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First Year NP

A New DNP Student Is Born
March 14, 2014 1:58 PM by Katrin Moskowitz
As I write this blog post I am sitting in a small dorm room on top of a mountain in Kentucky on the first day of my DNP orientation. I am back at my educational home: Frontier Nursing University. I will be honest with you in that I did not think that I would be here this soon after graduating.

Post graduate school I had educational burn out. Studying, clinicals, work and family had culminated to a boiling point and I had sworn off school for at least a year. Then a funny thing happened: I got a job which provided a schedule of many days off and my thoughts were, if I had school work to do, I could actually have time to complete it.

I researched a variety of DNP options comparing cost, time and the schools mission. With each category I immediately fell back onto Frontier. It is a hard thing to explain: the community, the history, the passion. It truly is one of those things that you have to experience for yourself. As I get ready to turn in for the night I know that I have come home.

I will be honest with you: I am nervous. This is a different nervousness than I felt when I first came to campus to orient for my FNP program. I was expected to be a clean slate and to learn as I went along.

Because I just graduated this past fall I feel that I really have not gained any expertise as a nurse practitioner. Therefore, how do I know what I want to change in nursing practice? I know that over the next 3 days some of my fears will most likely be eased. I will get to meet some graduating DNP students, sit in to observe their capstone presentations and be paired up with one for a mentor-mentee relationship.

The next 15 months of my life will not be easy, but I know that I will again be adding to my knowledge base and be able to provide patients and my community with excellent care. Ultimately I hope to be a faculty at a school like FNU that will help to cultivate future practitioners.

There is continued mention here on campus that I am now a leader. Eventually I will be looked upon as an expert in my topic for my capstone project. This again is a concept and role that I am not sure fits at the present time. During my journey I hope to seek out other leaders who will serve as role models and who will help sculpt me into the leader that I should one day be. Until then I continue to take in, learn and reflect.

The mountains of Kentucky do something to the soul. This environment here on campus provides a level of serenity that really allows you to think on a different level. The community is humble, the healthcare issues challenging, but all of it allows you to appreciate a different level of insight.

Practice What You Preach
February 28, 2014 9:39 AM by Katrin Moskowitz
Before I started my nurse practitioner program I was happy where I was in regards to my health. I was at a great weight, my diet had been free of any processed sugars and grains, and I was working out several times a week.

By the time I started clinicals in my primary care site I felt like a hypocrite. I had not been to see my PCP in 2 years, my gyn in 3, but I was up-to-date on my dental visits! My diet was filled with on-the-go bad choices, my full time job was now a work at home position, the gym was a foreign place and my weight was creeping up and up and up.

I am a determined person. I have completed 3 marathons, a half marathon and countless 5Ks but time was against any motivation that I had. There clearly were not enough hours in the day.

 Katrin Marathon

So each day that I was telling people how to make healthy lifestyle changes, reduce their stress and take hold of preventative medicine, I felt like I was definitely not practicing what I was preaching. Even so, I sold it with determination and many patients were making wonderful changes.

Now that I work in urgent care, 95% of the time I feel less like I have to worry about being in disguise. I do however spend 5 hours a week in primary care and therefore again began having feelings of guilt. I decided to get off of my high horse and make some dreaded appointments. 

Off to the lab for yearly blood work, appointment set for my yearly gyn exam and appointment made to discuss blood work and have a physical. I understand that no one truly likes having to go in for these routine appointments. I dread the discussion about my increase in weight and what my thoughts are about this.

I truly try to make my patients' experiences with me in primary care a positive experience. I have compassion for schedules, costs and decisions that are made around healthcare. I will be the first to admit that I am proud of my patients who follow through.

I had a patient who had not been to the PCP in 3 years. She too was worried that she would be berated about her obesity and was quite anxious about this. We had a wonderful discussion about her life in general and her goals and whether they were realistic or not. I encouraged her to make her appointment with her GYN, her mammogram and of course sent her for her blood work. When I called her to let her know she was severely Vitamin D deficient and how we would work on correcting it, she excitingly told me that evening she was off to have her mammogram completed and that her GYN appointment was scheduled. I felt like a proud parent and praised her for her follow through.

My primary care preceptor in school was amazing. She took the time to talk with her patients in a comforting and holistic manner. She spent her lunch hour eating while returning patient phone calls which I found to be truly dedicated. In the end you saw the results in patients who followed through and came to their appointments.

I understand that practices are busy and that this may not be productive for many but am curious to know how many of you are in primary care and call your patients? Do you find that this is adjunct in your care of your patients or do you find that this opens up other issues?

Changing Your Outlook
January 30, 2014 8:22 AM by Katrin Moskowitz
"Thank you" is one phrase that can change the outlook of your day. Last week while at work the office manager came up to my co practitioner and me. In her hands she held a letter from a patient, thanking the office for the great care that she received. The office manager eagerly asked us to see who saw her and I was surprised to find out that it was me.

I remember the patient well: An elderly patient who lives at home alone with a history of fragile, thin, aging skin. She tripped on the corner of her area rug at home and fell into a door jam, lacerating her forearm. I had briefly met her during my orientation period as she was having previous sutures removed.

Her current laceration was complicated - it had several flaps, was a bit jagged and of course was surrounded by friable skin. I spoke with her, letting her know that I would try as best as I could to put the wound edges back together again but that I was unsure it if would be completely possible. I needed to take my time as any major tugging of the sutures risked pulling right through the skin.

Because of this we had the opportunity to strike up a nice conversation as I placed her thirteen sutures. We talked about the New England weather, her life and family, and how she was enjoying her retirement. In the end the wound came together nicely and we parted ways.

It was nice to know that she appreciated the time and care that I gave. Most of the time I am lucky to hear patients say thank you at the end of their visit. It just feels plain good. I try and pay that same gratitude when I am out and about in the community, often just saying "I appreciate your time," whether I am at the doctor's office or paying for groceries.

Work has continued to go well. We are seeing an influx of positive flu patients and those that have been battling long winded respiratory infections. I am starting to see repeat patients which has also been quite enjoyable.

We had our first provider meeting that included the new PA and I received a lot of positive feedback. We discussed the new coding requirements for ear irrigation and the upcoming deadline to become certified to do DOT physicals. Needless to say it is a class I will be taking in March and yet another computerized certification exam to complete. I really thought I would have a break from that for a little while!!

According to the DOT guidelines, "By May 21, 2014, all certified medical examiners must be on the National Registry database, and drivers must obtain a medical examination from a certified examiner."

After that certification I will start looking for future conferences to attend. Will there be an NP Boot camp? Perhaps a national association's yearly conference? The choices are endless!

What's Up, Doc?
January 17, 2014 10:37 AM by Katrin Moskowitz

In our urgent care there are four full time providers: three physician assistants and myself. Our medical director, a physician, comes in one half shift per week. As we enter a patient's room, we always introduce ourselves by our title. "Hi, I'm Katrin and I am a nurse practitioner." There is never any bait or switch and patients are aware of who we are right from the beginning. Even so, I am referred to as a doctor on a daily basis. I always try and clarify my role, but for some patients t is just habit to call you doc.

For me, it is not anything that offends me. I understand that the role of the nurse practitioner may be a new concept for some. We are lucky, though, that the role is present more and more not only in the primary care offices but also in many specialty areas. Having nurse practitioners and physician assistants in these offices often allows patients to be seen in a timelier manner. Other nurse practitioners may take offense not being addressed by their true title.

I have taken it a little more to heart and have decided to apply to my graduate school's DNP program. I knew that at some point in my career I wanted to take the plunge, I just was not sure as to when. Because of the amount of days that I have off per week I feel like this is the best time to do so. So although I will not be an MD, I will one day be Dr. Moskowitz.

I am officially off of orientation at work and becoming accustomed to the increased work load. Two of us providers hold down the fort and we are seeing the winter illnesses such as influenza and sinusitis flow in. I have found that although I was not able to perform many procedures in the emergency room since I was an RN, I did pick up many tricks of the trades along the way.

This past weekend my coworker had a patient with a dislocated toe and she asked for my opinion and guidance. When she was unable to relocate the toe she asked if I would take a look and give it a try. I was able to relocate the toe and when asked how I knew what to do, I just smiled and thought of all the wonderful doctors in the ER who were willing to have a curious nurse in the room during procedures.

Every Tuesday morning I work in the director's primary care office covering his patients. This is a nice change to my week but comes with its own difficulties at times. While I can handle the sick visits without difficulties, I sometimes find it difficult to complete follow ups. I look forward to maybe one day being able to increase my hours in primary care and building up my own patient load and following my own patients from beginning to end.

Will You Be My Forever Patient?
January 3, 2014 9:45 AM by Katrin Moskowitz

My entire life, relationships have always been a struggle. Growing up as a child of the Army I learned to go into defense mode when it came to friendships. You knew that as soon as you became BFFs with another kid, someone was about to move to another state or country.

My entire career in medicine has been built around short-term patient relationships. In the ER you may have several hours with a patient, but more often than not they are in and out. Urgent care has been the same story with even shorter time frames. Yes, you do see some patients again, but they are not coming in for long term care. Now that I am a practitioner I focus on making the time I have with my patient the most pleasant and memorable, hoping that if they need me in the future they will come based on their past experience.

When I spent 6 months in my primary care clinical I saw a completely different side to patient care: longer relationships between the provider and patient. I have to say it was a nice change. I was able to see how patients trusted my preceptor and how the preceptor was truly able to incorporate the holistic care model.

It was not just about the medical problem but also involved asking about home life, work and other happenings. It felt less like an informal office visit and more like a caring one on one conversation with the added benefit of a physical exam.

I wonder if I am at a point of my life that I want extended relationships in my career. It was definitely a consideration as I looked towards where to settle as an APRN. I now have the opportunity to work part time in a primary care office in my own community. It would allow me to build up a patient load and follow them and build those relationships. It is in the early works but something that would allow me to dip my feet in the waters before jumping straight in.

As we start off 2014 I want to think less about resolutions and more about redefinition. I hope to continue to develop as a practitioner and truly take in anything and everything that I can that will allow me to continue to provide consistent and compassionate care. I also want to redefine my own health and happiness within myself in order to be able to relay that same feeling towards my patients. I encourage you to think about how you want to “redefine you in 2014”.

Getting Into the Groove
December 19, 2013 2:32 PM by Katrin Moskowitz

The last month has been a whirlwind. Each and every shift has provided me the opportunity to put my didactic lessons into play. Delegating has made my life easier and knowing what everyone in the office can and cannot do is immensely helpful.

The patient population has been good. Most patients are receptive and willing to listen to what you have to say. That is not to say that there are not those who you know will be non-compliant with your plan of care (and those who will tell you that outright).

In this setting we are afforded the ability to see patients for a recheck or call them on the phone for follow up and it is always reassuring to hear that patients are feeling better. There is definite appreciation to hear your practitioner's voice on the phone telling you that your labs are negative or positive or just saying "How are you feeling!" My preceptor in primary care made it a point to talk to her patients and return phone calls and I know that this was part of why patients loved her and felt connected with her as a practitioner.

While my transition has been going smoothly there are still areas that need continual development. My greatest challenge right now is x-ray interpretation. Granted, if there are obvious fractures I feel great and confident, however chest x-rays are still my downfall. They all seem to look the same. I am in search of a good website or book that will help me see the normal norms compared to mildly abnormal and then obvious abnormals. If you have one, please comment!

Procedures come and go on a daily basis. I have completed my first major I&D and although not my favorite compared to suturing, it is oddly satisfying to clear them all out of their purulence.

The largest thing that I have had to get used to is the fact that I have so many days off! Years of working 68 hours a week, while going to school full time was something that I was used to. Now that I only work 7 days out of my 14 day template, it is odd to actually have days off to do things.

I have started thinking about returning to school for my DNP. There have been a lot of discussions in regards to the transition and the requirement of NPs to receive their DNP. For me, it was always a desire to continue on; the question remained as to when I would go back.

My school offered a direct entry into their DNP program for current students but I felt I wanted to get a little time under my belt before I jumped in. Plus I was starting to resent writing papers and reading books so I needed an educational hiatus. Next fall however, I feel that I am destined to get back to school. My husband always joked that I would become an MD but I know that a doctorate prepared NP will be the life for me!

Who Will be My First?
December 5, 2013 1:35 PM by Katrin Moskowitz
Throughout life we build our own individual skill sets. Often times we are our own guinea pig and learn from our own mistakes. Often times however, if we build skill sets based on our careers these trial and errors often affect others.

During nursing school I remember being overwhelmed by the amount of new procedures that I was being taught. Granted, we had the aide of models that provided the perfectly accessible orifices, but eventually we had to perform those procedures on live and anatomically varying people.

Over the past 6 years as an ER nurse I can say that I became pretty proficient at certain things; IV starts, foleys, colostomy appliances, code medications, etc. Nurse practitioner school definitely built on these skill sets but also added new elements.

I had always listened to the heart, but now I was doing it more thoroughly and diagnostically. I had to become comfortable with more intimate exams including rectal exams, pelvic exams and prostate exams to name a few. During our clinical intensive we lacerated and sutured cow tongues and lanced our homemade lotion abscesses, but my clinical rotations did not afford me the ability to practice those on live individuals.

Starting off the bat in urgent care I knew that procedures would be a daily occurrence and to be honest I was looking forward to this. I was honest during my interview to let them know that I had no experience in things like digital blocks, suturing or I&Ds on real patients. Show me and then give me the chance to try it on my own, and I would more than likely excel.

I have learned that you have to be confident in your perceived ability to perform a task. Without that internal cheerleader, you often are defeated before you even start. I have seen so many procedures during my nursing career that I inadvertently engrained some great tips and tricks into my brain.

A lovely patient became one of my firsts. He had the unfortunate luck of stepping on a piece of glass while traversing his kitchen barefoot. In his heel he felt that there was something there bothering him with each step he took. An x-ray did not show with foreign body but palpation of the heel elicited a nice pain response. Off I went to numb my first appendage and go looking for a normally invisible item.

It did not help that he had attempted himself to find said piece of glass leaving a pitted heel to guess which hole might hold that glassy treasure. Off I went. Infiltrating a heel with a needle was a little more difficult than I had anticipated but after that ordeal was accomplished I was ready to go.

I had seen another ER provider at one time use an 18G needle to explore a wound first to see if they could come across the change in texture. Sure enough this worked and I was able to manipulate the glass out without having to use a scalpel to cut into his heel. I have to say I was pretty proud of myself and I did end up telling my patient that he was my first in this endeavor.

Since then I have placed my first sutures, successfully irrigated cerumen impacted ears, hand expressed abscesses, removed sutures and seen my first complicated patients who are like those proverbial Pandora boxes.

Each and every day has been a learning experience. I have learned that I could suture all day long. As I said to my husband, "It is like arts and crafts on people," putting them back together again. I look forward to being able to add new files into my file cabinet of skills and of course share them to all of you!

Identity Crisis
November 21, 2013 11:41 AM by Katrin Moskowitz

To my surprise, all of my licenses arrived the Friday before my projected start date of November 11. Here is an updated timeline of all of my paperwork endeavors:

  • 09/24 Passed school's comprehensive exam and officially graduated
  • 09/25 Passed boards
  • 10/11 Submitted Ct license application and hospital credentialing packet
  • 10/30 Received Ct APRN license, applied for Ct Controlled Drug License and NPI number
  • 11/2 Approved for Ct Controlled Drug License, Applied for DEA license
  • 11/7 NPI number received
  • 11/8 DEA license received in mail

Unfortunately, I was informed that my employer had not received back my malpractice certificate. Therefore I would not be able to start on Monday. I was assured that it would be "soon", but no definitive date could be given.

To say that I was disappointed was a true understatement. I had to take a different approach and just believe that it would all happen when it was the right time. The call to start came Tuesday afternoon while I was busying myself with household tasks. I was to report to human resources in the morning and start my official journey.

Day 1: I spent my morning taking care of the business portion of employment. I received my badge, filled out my direct deposit forms and then went on for some computer training. Lastly I met the vice president of the hospital to talk about my new membership as part of the medical staff. I then headed over to my group's administrative office and completed fire and OSHA training.

After lunch I was able to head over to the urgent care clinic and meet the staff and tour the facility. The staff was very warm and welcoming and my primary preceptor was eager to show me the ways of the computer system.

Day 2: "Time to see some patients" is the greeting I received when I walked into the door Thursday morning. I was ready, or was I? I started nice and slow. The hardest part for me was navigating a new computer system. I am technically savvy, but I felt clumsy and unorganized in my charting.

My mind also was stuck in clinical mode. I felt the need to report back on each patient that I saw. My preceptor reminded me "you are the practitioner now." Oh yeah! I am! It all really did not sink in until I had to handwrite out a prescription, with my name and my signature. "That's right, I am allowed to do this now!"

It has been difficult to shift my mindset and understand my new role, and I am sure that overtime this will improve and hopefully with it will come a bit more confidence. Later in the afternoon I was also able to meet the other new provider who is a new graduate physician assistant. I knew that we would be orienting together and I was selfishly glad that I would have someone to talk to during this time who knew and could relate to the difficulties I was having.

Day 3: More computer training. Very helpful to become familiar with the program that will help you through the busy times! In the afternoon I spent more time at urgent care meeting new practitioners, a drug rep and receiving my official schedule. I have a set date of independence of Christmas Day. What a present that will be! Trying to learn the lay of the land, one patient at a time, but also tying in all of this to find that inner NP that is waiting to burst out of her seams!

S.O.S: Need Patience as a Virtue!
November 7, 2013 3:38 PM by Katrin Moskowitz
The last few weeks have been a harsh lesson in patience and letting go. I am the type of person who likes to be in charge of my own fate and like to have clear deadlines and goals. While applying for the various licenses and staff privileges that are necessary in order for me to start work, I have also needed a lesson in how to trust the process, be patient and know (or at least have faith) that things will fall into place.

I know that there are a lot of questions in regard to how quickly various entities take to process applications so I wanted to give you a recap of where I currently stand. Please note that these vary depending on the state that you live in.

  •                 09/24 Passed school's comprehensive exam and officially graduated
  •                 09/25 Passed boards
  •                 10/11 Submitted Ct license application and hospital credentialing packet
  •                 10/30 Received Ct APRN license, applied for Ct Controlled Drug License and NPI number
  •                 11/2 Approved for Ct Controlled Drug License, Applied for DEA license

I am currently projected to start work on November 11, but that is dependent on receiving medical staff privileges through the hospital and this will not happen until my DEA license is received. I am having a hard time living in limbo.

I have heard that the processing for the DEA license can be as quick as a few days all the way to the projected time of four to six weeks per the DEA website. I am reminded that I am pretty fortunate at the above timeline as I have a classmate whose state of Illinois is just now processing applications received in August. I did hear from the hospital's HR department to verify vital statistic information so that is one step further into the right direction.

Now I need to shift the focus on getting back into shape. Before school, I had dropped my weight down through healthy dietary changes and many Crossfit workouts. I felt great and also knew that I could set a positive example to the individuals that I would be caring for.

During the 6 months of clinicals, this all went down the drain with a decrease in the available time to work out and heading back to "on the run" eating habits. My new schedule will allow me to work out a bit more, but I also want to work on getting back to running on a regular basis. I look forward to having a healthy outlet!

In the meantime I continue to wait, think positive thoughts and cross all of my fingers and toes for a Monday start date!

The Lull Between RN and NP
October 25, 2013 10:31 AM by Katrin Moskowitz
All required packets have been submitted to their respective entities. My immune system has been prepped with a TDAP booster, influenza vaccine and PPD administration. Drug screen was completed and now I have to do what I do not do best: wait.

To keep my mind busy I have been cranking out the hours in the ER as an RN and have also been researching ways to keep myself ready for NP action. Although I am performing nursing tasks, I always do my assessment and think, "What would my NP alter ego do?" I am very fortunate to work with other practitioners who I can clarify why they chose certain treatment paths without worry of feeling sublevel.

There are many different nurse practitioner educational programs available, so I know that clinical experiences can vary and with that, differences in the ability to develop certain skill sets such as suturing, 12 lead EKG interpretation, digital blocks, etc. 

For some, these might be skills that they would prefer not to have to complete, but for me, they are things that will keep my day varied and exciting. I have looked at some adjunctive courses to enhance these skills, but with them come a bit of a cost factor. Again, I am fortunate enough to have an understanding employer that knows that I am still developing these skills and will hopefully have a good preceptor who will show me the ropes. I have looked into obtaining the following additional resources for practice:

Hospital Stat 12 lead EKG tool

Tarascon Procedures

Dermatology DDX Deck

I would love to hear what resources you have used to help get you through your practice!

I have also had the opportunity to think about my long-term future and further educational goals. There is a definite push of NPs completing their doctorate. I had thought at first that I would jump right into the DNP program right at the finish of my MSN, but I am currently education-ed out. I need a hiatus after spending the last 9 years straight in school. Once I feel like I have settled into practice, there is also a definite desire to do some sort of teaching. And this is why I chose to become a family nurse practitioner! So many options out there in the world.

I look forward to finally posting about patient care, the lessons I get to learn and the transition into my new workplace. Until then life still seems pretty much like it always has!

Pass or Fail?
October 10, 2013 4:45 PM by Katrin Moskowitz
Greetings from the happiest place on earth: Disney World. When I planned this trip months ago it was meant to be a celebration trip and thank you to my family for sticking through the last 2 years of NP school.

In my mind I would have passed my school's comprehensive exam and the national boards. Just a few weeks ago I panicked, again thinking in my head about the possibilities of failure in either or both of those upcoming feats. Everyone around me had no worries, telling me that they had no doubt that I would pass.

They, however, did not just cram 2 years' worth of various knowledge bases throughout multiple lifespans into their heads. The more I reviewed materials, the more I felt like I maybe had not retained all that I should have. Self-doubt is a devious creature.

I scheduled my exit exam for the earliest available date I could and was able to schedule my boards the day after. Why would I do that? I just needed to get it done and over with. It was 2 days of acid producing, nausea-filled days and sleepless nights.

Exam one was scheduled at 9am with an 8:45 a.m. check-in time. I arrived early to park in the correct parking garage and walked to my respective testing center. No one was there. Office closed and doors locked.

I spent the next hour waiting and then having to make my way back to my car to retrieve my phone and figure out what to do. Needless to say it did not aid in my already elevated anxiety and once tags were straightened out, I was worried that taking the exam might not be such a good idea.

Instead, I pushed through and passed my comprehensive again. Phew. The next day was a different story. The new testing center was not only open, but organized and ready to receive me. In fact, entering the exam was like entering prison: Empty your pockets, turn them inside out, lift up your pant legs, turn around, hands in your pockets.

My anxiety was in control until I sat down and saw what I was doing there. AANP National Boards. I put on my lawn mower-looking provided earphones and dove in. At the end of the exam, before they release if you passed or failed, they ask you to answer a brief survey. Bad bad idea. In those 10 questions I felt my heart rate skyrocket and all I could click was strongly agree, strongly agree until I saw the final words: PASSED. I could have cried at that moment. Instead, I let out a huge sigh of relief and slowly headed to the exit.

The fact that I passed everything has still not sunk in. Even after filling out malpractice paperwork for my new job and signing APRN as my title. Now I just need to wait and pray that all of the licensing agencies act hastily. Now I can relax, enjoy vacation and prepare to enter the workforce in my new role!

Licenses, Contracts and Hospital Privileges: Oh My!
September 26, 2013 4:00 PM by Katrin Moskowitz
While I await my boards I have been compiling all of the necessary papers that are needed for purposes of licensing. With this also comes making a list of all of the fees that come with this. Although I will be receiving CME funds at the beginning of the year, my initial applications will all come out of pocket for me. Ready for the list?
  • Connecticut APRN License Application: $200
  • Connecticut Controlled Drug License Application: $40
  • DEA Number Application: $730 (ouch)
  • Hospital Credentialing fee: $200
  • NPI Application: FREE!

So all of this money is out before I even start work! If you have the opportunity to set aside money now, please do so. With all of these applications comes the waiting game. Once boards are completed I have to wait for the official notice from AANP in order to apply for my CT NP license. My license can take 1-2 months. I cannot apply for anything else until I have my license in hand. Did I mention I am not very good at waiting? Time to pick up some extra shifts in the ER as an RN as I wait and save to pay for all of these applications!

I did receive my final employment contract to sign. I am in no way well-versed in contracts and the interpretation of them. They are however a staple in the world of the NP as I have learned. I have had to sit down and, section by section, figure out what the next two years of my life will entail.

Depending on the setting and who the NP ends up working for, these contracts I am sure can run from simple to super detailed. I did find certain aspects of coverage very interesting. For instance: your obligations upon finishing a contract, getting out of contract and of course salary and benefits. Don't ever be afraid to clarify items or even have the contract amended.

Next order of business? Application for hospital privileges. Because I will be working for a hospital affiliated physicians group I have to be credentialed through the hospital. Enter paper packet number two. They really should have told us in school that applying for everything feels like signing mortgage paperwork; it is endless and overwhelming to say the least! I currently have a start date at my job of November 11, 2013. Although it seems so far away, I know that it is necessary in order to complete all of the above.

Until then I am continuing to study, study, study. The more I do the more I feel as though I have so much more to learn! I have self-doubt and nervous energy because so much is riding on this! Then I go into NP mode! If I were my patient what would I do? Perhaps a PPI for my acquired GERD? Perhaps an anti-anxiety medication, one that does not cause sedation? Or maybe just good old fashioned sleep and deep breathing! In the end I just need to trust in myself and know that what will be, will be.

Transitioning Into the World of a New NP
September 13, 2013 8:09 AM by Katrin Moskowitz
As I sit here to compose my first blog post as a new graduate, I am feeling a bit bittersweet. The last two years have been long, adventurous, overwhelming and exciting all at the same time. Now it is time to regroup and make my post-graduation plans.

This past weekend I attended a board review class and as I sat there, I realized that things are getting real. Just six months ago I was worrying about transitioning into clinicals and making sure that I was following all of those evidence-based guidelines. Now I am working on studying for my school's exit exam and of course my boards so that I can start work as a family nurse practitioner. I am feeling some definite PTSD from when I graduated nursing school and was preparing for my NCLEX exam. What if I don't pass?

I am fortunate to have the added pressure of having a job waiting for me as soon as I have my NP license in hand. It is a great position in a freestanding urgent care center that is part of a hospital's multispecialty physicians group.

The fortunate part of this position is that I will be replacing a physician assistant who is not leaving until December. This allows for me to have an extended orientation and transitional period into my new role. This was something that was very high on my priority list of my first job. The last thing I wanted was to be thrown out into a new role, hoping that things would fall into place.

I will be doing all the normal colds and coughs, but will also be able to perform office procedures, interpret X-rays and EKGs and spend half of a day a week in a primary care setting. Ultimately, it is the best of both worlds for me. I also will be working twelve hour shifts during the week and every other weekend, affording me the ability to have days off during the week to attend to doctors appointment and school activities.

For any new graduate who is interviewing for a position, please make sure you go in prepared. I was fortunate to have had a great regional clinical faculty who sent me some great questions to ask during my interview. Some of these included:

  • Are there productivity incentives? (The more patients you see or the more services you bill for, the more money you get?)
  • Does urgent care have appointments or is it a walk-in only?
  • How would you learn procedural skills such as I&Ds, suturing, digital blocks?
  • How many other NPs/PAs are there in the department? (This will tell you if they are used to working with us.)
  • Will you ever be alone (even on weekends) or will there always be someone there with you?
  • Do most of the patients you see have a PCP or is it likely they will have to return to the urgent care for follow-up?
  • Do you have electronic health records?

During the interviewing process I learned that most entities work with contracts. These are very detailed and full of jargon that I had never been exposed to before. I was able to get a draft copy and review this over and over again in the comfort of my own home and then make a secondary list to review with the administration of the group. Don't make such an important decision without having time to do this.

This next year promises to be an exciting one for sure. I hope to learn many new lessons that I can share with my fellow new NPs or NPs to be. Only we know how hard we have worked to be where we are today.

Heart-Wrenching Heart Patient
April 25, 2013 9:42 AM by Anne-Marie Gitchel
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 patient.

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 all.

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 given.

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 patient's heads.

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 appointments. 

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.

Eating Our Young
April 11, 2013 4:05 PM by Anne-Marie Gitchel
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!