First Day of the Rest of My Job

After spending Thursday through Sunday wading the mucky edges of the Slough of Despond and dreading today's arrival, my first shift back at work since Ugly Wednesday. I was, of course, in great need of just getting back to it, already. Four days is way too long to contemplate one's own professional inadequacies without the opportunity to do anything about them.

Fortunately, and perhaps not so surprisingly, today was fine. I never did get an e-mail back about my request to be assigned to a different preceptor, but at the beginning of the day, Linda the Clinical Nurse Specialist just switched me from Jessica to somebody else. I still don't know what she said to Jessica about it, but I had several cheerful and seemingly un-charged interactions with her throughout the day, so I think it's fine. My replacement preceptor was a bit, um, hands-on at first, apparently having been warned about my--you know--issues. And I spent a miserable half-hour or so thinking oh no, not again. But I managed to demonstrate some competence early on, and she backed way off after that, but stayed warm and approachable about the stuff I did need help with. I'm not sure what impression of me she walked away with, but it seemed not to be dire.

Meanwhile, there was the actual patient care. (Oh, that.) My guy with graft-versus-host disease (a risk with an allogeneic bone marrow transplant--your new T-cells from your donor decide to fight off your own tissue as a foreign invader) and cryptosporidium in his gut was having a hard time because he just learned that he's not going to get to go home in time for Christmas, after all. He was being uncharacteristically uncooperative, entitled, and at moments downright defiant. I got him to open up a little about what was going on with him emotionally, and I also got the chaplain (with whom he has a good ongoing relationship) to go see him, and by the end of the shift he was noticeably mellowed.

AND there was my new lady with the head and neck cancer. She's just about to start chemo, and is being put through all kinds of preliminary tests and procedures. Her jaw pain ranges from 5 to 8-1/2 on a 0-to-10 scale, and she is not really able to speak intelligibly because of the massive tumor in her left cheek. She wrote me a note telling me that she had a "fun day" and "enjoyed [me] immensely." Now, if a person can think even for a moment that she had a "fun day" on the day her Port-a-Cath was placed, somebody is doing something right, if I do say so myself.

Of course, I didn't bat 1.000 today. The buff 38-year-old guy in for his first round of MAID (a chemo regimen) for his bone cancer didn't smile at me once, and at best grimly tolerated my ministrations and my apparently not-so-ingratiating presence. But whatever. I measured his pee, I took his vitals, I unhooked his IV lines for a sec so he could get his robe off, and I told him that his mother called. I did what I needed to do.

I'm off again tomorrow (during which I intend to complete approximately a week's worth of Christmas-related tasks, plus two loads of laundry), and then back Wednesday and Thursday. I'm feeling immeasurably more upbeat and relaxed about it after today, and I hope that manages to carry through.

I leave you with a recent Cassie quote: "I have to poop really badly... No, no... I mean, I have to poop really goodly."

Empathlet

Yesterday after Cassie got home from preschool, we were sitting on the couch. I thought I'd been fronting pretty well, being warm and cheerful. At the moment, though, Cassie was playing with something, and I was looking desultorily through a catalog and thinking about work. Cassie looked up and startled me by asking, "Mama, are you feeling worried?"

"Um, yeah, I guess I am," I admitted.

"What are you worried about?"

I explained that it was nothing about home, it was just about work. What about work, she wanted to know. Oh, I said, I'm just taking a long time to learn some of the things I have to learn. That seemed to satisfy her, and she went back to what she was doing.

It's true that it's hanging kind of heavy on me just now. It might be useful in some soul-stretching way to be attempting something I'm not naturally good at, and to be struggling. I mean, this does fall in the not-killing-us-making-us-stronger category, right? I remind myself that I never expected to be good at this. I knew it would be hard for me, and I could only probably hope for adequacy, at least at first. But I still haven't heard back from my bosses about my request for a new preceptor, and it's making me feel particularly vulnerable and squirmy.

I'm also a little confused as to what to feel. I guess my best judgment is that my performance really has not been so bad as Jessica seems to think it has (Jessica unfortunately being the source of most of Linda and Maureen's impressions of how I'm doing as well). But what if I'm just being defensive? What if it really is that bad, and I'm just scrambling to continue to think well of myself? I try to think through individual situations, examples of where things haven't gone quite right, but I just end up all flummoxed and fuming and depressed. I don't know what to think. I don't know whose judgment to trust.

Well. When I was postpartum with Cassie, I felt at least this bad about my decision to be a parent. I felt trapped in a terrible mistake. And it did all work out pretty swimmingly ultimately. So for now I guess I just hang on and do my best and wait it out a while. And, um, definitely keep taking the Prozac.

Rosie, Problem Child

A follow-up e-mail I just finished composing (um, yes, it is 4 in the morning...) to the clinical nurse specialist and nurse manager of my unit in the aftermath of an excruciating meeting today (I mean yesterday) with them and my preceptor Jessica. (I cried--repeatedly--which irks me no end. I also had a blinding headache by the time I got home.)

Dear Maureen and Linda,

Thank you very much for meeting with me yesterday. I appreciate your frank feedback and hope that I'll be able to justify your faith in my potential as a nurse on Wright 10. At least please know that I'm trying my hardest and care very much about doing the best job I can.

You asked about things that I thought might help me progress and learn. There actually is one thing that I've thought of, and while I'm not sure that it's possible, I thought that I would mention it. It's a little awkward to ask, but I wondered whether I might be assigned to a different preceptor for some or all of the rest of my time on orientation.

I want to be sure to make clear that it isn't that I don't think that Jessica is appropriate, or nice, or caring. She is all of those things. It also isn't that I don't think I have things to learn from her, or that I think her assessment of my strengths and weaknesses is inaccurate. It is just that, for reasons that I don't fully understand (but I suppose have to do with our very different personalities and styles), working with her, I tend to end up with a kind of black cloud over my head. Something about the dynamic between us results in my feeling discouraged, defeated, defensive, misunderstood, and unvalued. I find myself often having to manage my own emotional responses to our interactions rather than being fully present for the content and learning potential of the matters at hand. I also find myself making dumb mistakes under her scrutiny, which of course (understandably) leads her to feel the need to scrutinize my work ever more carefully, and the pattern is self-reinforcing. (Which isn't to say that I don't make dumb mistakes working with other preceptors! I do! I just think my rate is noticeably lower...)

I very much want to avoid any blame of Jessica--I think she does a fine job, and we're probably just mismatched. The last thing I want is to create any ill feelings between us--I'm very grateful for the care she's taken with me, and very much hope that we can continue to work harmoniously together as colleagues. I was thinking that maybe I would tell her that I just wanted to try to start fresh and put the past behind me, which is also absolutely true.

I am happy to continue working with Julie Piccolo, and I have also enjoyed the shifts I've worked with Marcia Moreau and Sue Kennedy. I've never worked with Liz Carrier, but wonder whether that might not be a good match, too. I understand that there are likely both pedagogical and logistical reasons for new nurses to have continuity with one preceptor, and besides, other people might not have availability, so if it isn't possible for me to switch, I'll understand and just make the best of it.

One final, probably unnecessary, thing--I know it was just a kind of example to illustrate a point, but I want to be sure you know that I'm not in the habit of standing around talking with patients for ten minutes at a time (much less forty-five). I may well waste time finishing a conversation after I have completed my tasks in a patient's room, but it's more on the order of 30-60 seconds. Room for improvement, certainly, but I just wanted to be sure you were aware of the magnitude.

Thanks again for meeting with me, and for all your care and encouragement.

Rosie

Decision

The Friday before last, I reached 26 weeks in my pregnancy. Third trimester has now begun. This milestone brought with it (quite promptly, I have to say) a sudden, marked increase in uncomfortable Braxton-Hicks contractions, which kind of freaked me out until I talked to the midwife on call that Sunday night, and she reassured me. I've also been getting winded much more easily lately, and sometimes my heart rate goes up above 100 for no apparent reason. And with my big belly, I'm having a harder and harder time slipping, say, between the IV pole and the privacy curtain, or past the other nurse in the med room to get to the automated dispensing computer.

The kid is moving around in there a lot, which I guess is kind of fun, if distracting, and last Sunday Cassie actually got a chance to feel it with her hand. So that was cool. But mostly I'm getting irritated with and tired of this whole pregnancy thing, a feeling I try hard to suppress, since with any luck, I'll be suffering through it for another 3 months. (You hear me, little one? I may kvetch and moan, but you are forbidden to pay any attention. You have to stay in there at least until mid-February, okay?) Novelty and fascination got me through most of my first pregnancy, and besides, I kind of didn't mind waiting, what with anxiety about being a parent and worries about labor and delivery. This time around, though, the crankiness and impatience are setting in way earlier.

The other thing that's different about third trimester this time is that I'm now on Prozac. So I have to make a decision. Some studies have shown neurological symptoms in newborns of moms taking SSRIs during the last months of pregnancy--mostly hypertonia (being too tight, as opposed to being too floppy) and difficulty initiating breastfeeding, as I recall (but don't quote me--it's been a while since I read about it). For a long time, I pretty much assumed that I would stop taking the drug as soon as Week 27 rolled around. I was feeling really pretty solid, emotionally, and thought I might not even relapse if I went off. And anyway, I figured, I've gotten along with untreated depression for a lot of my life, so what's a couple months, in the scheme of things? We're talking about the health of my baby, here. My shrink did seem a little leery, and made jokes about coming to the delivery room with a Prozac IV drip to start as soon as the kid was out. But basically I felt good about the decision.

It so happened, though, that during the week of hospital and nursing orientation for new hires at OFH, I noticed a posted notice while waiting for an elevator. **Pregnant? Depressed? Taking Antidepressants? Do you have questions about depression and antidepressants in pregnancy?** Um, why, yes, I do! Please tell me more, yellow xeroxed sheet of paper! The obliging piece of paper explained that OFH researchers were conducting an observational study of pregnant women with a history of depression. So I used the campus phone on the opposite wall to call the number, and got set up with an appointment for an initial intake visit.

So basically, a research assistant does the initial interview, asking a bunch of the kinds of questions you would expect, about history of depressive episodes and history of treatment and stuff. And then you get to talk to one of the MD study investigators, who does a bit more interviewing, and then you get to ask anything you want. So I laid out what I was aware of, and how I'd made my decision thus far, and asked what she thought. And she was great--nonjudgmental, thorough, thoughtful, and able to pick up on the fact that I had a certain relevant knowledge base already, so she didn't talk down to me at all. And what she said was this: there were two studies published looking directly at this question of the effects on babies of their mothers having been on antidepressants during pregnancy. Both had small N's (she couldn't remember exactly, but on the order of 20 subjects each), and in neither of them were the observers blinded to the exposure status of the babies. (Jeez. Way to go with the study design, people.) She said that, yes, they did find some evidence of some neurological effects on the newborns of mothers who took SSRIs during their 3rd trimester, but it was also notable that they did not control for the severity of the mother's depression, which may itself have an effect. Furthermore, all the effects noted were within the first 48 hours of life. They didn't see anything longer lasting than that. Finally, she pointed out, other studies have shown a many-fold increase in the risk of postpartum depression in women who go off their antidepressants for even a few weeks, as compared with those who stay on.

So basically, my understanding is that even if the effects observed in those studies are absolutely real, and even if you could say with 100% confidence that everyone would have them, you're weighing two days of neonatal neurological symptoms versus a greatly increased risk for maternal postpartum depression. Another thing to consider, the psychiatrist lady said, was that I was on fluoxetine, which has a very long half-life and may well not have the same kind of withdrawal pattern seen with shorter-acting SSRIs. Besides which, I was on a relatively low dose (20 mg), which I should also take into account.

And so I'm staying on my lovely little white ovals. My reasoning now is that I have duties not only to my newborn during the first two days of life, but also to Cassie, and to the baby over the course of its babyhood, and to my patients when I go back to work, and to my marriage, and to myself. A high risk of depression undermines my ability to be fully there for all of the above. And for Cassie, particularly, this is going to be kind of a dicey moment. It's not even the risk of Mama being depressed for a while any old time--this is the period when she gets her blissful only-child life irretrievably altered through no fault of her own. I just need to try to be there for her as much as I possibly can, given the circumstances. The squally, poopy, absorbing, exhausting, distracting, ever-present circumstances.

I feel even more solid about the decision as a few times in the last couple weeks, I've felt for a few hours or a day the front edge of a depression. It ebbs away again, and I'm fine, but newly sobered by what exactly depression means. The gray, heavy kind, and even worse, the sickly yellow-brown miasma kind that taints everything it touches and makes it seem that there is nothing sound or bright or wholesome in the world. Feh. Good riddance.

Vitamin H

Since my shift-of-agony with my previously wonderful and understanding preceptor, Julie, things have gotten distinctly better, though all is not resolved. For one thing, my next two shifts happened to be with Jessica, and I was busy and running, and she had to step in a couple times to fill little holes, but mostly they went fine. At the end of the second shift, Jessica just said (in a light, rather matter-of-course tone) that I gave very good patient care, and I just needed to work on my time management. This felt to me absolutely fair, and to be honest, I never did think that getting things done quickly and efficiently was going to be my strong suit. I truly think that the best I can hope for in that realm is a general adequacy, a level I'm all too aware that I haven't yet reached.

The non-big-deal-ness of it all made it much easier, then, the next shift I had with Julie, to meet her lingering attitude of Great Seriousness and Sober Concern with a (mostly genuine) brisk optimism. "So," said Julie, in the kind of tone one uses to ask about the results of a nasty court case or a biopsy, "how did your shifts with Jessica go?" I pretended I didn't notice the spirit in which the question was asked, and said, "oh, pretty well! I really tried to plan my whole days myself, and I think I'm getting there. Jessica had to help me out a couple of times, but I managed to get through most of it on my own." This left her mildly nonplussed, which I admit gave me some gratification, and then I bustled off to my tasks, which of course was what I was supposed to be doing. Julie did warm up a bit by the end of the shift, which was good, though we're nowhere near back to where we were when all was sunny and fine.

Then Julie and I had a PM shift (3-11) together last Friday. We agreed that I would take 3 of our 4 patients. One was supposed to be discharged to rehab just a couple hours into the shift, but due to a kind of ridiculous misunderstanding, that ended up not happening, and he had to stay overnight with us. But he was easy (and easy-going), as was my friend the 28-year-old woman with the tattoos, Buddha-calm, and nasty leukemia. They both needed medications and vitals, but that was really about it. Which was good, because patient #3 was a lady with a very extensive psych history (let's call her Ms. Q, because that's not her name) who was starting chemo that night. Ms. Q is a large middle-aged lady with messy hair and prominent eyes (that's from her thyroid condition, though it has the unfortunate effect of accentuating her appearance of instability). She was intermittently lucid and appropriate toward the beginning of the shift, if very needy and tearful and anxious as we got ready to start the chemo. She had a sitter, but was still continually on the nurse call button. Sometimes she'd have forgotten what she wanted by the time I got my gown and gloves on (she was on contact precautions, naturally) and got into the room. We nonetheless got her first unit of blood and her premedications into her without much in the way of untoward incident. Lots of hugs and reassurance, plus a milligram of IV Ativan, allowed the beginning of chemo to proceed as planned. (Originally she consented for chemo herself, but after involvement of the psych team and the hospital's lawyers, her brother also had to sign a consent.)

When Ms. Q's afternoon potassium level came back at 5.1, though, she needed an EKG and some Kayexalate to bring the level back down (5.1 is not horribly high, but when chemo causes the breakdown of cancer cells, even more potassium is released into the bloodstream, so you really need to stay on top of it). Plus she did need that second unit of blood. She refused it all. She switched from "I'm going to be brave; I'm going to fight this cancer" into "I just want to rest. No! Turn off the light! Leave me ALONE! You NEVER let me SLEEP!" (There were moments when I was just flabbergasted by how much she reminded me of Cassie at her tantrum-y worst.) Tom, the sweet overnight intern, came in and managed to talk her back into accepting treatment, but after he left, she changed her mind again.

It ultimately took me, Julie, Tom, and Soledad, the very competent and sweet nurse's aide, to wheedle and cajole and soothe Ms. Q. Oh, well, and there was a little bit of Haldol in there, too, I have to admit. And Julie brought her a grape popsicle. She got all of her treatment, and her EKG was fine, and she didn't spit out the nasty-tasting Kayexalate. She actually gave me no trouble at all about her bedtime insulin, which was a relief. Oh, did I mention that somewhere in there, she lost a huge filling from the front of her mouth? (I stuck it in an emesis basin on top of the refrigerator and promptly forgot about it until the next morning, when I had to call the floor and ask to speak to Ms. Q's nurse.) Anyway, then it was well after 11, and I hadn't done any documentation.

We ended up being there until 1 am. Julie gave me a ride home. AND she said something about how, time-management-wise, she just couldn't think of how we could have done it differently, to get out earlier. That felt to me like a significant change, because from my perspective, it had truly been seeming that whatever running and reshuffling was required, whatever fires needed to be put out, any failure to get everything done on time she considered solely my fault. Maybe it was the fact that she'd actually physically been there for most of this shift that softened her a bit on that point. Maybe she's actually mellowing a little. I guess time will tell. I'm still struggling with whether to say something to her or not. I've been playing it by ear, and there hasn't really seemed to be an opportunity yet. I don't know. It's possible I'm just chickenshit.

Tonight I start a run of three night-12's, 7 pm - 7 am, with Jessica. It is often, if not always, less busy on nights, and with luck a girl actually can get to sit down a fair amount. Not if I'm assigned to Ms. Q, of course. Oh dear.

Today

Today we sent a 21-year-old home to die. It will be a few days, probably. The lady in 24 coded and went back to the MICU. And my patient in 38B had all his teeth pulled.

I'm so tired I can't see straight. I work 3-11 tomorrow, though, so maybe I can finally write something before that.