The Bottom Line :: N30020 Clinical Journal Entry #15

This week was my 2nd week returning to nursing school after my 1-year "health hiatus."  Another 4 hour lecture and of course on Tuesday, and another day at the hospital on Friday.  Last week was full of orientation, procedures, class projects, etc., so it was nice to actually have patients today.  Apparently assignments were switched and we're on the "Adolescent" unit for the first part, followed by what we call "the Little Kids" unit.

To be completely honest, I was not excited to be on the adolescent unit.  I've never had a patient in his or her teens or tweens, and while trying hard not to judge something I've never experienced, I just don't have an interest in it.  So I was picturing a braces-clad, iPod-tethered, whining "adolescent" when I heard about our unit switch.  

But the heavens saw me in my little white student nurse uniform when my instructor gave me a 2 year old.  

This was going to be a good day.

Apparently, the little kids' unit must have been in overflow because of our 8 patients on the unit, almost half being toddlers or preschool-aged.  Unfortunately, the unit is in the middle of some kind of changes or moving, so the 10 of us joined the RNs and 2 new nurse orients in taking care of 8 kiddos.  We were "paired" with a peer, and there was nothing to do at a few points during the day, but it worked.

Today's assignment: R, in for a nephrectomy. Lower percentile height/weight.  Diagnosed with congenital atrophic kidney with grade 3 reflux.  Preexisting hypospadias, congenital chordee.  In simpler terms, [and if you are scared of penis mentioning, you might want to skim for a little.....] R has one kidney that is too small.  Too small, in fact, that the urine backs up into the kidney.  It's kind of complicated, but the human bladder has more pressure than the kidney, so the back flow in case like R's causes much more pressure than the kidney is made to handle, ultimately damaging the kidney.  As for the hypospadias... At birth, normal male genitalia has the urinary meatus (opening) at the tip of the penis, but with hypospadias, the opening is abnormally placed and is generally repaired when the baby is a little older.  R's congenital chordee is a result of his hypospadias, and that just means that his penis curves downward.

In discussing with his family, it turned out that little R was born with the hypospadias and chordee.  The doctor advised surgical repair around 18 months.  When they were re-evaluating him at that age, the doctor was surprised to also discover the condition of his kidney. Of course, removing the kidney took priority over penile reconstructive surgery, so it was removed yesterday, laparoscopically.  (Remember, the majority of people have two kidneys, so although the remaining kidney will work harder, it will hopefully continue to be healthy.)  R did well in the surgery and the doctors will fix his other abnormalities once he recovers and is doing well.  His specialist explained how common it is to have some kind of kidney/urinary problem paired with hypospadias, so that's the association.

The goals of the day were to remove R's Foley catheter, handle his pain via Tylenol with Codeine, remove his IV, and wait for him to urinate.  (A patient cannot have a Foley removed and go home without first urinating.  It's protocol.)  Well, little R decided he wasn't going to urinate.  He decided he wasn't going to drink either.  Nice.

Our shift is 0700-1730.  Between 0800 and 0900, I removed R's Foley and IV.  Both involved kicking, screaming and flailing, but we made it through.

You know, it's funny...  I remember the first time I ever gave a shot to a patient - it was so weird because as I stood there, syringe in hand, clinical instructor at my side, a thought came to me.  As a nurse, I'm going to have to hurt people.  I pondered it, distressed, until I realized we only hurt people if they'll be much better off for it.  These kiddos have to have IVs and Foleys and surgeries, and they have to drink certain things and go scary places, and it's mean and terrible, and sometimes it feels so wrong.  Anytime I have to bother a child for anything, I can't help but picture myself in that bed by the window, watching Sesame Street, clinging to my "lovey" for dear life, hoping a nurse wasn't going to come back in.  But they did.  And we do.  Because at the end of the day, it's all to help these precious babies.

Anyhow, back to R.  We pushed about a zillion popsicles, and another round of pain meds induced a nap. Kids always pee in their diapers during naptime, right?  Well not R.  It seems like all we did all day was keep checking to see if he voided yet.  There was nothing else to do, and I was bored out of my mind.  We did the playroom, parent teaching, Child Life consulting for support on his major activity restrictions as he recovers... we covered all of our bases.  Still no pee.  Not even a little.

I couldn't help but observe R and family.  The look on Mom's face said it all.  Her child was going to have a simple surgery until they found out he was in kidney failure.  She had likely been awake for days straight, and she was agitated with everything.  Every defense in the world was up because this was her child, and he was hurting.  He was broken and there was nothing in the world she could do to fix him.  R would scream and kick and cry as I pushed his Tylenol with Codeine into his mouth with a syringe, and Mom looked like she was never going to get used to that different cry, that cry of desperation and fear that her son had probably never expressed before.  As for R, there were times when I mentally imagined myself as him simply because I couldn't not.  Hooked up to tubes and wires, eating new foods, listening to weird sounds, seeing more people than he's ever seen in his entire tiny life... It's a nightmare. Then I remembered how the two things I trusted the most - Mommy softly singing to me, rocking back and forth, and of course Dad's big strong arms - were, for the first time in my life - not enough.  What happens when everything you've ever known seems so, so small to this new, terrifying world you're being shoved into?  Exactly.  By midday I had connected with patient and family.  They were so grateful and couldn't believe how R was opening up to me.  Yes, I do well with kids, but this is different.  The bottom line here is that I have walked their paths, and that was the security this family, felt from me.  I was one of them, one like their little boy.

Although I liked them, I was also secretly hoping R would pee by noon or something so I could get a new admit - hopefully something more interesting, too!  But no.

R did not pee until about 1500.  

Yay for R!  We had him discharged in no time, but it was almost time for post-conference, a new patient wasn't up yet.... so we were just bored. Again.

But little bit of humor here... R's room "neighbor" was in for - get this - swallowing a pirate coin.  Almost 4, he loves pirates and somehow swallowed a "pirate coin." Poor little thing had to have it removed because it wouldn't pass.   He's also excited about his "pirate birthday party" this weekend and kept asking for his coin back.  Will we see him next Friday?  Oh, it's possible...

Kids.

Anyways... during my "boring times," I of course chatted with my fellow peers and the nurses.  I love hearing people's stories, but heart skipped a beat when my friends said they had a teen in with pancreatitis but he also had cirrhosis as a result of congenital liver disease. "He's really a cool guy, you should go chat with him!" my friends urged me.  (They probably felt bad for me standing around for half the day!)  So in I went.  I wasn't sure what to say as far as how to relate my connection with him, so I waited, determined not to be pushy. We just chatted and talked about life for awhile, and when it came up, I asked him who his specialist was.  I was pretty sure this was my opening because my liver doctor is the absolute best pediatric liver specialist at the Clinic, probably at least in the region or maybe the country, and she is no longer all-GI but hepatic patients only.  She's phenomenal, and I think she's the only totally, completely liver-only peds doctor in the entire CCF network.  Anyways, he said her name, and I replied with, "Oh great, she's my doctor too."  Suddenly that invisible "you have no idea what I'm going through" fell to pieces and we started conversing like we had been best friends for years.  We each shared our histories, our prognosis, our treatments, our frustrations.  We talked about procedures only we could understand and compared our list of similar medications. 

We'll call my new friend B.  Apparently B hasn't been able to go to school for the past couple of years and is lonely and bored. "I can't do anything," he told me, to which I asked him, "The fatigue, right?"  He grinned.  I had broken the practitioner-patient wall.  Maybe too far, but I couldn't help it.  

At the end of the day, I said goodbye to B and I secretly wished I would see him again.  I told him I'd be thinking about him and you'd better believe I will.  This is where I will be having trouble with attachments.  I've never met anyone young with liver disease and I can't express how comforting it was to be with him.  It's like waiting forever to feel like you belong and then finally feeling you fit in.  He did, too.  Again... Bottom line?  I was one of them, one of him.  (Oh and I was a little mad at my instructor for not giving him to me as my assignment.  Ahem.  But maybe that's a good thing?)

So back on track... finally, 1630.  R went home, remember, and I told B goodbye.  Post-conference is just an hour of talking about your patient, pathophysiology, meds, treatment, plan of care... blah blah blah.  I usually like post-conference, and today I did, too.  Until B's student nurses explained what was wrong with him.  

I didn't know there were dots to be possibly connected that far away from the truth.  Where in the world were they blaming x-symptom on x-condition, or x-condition as a result of x-medication that according to them, the doctor should not be prescribing.  My jaw was on the floor, and I pretty much had to consciously tell myself not to butt-in.   He was not my patient, and it would be a little tacky of me to steal their thunder anyways.  But I was sick, seriously disturbed.  How did I, talking to the patient for maybe an overall total of 20 minutes, know more about his life, social/emotional needs, fears, and future than TWO people who had been with him literally all day?  They missed so much, completely wrongly described liver disease/portal hypertension-induced conditions that I myself have.  Then they decided to tell us that he was on the liver list, but he probably wouldn't get one because, due to his specific disease, his liver might fail all over again. Umm?  Sorry guys, that's not how they do transplant priorities.  It's a number and a system, and who are you to say that your very end-stage patient is "probably really low on the list"?  God forbid you told the patient your opinions on how organ procurement an transplantation must operate.  

What I learned from that short experience is, how often do we entirely connect the wrong dots?  I thought about it later, and I realized that if I didn't know about the disease, there is no way in this world I could see my personal list of procedures, meds, and diagnoses and connect them into the least form of common sense.  It's a messy, messy disease, and I only know so much about it because I ask my doctor questions after questions and read journals, books and well, live the life every single day.  So who am I to judge them?  Perhaps their technique behind "how can we make this make sense?" seemed to work for them, but just not for me.  And not for B.  Meeting him today was one of my highlights of nursing school and my nurse technician job, too.  He seemed to be thrilled, as well, to find someone to connect with, and was just grateful to find our common bottom line.

This nursing thing is the hardest thing I've ever done in my life, but sometimes, it just feels so right.  It feels like I'm answering my heart and soul's calling, and well, isn't that the bottom line of life?