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First Year NP

NP's Orders
July 28, 2014 10:53 AM by Katrin Moskowitz

There are not many things that frustrate me in my clinical practice. Most patients are open, receptive and leave shaking their heads in agreement to your plan of care. What happens once they leave your office is often unknown. You hope that they venture directly to the pharmacy, take their medications as prescribed and their health improves.

What I am occasionally finding is that my hope of 100% patient compliance is just a dream that I have comprised in my own mind. As a new practitioner, I really focus on patient education: informing them of the expected course of illness, how to take the medications, possible side effects of those medications and, of course, things to be concerned about.

In our urgent care, we encourage patients to come back for rechecks for common procedures such as suture placements and incision and drainages - we want to make sure things are improving as expected.  I am amazed at how many patients decide that they do not need to start their prescribed medications because they thought that "things will get better on their own." This in turn leads to worsening conditions, longer recoveries and frustrations on both the patients' and practitioners' parts. Is there an answer to this commonplace problem? Maybe I should be more firm when going over prescriptions, repeating the importance of taking medications as prescribed.

My hours in primary care, as limited as they are, have been quite successful. All of my patients who have come in have completed their blood work and have made improvements with lifestyle changes and follow ups. I enjoy showing patients how they can make simple changes that can last them a lifetime. I know our instructors said we may not be able to change the world but I hope to at least impact one person at a time. My success streak in primary care may be short-lived but I will enjoy it while it lasts.

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Keeping It Interesting
July 14, 2014 9:35 AM by Katrin Moskowitz

The last few months have been a balancing act, but one that I am enjoying. In the last two months I have been back in my Emergency Room working as a provider. I have been very fortunate that the staff that I previously worked with as a nurse have accepted me in my new role and continue to work with me in an efficient and professional manner. I was approached by a hospitalist and asked how I was being accepted and was happy to tell her what a wonderful transition it has been. It felt great when she said, "Well you worked so well with them before, I did not expect anything else."

With my new role has come the ability to provide input on departmental issues from two different perspectives and advocating for patients in a whole new way. The ER providers have been wonderful to consult with and they have helped me to grow each shift. No day is the same and my mind is challenged vastly. I have been able to order new modes of testing and I enjoy getting results within an hour (versus twenty four hours in urgent care).

I continue to work through my DNP program. It has not been easy, because, as they say, doctoral studies are a whole different beast. There is so much more in the way of scholarly writing and in-depth reading that I find sometimes hard to find motivation to complete, especially now that the weather is so beautiful. Those are excuses, however, and I just need to sit down and do it! I just think of the end goal: heading to Kentucky as Katrin Moskowitz and returning as Dr. Moskowitz.

My family continues to be very supportive, and without their tolerance for my perpetual need for learning, I would not be where I am today. They do not believe me when I say I am done after my DNP is complete, but I promise that my career as a student will be! In the meantime I just need to organize my calendars, distribute my time and continue forward one day at a time!

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Diversity Impact 2014
June 30, 2014 12:03 PM by Katrin Moskowitz

I recently had the opportunity to return to Hyden, Kentucky for their Diversity Impact weekend. This is the second time I have had the privilege to attend and was even more excited to be there as an alumni of Frontier Nursing University.

When I first thought of diversity, my mind automatically jumped to the word minority. I soon found out that diversity can describe both major differences amongst us but can also include the things that we share. Either way, each one of us has the opportunity to bring all of our own diversities to the table in order to learn as both individuals and also as professionals. The weekend included students, both women's health, family and midwifery, graduates and faculty.

The weekend encompassed candid discussions, eye opening exercises and special guests. We had the pleasure of having Kitty Ernst join us who herself worked hand in hand with Mary Breckinridge herself. This woman is a spitfire with a passion for women's health that is indescribable. She reminds me so much of my Oma in Germany and I smile being in her presence.

Mid-weekend we were told that we would be joined by Cristi Turlington Burns. Known for her modeling career she also is an advocate for decreasing maternal and infant death during childbirth around the world. She spoke with us about her organization: Every Mother Counts and showed us video clips about the midwives that were being trained through her fundraising efforts in Haiti. I recommend that you view her documentary: No woman, no cry to understand the plight of birthing women throughout the world.

Being in the mountains of Kentucky allows you to connect with nature, the mission of Frontier Nursing University and humbles you from the soul out. It is always hard to leave as the connections that are made with individuals in such a short amount of time is inspiring. 

 

 

To end the weekend the local news station also paid us a visit. Here is a great segment that they were able to put together:

Diversity Impact 2014

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Patient Perceptions
June 16, 2014 11:45 AM by Katrin Moskowitz

During my time as an emergency room nurse there was always a level of frustration in regards to what patients perceived as an emergency. I always said, "One person's emergency is not another's." When our fast track area was open between 11 a.m. and 11 p.m., this was less of an issue as you could funnel less acute patients through this specially intended area. The frustration increased, however, when these less emergent patients came after the fast track areas and bogged down the care of the acutely ill. Nevertheless, we took care of everyone, because in their minds they needed to be there.

In urgent care I am seeing a complete opposite of patient perception. Just last week I sent the following two patients directly to the emergency room for further evaluation:

Case 1: 58-year-old male who was shopping at a local grocery store and told his wife he needed to go sit down in the car. The patient developed sudden onset of right lower leg redness and swelling. Has a history of a two week admission 4 years ago for severe cellulitis. When they arrived home the patients temp was 99.8 and one hour later it had spike to 102 with rigors and general feeling of unwell. The redness had increased and the lower portion of the leg now appeared greyish blue.

Case 2: 31 year old female with right lower quadrant abdominal pain that started that morning and continued increasing over the day. This was accompanied by nausea and then the inability to stand up straight. Right-sided lower abdominal rebound tenderness and guarding.

Both of these patients were admitted, case 1 for cellulitis with sepsis and case 2 for appendicitis.

Now I may have the advantage of anticipating or explaining to patients what may be done for them at the ER and I will be honest that I will use it when necessary!

I have also been afforded the opportunity to return to my ER stomping grounds as an APRN per diem. I have already completed some mini-orientation shifts and next week will work my first official 12 hour fast track shift. It feels great to return to my community, and also to work again alongside the staff that I grew to love over the last 7 years. I look forward to increasing my skill sets and fine tuning the ones that I currently have.

Time really is flying by. It still seems surreal that this is my career and this is what I get to do on a daily basis.

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Inspiring Primary Care Innovation
May 27, 2014 9:07 AM by Katrin Moskowitz
I recently had the wonderful opportunity to attend the Weitzman Symposium with a focus on primary care. It was hosted by Community Health Center, Inc., and it was held on the beautiful Wesleyan University Campus. The focus was on inspiring primary care innovation. And inspire me it did.

Community Health Center, Inc. (CHC) in Connecticut has a longstanding tradition of implementing new and innovative solutions for its patient population, which is mostly comprised of underinsured, diverse and low-income patients with limited access to specialized care. I will be honest that one reason I did not enter community health directly out of school was the thought that I would be utterly frustrated by the inability to provide the care I felt a patient needed, due to dictation of state insurance. I learned on this day that this is not how it needs to be and that CHC was working hard at changing that thought process.

The day included several wonderful speakers and then a responsive panel from CHC who educated the audience about how they, in their community setting, where implementing the innovative ideas that the speakers had presented.

Thomas Bodenheimer, MD, discussed the pressing issue of the shortage of primary care providers and whether recruiting more providers would make a difference. Instead he encourages centers to "share the care." This means allowing medical assistants and nurses to work at the top of their licenses in order to lower the burden on the providers. Therefore, if providers are not spending most of their time trying to accomplish tasks that others could complete, they could expand their case load. CHC spoke in return on how it has in place standing orders for nurses and medical assistants to be able to manage such things as hypertension medication and diabetic foot checks.

We heard from Aaron Smith, cofounder of the Young Invincibles, who took it upon himself to educate and empower the youth of the country to take control of their healthcare options and who was on the forefront of the move to ensure that young adults are covered under parental health insurance until age 26. Sandra Sarkar, chief of staff at Health Leads, gave an invigorating speech about how her company was taking steps in bridging the socioeconomic barriers to healthcare.

The day taught me to not be afraid of challenges, but instead be a partner in finding innovative solutions.

As Ghandi has said, "Be the change you want to see in the world." For more information on CHC, visit: http://chc1.com

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Time Flies When You Are Learning New Things
May 7, 2014 8:04 AM by Katrin Moskowitz
It is hard to believe that I have been in practice for 6 months already. It only seems like yesterday that I sat in front of that ominous computer awaiting my fate. I consider myself very fortunate to have found a position that allowed me to ease into my new role and learn new skills at my own pace. I have been off of orientation since January and continue to love what I do.

Having been an ER nurse for my entire nursing career, I have had to get used to the amount of patients I see who are for the most part healthy. This is especially true for the elderly population that I encounter. I guess my view has been a bit skewed, since I had seen so many elderly patients so sick. Now I have patients over the age of 90 walking in on their own, taking minimal medications and enjoying their lives.

I really enjoy the patient interactions and the variety of my daily schedule. Now that the seasons are changing, so are the common presentations. As the weather has warmed up we are beginning to see the tick bites and poison ivy dermatitises erupt. We continue to see positive influenza results and are beginning to see more orthopedic injuries as children begin jumping on their trampolines and riding their bikes. My favorite procedures still remain suturing, incision and drainage and, funny enough, ear irrigations. Patients are often perplexed as to why I would like to do those things, and I tell them that it has to do with instant satisfaction! There are many times that I send a patient on his or her way with medications that may take days to truly allow them to feel better, but with these procedures we have a resolution right away. Procedures also give me the opportunity to talk to patients for a longer period of time, which is often a nice change to the quick in-an-out mentality.

I also spend 5 hours per week in primary care. This has been a challenge on its own, mainly because a schedule is preset for you. I have had to learn to pinpoint my conversations with patients, preplan my day and delegate in order to stay on point. I do enjoy the ability to follow through with patients when I start them on new medications and build relationships with them over time. My primary care preceptor was instrumental in showing me how I can impact a patient's life in a short amount of time.

I would not change where I am at for anything. I am glad that I made the career choice that I did. Over the next few months I will continue to build my skill sets and hope to gain more knowledge in the areas of x-ray and EKG interpretation. I am continuing with my DNP classes, which has also allowed me to gain new perspectives on what else is going on around the country.

Lastly, I want to give a shout out to all of the people in New York state who worked diligently for passage of legislation that will allow APRNs to practice independently after 3 years of practice. This new law will open the doors for many NPs in the state. I look forward to what this may bring for my own future.

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Trusting your gut
April 25, 2014 8:22 AM by Katrin Moskowitz
As a new practitioner there is always that "second guessing yourself complex" that hovers over you like a black cloud. One benefit that I have had is that I have 6 years or ER nursing experience behind me. It allows me to have that gut feeling that tells you something is not quite right. This feeler system has definitely followed me into urgent care. I do rely on others around me to give me second opinions when I just can't put my finger on what is going on. Sometimes, however, this can give you a false sense of security.

Two weeks ago I took care of a 58-year-old woman who had undergone a right hip replacement a few years earlier. She was out and about power walking when she tripped over uneven pavement, falling forward onto her right side. She came to me 2 days later with persistent right sided groin pain. I decided to x-ray her hip to make sure that her prosthesis was in place and that no fractures were present. Now I will be the first to admit that I still have not grown completely comfortable reading x rays. I have only been at it for 4 months and see new films each and every day. I did note a lucency on the acetabulum but was unsure if this may have been an anomaly due to the previous surgery. I decided to call the radiologist in the reading room to get his opinion. After a brief explanation and discussion, I was told that the reading was negative. I felt relieved and spoke with the patient and explained that I spoke with radiology to review the case. I advised her to follow up with her ortho and to use her crutch for assisted weight bearing.

The next day I received a call from radiology about the same patient. Alas, that provider saw a concerning lucency on the film and asked that I bring the patient in for additional films including an oblique view. My heart sank a little. I called the patient back, we completed the oblique view and sure enough there was an obvious fracture on the view. I was relieved to hear that the oblique view is not one normally ordered. In the end the patient still followed up with ortho and it did not change the plan of care. I discussed it with my collaborating doctor. I knew that I had followed correct procedures and that I had handled the interaction with the patient well; the physician agreed.

A lot of what we do in urgent care is trying to take in all that the patient provides us in a very short time. Yes, most of what we decide to do is based on out assessments, but there are times when our senses give us additional information.

This was what I saw about a month ago when a 49-year-old patient came in complaining of nausea and vomiting for one month. He had a multitude of comorbid conditions including liver issues, obesity and GERD. He was due to have an endoscopy in 4 days and his current PCP was unable to see him in the office that week. I did his exam, which was benign, and told him that there were limited things we could do in our setting. I offered to complete some basic blood work on him and to order some medications for nausea and urged him to go through with his endoscopy, since it would mostly likely give reasoning behind his symptoms. The next shift that I worked, I was checking labs and noted that his BUN and creatinine came back at a dangerous level. I quickly looked him up in the hospital system and saw that he had been admitted for renal failure and discharge. I quickly called him to follow up and see how he was doing. He immediately said "Thank you so much, you saved my life". The lab had called him that evening and he promptly went to the ER. Those are the moments when you make decisions based on gut feelings and the payoff is immense.

We as practitioners new and old need to trust our education, our experience and of course, our gut!!!

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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.

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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?

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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!

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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.

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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”.

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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!

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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!

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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!

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