I had my first jaw dropping patient last week. You know, working
in cardiology, you see a lot of the same thing. Acute coronary syndrome, atrial
fib, heart failure...Turn 'em and burn 'em, that's my motto. Thursday, I had my
first patient that I was completely side-bombed over.
That day, an 86-year-old female presented to the ED for shortness
of breath. She's admitted to the hospitalist service. Labs are drawn and the
patient has a BNP of over 2000. She arrives to the floor and a cardiology
consult is placed. I quickly make my way to the room to do the consult and when
I initially begin to talk with the patient, everything seems to be "normal."
Then the story unravels.
The patient has been diagnosed with diastolic heart failure for years.
She's never had a true exacerbation. She saw her cardiologist in September for
her annual follow up. At that time, the patient had generalized complaints of a
minor increase in shortness of breath, but there were no medication changes
instituted at that time.
In December, the patient was having more shortness of breath and
also began to feel quite fatigued. Her husband had begun to notice some
physical changes indicating she was retaining fluid. They decided at that time
to see her primary care physician, who drew a complete blood count on the
She was severely anemic with a hemoglobin of just over seven.
Since there were no obvious signs of bleeding, he set the patient up for an
upper and lower endoscopy. No GI consult; just set up the procedure. They both
were insignificant so the physician ordered five transfusions over the next 4
weeks and then left it at that. No follow up on it.
Let's fast forward about 4 months and get back to me interviewing
this patient and her husband. She is clearly uncomfortable while she is just
lying in bed. They tell me that she's progressively become more swollen over
the last 4 months but they don't know how much weight she's gained because they
don't have a scale.
About 3 weeks ago, the patient became extremely fatigued and was
requiring a moderate amount of assistance with her activities of daily living
and for the last week, it was absolutely complete assistance with everything.
She couldn't move at all.
At this point, I've done my questioning of the patient and her
husband and I was still thinking this wasn't too crazy of a case. And then
comes my physical exam and where my jaw drops. I proceed with my cardiac exam
and realize that there is 1+ pitting edema where I place my stethoscope on her
chest to listen to her heart sounds, and mind you, I'm not pressing hard at
I have her husband assist me in getting her rolled over because
at this point, even just lifting her arms was a difficult movement for her. We
finally get her rolled over and the poor patient had pitting 3+ edema to her scapula.
This folks, is the perfect picture of, yes, anasarca.
She had 3+ pitting edema down her entire body. I couldn't get pulses
in her lower extremities. Her upper and lower extremities were cool to touch
and had a decrease in sensation.
So after I finish my exam, I talk to the husband a little bit
longer and then go to the dictation room with chart in hand. I managed to find
her cardiology clinic chart and start delving. This patient has managed to have
CHF for this long and has truly not had an exacerbation.
Please remember we live in Northern Michigan. There is a great
percentage of our population that is not highly educated. Unfortunately, the
socio-economic gap that exists has a huge impact on many of our patients truly
understanding their diagnoses and the lifestyles changes that need to be
enacted to ensure that they don't become exacerbated. And this patient is the
prime example of that.
They were not able to tell me the first thing about heart
failure. And this isn't at the fault of their outside providers. It's simply
because they just couldn't wrap their heads around the information when it was
You know that form that you do as a floor nurse asking a patient
what is the best way that they learn? You know. One of the many that you just
click boxes without really even asking the patient. This is one of the most
important questions that need to be asked. We need to know how to teach our
patients, or, to pound it (for lack of a more appropriate term) into our
I went into her chart to assess what medical therapy she was on
and what tests had thus far been ordered. I called the echo tech to find out
the "unofficial" results of her echo and was informed that they were unable to
do the test. They tried but the patient's excessive fluid level did not allow
for the ultrasound to be able to visualize the cardiac structures
appropriately. We had to wait.
The lasix drip had been going for a couple of hours (why the heck
a lasix drip, I don't know; don't get me started on that) and so now we were at
that time that I like to phrase "hurry up and wait." (Military background. Can't
help it.) So I made changes to her oral medications to ensure she was on the
most appropriate therapy for her heart failure, which is much more detailed
than I remember when I worked in a cardiac stepdown unit.
When I went in Friday morning, the patient looked better. She was
actually sitting up on the side of the bed. She needed some assistance but not
as much as she had been and she had diuresed about 2 liters. So we continued
that process over the weekend.
We had a newer hospitalist on service on Monday and I met up with
him to discuss the case. The patient had been severely anemic since December
and had come in to us anemic. She had continued to drop and over the weekend,
this had not been covered.
He said that this was chronic and I let him know that I was
concerned because the numbers didn't lead me to believe that it was an anemia
of chronic disease and that it had truly been worked up. He told me to focus on
the heart. Nice. Then he told me he wanted to discharge her, but was going to
wait one more day. Another jaw drop. She had diuresed over the weekend but she
still had 2-3+ pitting edema to her lower back and was still really weak. I
told him I thought that was being a little aggressive.
I guess my input went unheard. I had class the next morning and
when I rolled in after lunch, I learned that my patient had been discharged.
Yep. Discharged. I couldn't believe it. I spoke with the cardiologist that I
worked with and he said that he told him he thought it was a little early, but
the guy discharged her anyway.
So I did what I do best. Got fired up and started making calls. I
called the primary care office, the cardiologist's office and our heart failure
clinic. I got appointments set up and then I called the patient. I talked to
her husband and told him the importance of remembering what we talked about.
Remember to limit her fluids, and watch her salt intake and go to her
Now all I can do is sit back and pray that she makes it to her
appointment in 4 days. Pray that she doesn't end up back in the hospital and
pray that she is safe at home with her weakness. Not many patients really get
into my heart but for some reason, this one did. It's patients like her that
make me realize why I do what I do. To be the advocate for patients who just
don't get it.
So I've written about cases the last couple of times and I'm
thinking it's time to give you guys an update. I've been in my position as NP
in an acute care setting seeing cardiology patients for 3 months now. I can't
believe it! It's going really well and I'm really grateful that this
opportunity was given to me. I've learned so much already and I learn so much
more every day.
I've had my ups and downs with administration with the adjustment
of trying to maintain my family life and work life. It's slowly coming together
and things are looking more positive every day. I truly love the colleagues
that I'm working with and the doctors. They are all extremely supportive in
regards to patience and teaching, and for that I'm truly thankful.
I think one of the biggest challenges that I've emotionally faced
is having the feeling of distrust from the "older" nursing service. I feel like
I truly developed a positive rapport with the floor nurses and I believe that
they understand that I'm new but that I work my butt off make the best
decisions that I can for the patients. They also like the fact that I was a
floor nurse and I'm sorry, but once a nurse, always a nurse!
There will never be a day that I won't empty a urinal or take a
patient's old lunch tray away. Where I've met challenges is with some of the
higher-up nursing staff. I understand that I'm in a position that has great
effects on their patient population. I get that they don't know me from Sam
Jones and so there is that distrust there.
I just have an issue with the way that it's handles sometimes.
Tone...That means a world of difference, you know? The way that you speak to
someone will either make them want to listen to you, support you and respect
you, or it will make them shut down.
That's where I'm at at this point. It's tough. I'm the new guy on
the block. I get it. Don't run me off. You know why? You'll just end up with
someone else new on the block and starting all over again. It's one thing I
never, ever understood about the nursing community. Why do we "eat our young?"
We should support them and teach them. They are the future! We are the future!
We need to work together to support and encourage one another. That is truly
the way to ensure the best possible healthcare is given to our patients.
So I'm off to another hectic week! It's been crazy, crazy and
it's not even summer yet! Hope you guys are having a great week. Please give me
some ideas on topics that you'd like to delve into. It makes for a more
interactive environment, which in my opinion is always a good thing!
In our acute care setting, we deal with death and dying on a
daily basis. It truly amazes me, the differences in between patients' reactions
when facing a "death sentence." I'm sure this can be noted in all walks of the
healthcare system, as well, but it's by far been most noticeable to me in the
Take Mr. G, for example. He's 67 and had just been told that he
has metastatic cancer and that he has approximately 4 weeks to live. Prior to
this devastating diagnosis, he had been in what he thought was good health. He
had never been admitted to a hospital and led what he believed to be an active
and healthy lifestyle.
Now take Mrs. A. Mrs. A is 83 and had just been told that she has
a very short time left, due to her heart failure progressing so much that she
was continuously going into atrial fibrillation.
Both of these patients had been told they have terminal
illnesses. Now here's the difference that gets me. Mr. G. is at peace with his
diagnosis with his family surrounding him. He states that he's ready to go
whenever it's his time and that he's just going to continue to live his life to
Mrs. A. on the other hand, is an emotional mess. She is
devastated and has no one around her besides her providers to lean on. She says that she isn't ready to die. She's been a physical disaster with her
health for the last 5 years and is constantly uncomfortable because of her
heart failure. She, however, isn't ready to pass.
Why the difference in the patients' reactions? Does
Mrs. A. have dealings with family or friends that need to be taken care of to
put her at ease? Is Mr. G. comfortable with his idea of the afterlife, whatever
it may be? I guess we'll never know what the true reasons are for the
difference in these patients' responses to diagnoses of terminal illnesses.
All we can do is try to live our lives to the fullest and know where we are in
hopes that once it's our turn, we will be at peace with ourselves.
The time has come! I've passed boards, obtained my state license and I am scheduled to have "temporary privileges" at my facility next week! This is such an exciting time for my family and me! We've worked so hard for so many years and this is it.
The really amusing thing? I opened the mail a couple of weeks ago when my license came through and it's a little piece of paper that said I was a nurse practitioner. Didn't say adult NP. Didn't say a specialty in gerontology. Nothing. Just "NP." Same effect when my certificate came from AANP. Generic. Not fancy. My husband said, "So that's what $30K bought us, huh?" It was quite amusing actually.
A friend commented that her teaching certificate was more fancy. Makes me chuckle. When you look on paper, that's it. But in real life, it's amazing. It's more than a piece of paper. It's a life change. It's a position change. It's the most important piece of paper I've ever had, and I love it! The way that I feel every day when I go to work is what I paid for. Loving this job and loving the patients I'm helping to stabilize in this setting is what I paid $30K for.
I had requested statistics from my fellow classmates on certification and how many had passed, how many had jobs, were licensed, etc. I didn't have a very big response. Not sure why exactly, but I can tell you that I had responses on the prolonged times that it takes for EVERYTHING! Once you finally get your date for boards, it takes about 4 to 6 weeks to get the official response in the mail. Then you have to get that sent to the state and submit your application for your license. That, in itself, takes 6 to 8 weeks. I'm hearing from classmates that it takes that much time or longer for being credentialed! Add the time spent in finding a job if you haven't already? Well, you can pretty much guarantee that you're going to be working about 3 months after graduation, at minimum. I'm working, but with lots and lots of red tape! Until NEXT WEEK!!! Then bring it on baby!
So I go from working part-time as a nurse to not really working
and just doing clinicals. My preceptors were pretty good about working with us
regarding schedules, which was amazing because I have 2 kids and a crazy
husband. This was more beneficial than I EVER realized!
Now? I realize... Let's see... In my first three weeks, I've
gotten snowed in at my house (couldn't get down my hill) and my kids have been
sick twice. And then I get the call that I was needed in management's office. I
was sat down and asked if everything was ok. They are concerned because I've
missed so much time and questioned if I really feel "committed to the team."
This killed me. I felt absolutely TERRIBLE about having to call in and then to
be questioned about my commitment was the straw on the camel's back.
I LOVE this job. I love the people that I work with and I love
everything about the institution. To have this questioned was disheartening. I
can totally understand where they're coming from, though. They don't know me
from Joe Blow and I'm calling in right off the bat. I've hired a nanny but
she's only available on Mondays, Wednesdays, and Fridays so of course the kids
have to be sick on Tuesdays and Thursdays, right? That's really the only thing
that makes sense.
I think my biggest issue is the strong feeling that I'm the
crappiest mother in the world. All I really want to do is stay home and take
care of my babies when they're sick. We're seeing such a huge increase in viral
cases that are having devastating endings at work and that just adds to my
increasing anxiety about nurturing my little ones.
The practitioner in me knows it's probably "just a virus," but
the mommy in me is yelling that my baby is sick and it might be worse than we
all think. All I want to do is cuddle him all day and let him know that his
mommy is right here and loves him more than anything in the world!
And then reality sets in. The mortgage has to be paid, the utilities
are best when kept on and no one's happy if there's not food on the shelves. So
off I go to work to tend to those sicker than sick in the hospital and pray for
my sick little one at home.
I had one of the most difficult days I've ever had from an
emotional standpoint at work last week. There was a patient that had close
personal ties to our facility that was admitted for new onset a-fib. He was
young so we cardioverted him and thought that he would be fine. He had no
significant medical history and was in decent physical shape.
He was sent down the next day for a Cardiolyte stress test to
work-up the cause of the a-fib. This is where things get difficult. You send
your patient down for a scheduled test and then get a stat call to the area,
where you find him being resuscitated. WHAT?! What the heck?! He's coded for
close to an hour in Nuclear Medicine, while en route to the cath lab and
actually in the cath lab.
The doc does his damnedest to figure out why this patient is
still not having any type of rhythm while he is still being coded. I've never
seen a team work so well together trying to save a life. In the end, it's not
all candy and roses. We don't save everyone. Life isn't the easiest. He was the
first patient I've truly lost as a nurse practitioner and I promise you that
this case is forever etched into my brain.
It comes with the job though. Well, that's what my dad says. And
I, as a practitioner, know this. I've coded umpteen patients in my nursing
career and I've seen death. I'm not going to say that it doesn't bother me
because it's always made me sad, but from my standpoint I believe that death
isn't the end so I usually handle it ok. I think that this patient was
different for me because of the ties that he had to our facility, his age, his
wife's hysterical reaction (which is ENTIRELY understood) and just the fact
that it was completely out of the blue!
You just have to tell yourself, or at least I do, that there's a
reason for it. None of us know it and we don't understand it, but there is. And
then we just have to keep moving on. Keep saving lives. Keep helping patients
that are here right now. And remember to keep in mind that we will lose
patients, but thankfully we save so many more.
Return to the ADVANCE for NPs & PAs homepage.
Well, as you guys know, I've passed boards and have already
accepted a position in an acute care setting. I actually started yesterday and
am so excited! So far I've been in orientation and the anticipation of actually
rounding and caring for patients is killing me! I start rounding next week and
am really looking forward to sharing this journey with you guys.
So I've debated and debated on what my topic for this blog was
going to be and I finally figured it out. I have gone from working three
12-hour shifts as a registered nurse to working five 8-hour shifts. Yep. You
guessed it. I work banker's hours. Monday-Friday from 8-5.
Sounds nice, huh? Well, you factor in the 1+ hour drive there and
another hour home (I live in Northern MI and with all the snow storms, lately
it's pushing 2 hours each way) I'm gone from home from at least 7am-6pm. So
here's my dilemma and I would LOVE to get feedback from my readers on this!
When do you take care of YOU?
I'm getting up at 4 so I can have time to do 30 minutes on the
elliptical before I get my two rug rats up and get them ready for school and
out the door. I have exactly enough time to do that and barely make it to work
on time. I am super OCD and not having time to keep my house clean is making me
more stressed out and I feel that I am not able to do my wifely and motherly
things that I'm used to doing.
So that's my excuse as to why I'm not exercising and eating the
way that I'm used to! What's your excuse, and more importantly, what can WE do
to remedy this situation? We are practitioners here! We preach to our patients
about the lifestyles that protect our hearts, minds and bodies and then we go
to and get McDonald's on our way to or from work and pass out at night after a
glass of wine from exhaustion.
Now what does that say for ourselves? I'm really looking for
feedback here. This is a great spot to network and get our creative juices
flowing so that we can better ourselves, which in turn is going to be
beneficial for not only our family, but our patients as well!
Since I'm the blogger, I guess I technically should be the first
one to throw out some ideas. Like I said earlier, I'm "kind of" OCD (not
technically, but just funny about cluttery areas and germs) and I am, you
guessed it, a Virgo. For those of you that don't keep up with that kind of
information (well, I don't either. I just know I fit the bill), virgos are very
Control freak (raising hand), consistent (raising hand again) and
outgoing (Who? Me? Nooo). So one area that is of high importance for me is
organization. Since we're on the topic of a lack of time, I have figured out
that maintaining organization really helps with an overall increase in my free
time. About a year ago I discovered a website called Cozi (you can access it
that is AMAZING for organizing everything from your schedule to your shopping
lists to your recipes! It has an app that you can put lists on and they
transfer over automatically to your spouse's phone on their list! That's right!
No more excuses about not having the notes!
So, there's my first idea for you guys so that you can give
yourself a little extra free time. Now, what do you have for me? I look forward
to hearing your responses and I'm REALLY looking forward to sharing my journey
ahead in regards to being a new NP!
I really felt prepared. I had done a review course by a company that claims a
pass rate of 99%. I had also studied a very well-known study guide, in addition
to listening to 2 sets of CDs (one of them for the last year!). I then took 2
"predictor" examinations with decent scores that were predictive of me passing
morning was fairly uneventful. I did everything you're supposed to do. Got a
full night's sleep the night before and woke up in the morning to have a good
breakfast. Made it to the testing site and then was told I should have come in
30 minutes early (I could never recall seeing those instructions anywhere).
Needless to say, they were "graciously"
able to accommodate me. After sitting in the waiting room for another 30
minutes, they shuffled me back to the area where you are pretty much TSA'd (I
find this terminology humorous). I get seated and the first computer was
broken. After the lady tried to figure it out for 10 minutes, she gave up and
put me at another computer. I get it started and realize that it was giving me
4 hours from my original appointment time of 0900. Yep. That's how it started.
I lost an hour right off the top. GREAT!
could sugarcoat it for all of you soon to be new grads, but I'm not going to. I
made pretty good grades in school and felt pretty confident after the predictor
exams. Those exams were a joke in comparison to Boards. And hey, maybe I was
the lucky one, and just managed to get the 150 most difficult questions out of
the 1500 question bank. I do have good luck, you know! It was excruciating.
I was literally crying (not bawling out
loud; that's later) when I hit submit and held my breath and prayed like I have
never prayed before in my life. It took absolutely FOREVER.
When the screen finally popped up, it
was 2 huge paragraphs and I actually had to pull myself together and get my
eyes uncrossed to find where it said "PASSED." That's right, people! By the
grace of God, I PASSED!!!
Now there's still that nagging voice in
the back of my head. You know, the one that's saying, "Well, it said that it
was preliminary score (they always say that), so you really could have failed."
You know that voice, right? I managed to make it to my car (after some more
TSAing) and then I broke down.
I called my husband and I was crying so hard
that he thought I had failed. I pulled myself together, somewhat, and told him
that I passed, but that was it the most excruciating time of my life. And I
still stand by that. EXCRUCIATING. But I passed, and that's that. Now let's
So I'm a new NP! Yep! That's right! I said it! I'm a NP!!! Do you hear me world? Okay... Well... As a new graduate, we're all excited. We've worked so hard over the course of the last several years and it's finally here. It's anticipated and expected. And then? It arrives. I'm not sure if it's just me, but this is how my last year went. January: "I can't believe it. I'm graduating in 12 months!" June: "Ok! 6 more months to go!" September: "It's never, ever, ever going to get here." November: "Oh my gosh! One more month! Woot woot!" December: "What? It's here? I have to take boards soon? Hold on a minute! Wait! NO! Not yet! I'm not ready!!!" Please tell me that I'm not the only one that felt this way. Right?!
So I graduated on December 15, and boy was it exciting! Scary, yes, but still exciting. The anticipation of boards is killing me and I know that I can't procrastinate forever. I'm anticipating sitting for them the second or third week of January. After much contemplation, AANP is the certifying body I decided to go with, really just due to the fact that, personally, I hate statistics and everything that goes along with it. The thought of being tested on it during boards makes me sick to my stomach.
I'm really and truly looking forward to writing this blog and interacting with my readers! I know that this will be quite the interesting year coming up and me, being the outspoken person that I am, will be quite the "voice" for others that are in the same position I'm in. About a month before graduation, I accepted a position in a hospital and dun dun dun... I have a degree in primary care.
Now don't get on a high horse with me here! I already know the dilemma and I'm fully prepared mentally to head back to school to get certified in acute care. The only reason I feel halfway okay with accepting this position is because of my strong background in critical care and cardiology. I had another opportunity in the primary care setting, but to be honest with you, I just didn't feel the fit. The group I'm going to be working with really feels right to me. You know what I mean? Just a gut instinct.
So for the next year or two, I hope that you will follow my blog about being a new NP and life's trials and tribulations. Please feel free to leave comments and if you want me to broach a topic, just tell me!