the big picture of providing good patient care. It's really nothing egregious, and I think she probably provides perfectly safe patient care, but she often doesn't go the extra step--doesn't look stuff up when there's a little question; she just fills in paperwork to get it filled in and doesn't take time to think carefully about it. Things like that. Julie always seems to do both, to get things done efficiently and to make sure to serve the larger good of patient care.

At the end of the shift, as we were sitting and charting, Jessica and I were talking (pretty amicably by now, thank goodness), about the weekend and when we were next on together. She had been looking out for me and made sure that since the Clinical Nurse Specialist was on vacation, we got the Nurse Manager to make up a schedule for me for the next few weeks. I was really very grateful, because I was feeling shy about making it happen, but at the same time really wanted to know what my life is going to look like. And we saw on the schedule that our next workday was Tuesday. "So at the beginning of the shift, we'll sit down and plan out the day together," Jessica said. Oh dear, here we go again.

"Um," I said. "Um, I was thinking that maybe I should try to plan out my day myself. I really, really appreciate your stepping in with Room 16 so that I could finish up everything for 32A today. It made it so much easier. But I'm thinking it might be a necessary part of the process for me to, you know, make mistakes, and to some degree suffer the consequences, you know? I mean, not to the point of, I don't know, going to cry in the bathroom or anything, but it just seems like I really have to learn the process of time management from the inside out. So I should try to kind of, you know, go through the process from scratch. So I can slowly learn how to be independent. I mean, if I'm really super overwhelmed, I might have to ask you to rescue me a little occasionally, but I think I should try to do it by myself."

I have to admit, I felt like a frigging genius. None of what I said was at all untrue--I had just managed to find a place to stand from which I could say what needed to be said without it being at all threatening or angry or anything. It was all about my shortcomings and my weaknesses and my vulnerability, and not a whisper about her driving me bats. And she relaxed immediately. She seemed truly relieved. I gave myself an internal high-five.

So that's the plan for Tuesday, and I have to say I'm feeling fired up. My twin (and fortunately complementary) goals: provide excellent, safe, and efficient patient care, and keep Jessica off my damned case. I figure I have to be so good, so thorough, so on top of things, that she isn't tempted to put her little fingers in. I'm in the process of making up my own special scut sheets, a format for writing stuff down and figuring out my priorities and keeping the important things in mind, and prompting myself to do the stuff I have a tendency to forget. And then I'll go in a little early, and I'll read the charts and look up the labs and get everything all mapped out for myself. And buy myself the right to go in and check in and say good morning to my patients before I get their damned 8am meds, if I so choose. We'll see how it goes.

What's the Name for the Meal You Eat at 1 AM?

So. The night shift. 7P - 7A. I've now done it, twice. I think maybe it was about as hard as I thought it would be, but kind of differently from how I imagined.

My first night started inauspiciously. I usually take public transportation, but I was recently clued into the fact that we get free parking for night and weekend shifts (weekday parking is kind of prohibitive--you either sign up for a remote parking garage or pay fall-down-dead non-validated rates for a spot in one of the patient/visitor garages). Filling out a form and putting a little orange square sticker in my back window allows me to swipe in and out of the patient/visitor garages with my ID at designated hours. So I did that. ("Welcome to OFH!" said the parking office guy, with apparent sincerity, after he handed me my sticker.) And so Sunday night I drove. It was, naturally, dark, this being November and all. And it was raining. And then right as you get off the major crosstown artery to go to the hospital, there's a lot of construction. (Supposedly there's going to be this fabulous new subway stop that's actually going to be handicapped-accessible (that would be a nice little touch for the major public transportation access to one of the largest medical centers in the country, don't you think?), but it doesn't seem to be happening very fast.) And so the streets are now configured a little differently than they were the last time I drove to OFH, which was when my dad was an inpatient there a year ago. So. Well, see, I'm not sure quite... I mean, taking the right fork seemed at the moment... What I'm trying to say is, I somehow ended up going the wrong way on a one-way street. This was Sunday night, and so I managed to get the block and a half I needed to get to the OFH entrance without encountering any other cars, only realizing with horror about halfway along what I was doing. I pulled into the parking garage with my face bright red, emotions split about 30%-70% between delayed-reaction fear and profound, staggering embarrassment. OK, Rosie, nice work, and now you're going to go take care of sick people and be responsible for putting substances into their veins and stuff? Great. Just great.

Fortunately, there was no equivalent event on the oncology floor, though as the night wore on, I did find myself getting stupider and stupider. I had been worried about getting sleepy, but that wasn't it. I really didn't feel drowsy at all. I just felt as if my mind were moving through gradually congealing oatmeal. By the time I was supposed to write my end-of-shift notes in the chart, I sat there for probably a full minute staring at the page before I could even think of how to start.

I was surprised to find that the second night was easier than the first. I had really been able to sleep during the day on Monday, for nearly 7 hours, so I was in something a bit closer to a normal state. I did get sleepy and dumb right toward the end of the 12 hours, starting around 5:30 am, but I was overall significantly sharper. Plus there was a big plate of cookies a patient's husband had brought in for us.

I was also struck by how strangely different time is during a night shift in the hospital. Somehow I pictured 3 am feeling more... more like 3 am, I guess. Instead, it feels like an entirely different time from 3 am in the normal world. It's just that they happen to be called the same thing. Like homonyms. 3 am on the oncology floor felt like a kind of dull, prosaic downtime. Slow, maybe, but not remotely eerie or creepy, and frankly not even that quiet. Michelle and Kelly, two of the younger nurses who are apparently great friends, got the giggles both nights, the first night telling stories mostly on the theme of patients-and-poop, and the second night talking about miserable attempts at downhill skiing.

My new preceptor, Jessica, turned out to be very petite and pretty in a fresh-scrubbed way, with a movie star smile a little bit too big for her face. I probably have about 10 years and 90 pounds on her, but, well, who's counting. She was fine. Sweet, I guess, in a not-too-intuitive way. All the preceptors I've ended up working with since Julie (who I had for my whole "clinical" in my nursing refresher program, and whom I've also had a few times since becoming an employee) just make me appreciate her more. Not only is she a really exemplary nurse, extremely thorough and disciplined and great at keeping big picture and details in mind at once, she's amazingly tuned into just what you need when you're learning. She knows when to step in and help, when to step back and stay quiet, and when to disappear for a while to let you really have some independence. Jessica was never impatient or curt or anything, but she was kind of inconsistent, and our rhythms were all out of whack. The first night, her decision was that I was just going to take one of her two assigned patients (the usual night shift load on this floor is 4-5 patients, but Mr. A was looking really unstable, and it turned out the staffing level permitted her to get just him and one other). So I didn't really do the preparation for taking care of her other patient. But then it turned out that Ms. M really didn't need much between about 9pm and 6am, so I ended up doing a lot with Mr. A as well. And I was never clear on what should be my responsibility and what shouldn't. And then she suggested I write his note, too, at the end of the night. Which was fine, I guess. I mean, I mostly did know what the story was with him. I just felt all unprepared and off-balance. The second night, I got my own two patients, Ms. M again, and then a new lady with leukemia, Ms. G, in for her first round of chemotherapy. And I was able to plan a bit better, and that felt good. But then a couple times, Jessica asked me if I wanted help with some task (e.g., drawing blood off a central line) or felt confident handling it myself, but didn't seem to believe my answer when I said I could do it. She ended up coming with me anyway, which made me feel flustered and hovered-over, and I made some mistakes I might not have made alone, and anyway would have benefited from just working through on my own. I ended up all frustrated and embarrassed. Mad at her, mad at myself, black-cloud-over-my-head-ish.

As ever with trying to write about this job, I still have a zillion unsaid things (many still unformed) whirling around in my head, but I have to go pick up Cassie at preschool now. I had a four-hour nap midday today, and will try to sleep normally tonight. I'm back to the day shift the day after tomorrow, 7A-7P.

Nocturnal

Tonight, in a few hours, I work a night shift for the first time in my life. (The closest I've come is when I worked in a mall movie theater a couple summers when I was in college. Fridays and Saturdays, the last shows ended around 1 am, and then my friends--fellow Crossgates Cinema 12 employees--and I would hang out, talking and laughing and maybe drinking, and roaming around in the benign, expansive suburban summer nights.)

7 PM to 7 AM. I'm a little intimidated by the thought of it. I do it tonight and tomorrow night--tomorrow night being even a bit scarier, because of course a person can do anything for one night, if there's all the time in the world to recover afterward. But if I don't manage to sleep a lot during the day tomorrow, I'm kind of screwed for my second night.

In a community hospital, I guess there would actually be more to be worried about. All the doctors go home, and it really is the nurses' show. If something goes terribly wrong with a patient, you can page, but the MD is answering from his/her own little bed, and it's up to you (well, and of course the other nurses who actually know what they're doing) to deal with it until such a time as help arrives. In a teaching hospital, though, there are always a few covering interns and residents floating blearily around, maybe snatching naps in the call room but not more than a minute or two away.

So it's not that. It's not really rationally justifiable, I don't think. Certainly part of it is, what if I wimp out? But there's also this weird feeling, like night is for sleeping, and working nights is breaking some kind of taboo. And what if everything's different at night? What if it's strange and quiet and creepy? It makes no sense. I can picture what it will be like, really, and if anything, it will be a little bit boring, and also a drag because the cafeteria's closed. But beyond that, it will be awfully ordinary. But there's this dumb, prickly, lingering sense that I'm going to be encountering the unknown.

Well, and I kind of am, because I have a preceptor tonight I've never met before. People say she's nice. I don't know. Kind of everybody's nice. Well. Some people are a little snarkier and have more of an edge than others, but the culture is awfully strong on the unit that all the nurses are nice to each other. It's really striking.

I also am not sure what happens on nights. I think each nurse has more patients, because there's less to do. Substantially less than half of medications are given at night, and there's not changing the bed and getting the patient washed up and stuff. Dressing changes and line changes usually happen on days. Patients mostly don't go down for tests or anything. If they're lucky, they're actually sleeping through much of the night. There's a little flurry of medications and vital signs and stuff around 8 pm, and maybe a few bed-time-ish things around 10 pm, then maybe some IV antibiotics to hang at midnight. Then at 4 am the poor dears get their morning labs drawn, and occasionally you'll hang an IV medication then too. I don't know. I have trouble picturing the rhythm of it. But, well, my ignorance will not now last much longer.

I'll let you know how it goes. Meanwhile, I am off to take the suggested pre-shift afternoon nap to help gird my gravid loins.

Orientation. Disorientation.

Gosh. Well. I think the thing is, there's so much that I'm taking in, I'm not sure I have anything coherent to say about it.

I started at OFH (Other Famous Hospital, a very large metropolitan medical center) on October 11. There was a week of the kind of orientation where you sit in a room with other new employees, and a variety of people talk at you in 20-60 minute blocks--the first two days were all new hires, and the following three were just for nurses.

I learned that there are about 19,000 employees at OFH, and it's the second-largest employer in the city. I learned that if you are in a threatening situation, and you don't want to alert people to the fact that you're calling security, you can call the security number and ask to "page Dr. Johnson," and then the person on the line will ask you a series of yes-or-no questions to find out what the situation is, and send a security team right over. I sat next to a Puerto Rican pharmacy tech and learned some basics of Puerto Rican-US relations from the average-person point of view. I learned that I'll get paid weekly.

I got my ID, and in my picture you can just tell that I'm wearing my favorite purple maternity jumper, which I have to send back to Marina now, because she had the temerity to get pregnant herself before I was done using her stuff. (Can you imagine?) On my ID, it identifies me as RN, BSN, and a little part of me feels like it's lying, even though it's officially true.

But it's actually starting to happen--my transformation. I am turning into that hospital nurse that until a year ago I never thought for a minute I'd be. It's weird as hell. I have shifts where I'm so caught up in learning the job that I don't even think about it. But there are still occasional moments when I have that shock and feeling of dislocation. I'm watching my hands do something--spike an IV bag, set the flow rate on the pump, or punch into the Omnicell (= SureMed = Pyxis = electronic medication dispensing thingy) and get out some insulin and draw it up--and I have a fleeting alarm go off: WAIT! I DON'T KNOW HOW TO DO THIS. I'M NOT A HOSPITAL NURSE. And even though less than a second later, I remember that of course I know how to do this--and I can walk myself through how I learned--a slight feeling of unreality, or at least improbability, lingers. My whole self-perception hasn't caught up. I have trouble integrating it into a coherent whole. How is it that I can actually continue to be myself at the same time that I am this creature who wears scrubs, and tracks Is and Os, and knows which line of the triple-lumen Hickman you give the antibiotics through?

The other freaky thing is that I seem to be blissfully happy at it. That's even stranger, really. I haven't figured out how to think about that. Time will tell whether it's lasting, I guess. I've only done--let's see, I've already lost count, but maybe 5 or 6 shifts as a genuine employee. I'm still on orientation (and will be for several weeks to come) and haven't even gotten back to having two patients yet (though I did that a couple times while I was doing my clinical for school). So things could easily get hairier, workwise. I mean, they will for sure in some ways. The thing is, I feel ready for it. The other nurses are helpful and available, and I don't feel alone at all in what I'm doing. That's huge. And I'm also really grooving on doing patient care again. I love, love, love getting to talk to people, making a little relationship with them, making it so they feel heard and noticed and genuinely taken care of. I don't know. It's just so much fun.

I'm starting to think that maybe the novelty is also part of my ultra-Prozac glow these days. As much as I think that I hate being new at things, hate being bad at things, it is also true that I hate feeling stagnant and bored. I get all stale and cranky and in a funk if I'm not learning anything any more. And I guess maybe feeling a little overwhelmed by all there is to know makes me feel exhilarated. It means there's something to strive for, something that's bigger than me. I don't have that claustrophobic feeling of sitting around just breathing my own air. So maybe in a few years, once I kind of have this job down, I'll start feeling itchy again and ready to take on something new. It's actually a little bit reassuring to think so, because it jibes better with my own self-image than this picture of the happy nurse, padding blithely around the ward in her dorky shoes (among the younger, hipper nurses, Dansko clogs--preferably in cordovan--seem to be the de rigueur accompaniment to scrubs, but I find I am content in the ridiculously retro, insanely nursy white lace-ups I bought in nursing school), charting vital signs and emptying urinals with a bizarre sense of deep fulfillment. (I mean, really, wtf?)

I think I have about a zillion more things to say about my last few weeks, but they'll probably keep. I really want to empty wastebaskets and clean toilets, not to mention, um, actually brush my teeth, before I go pick up Cassie at preschool. (I have the hardest time structuring my days off, and I seem only to be able to get things done in a lurching, haphazard way.)

More soon.