Saturday, August 9, 2008

Lessons Learned: Week 5

(cross posted on
Not a lot of time right now, but I was reflecting on last week's dichotomy of humor and despair. That's kind of what it's always like: an emotional roller coaster, and you've just got to stay stable.

We're learning what honor it is to be a nurse. I mean, really. That's part of week 6's lessons, but it seriously hit home for me in week five.

The most difficult thing, I learned, is not to watch someone die or even lay there and suffer.
The most difficult thing for me, I've discovered, is to watch the eyes of someone who loves that patient, and who has loved that patient for decades, as that patient is treated, tested, writhing in pain, out of it.
When you see the partner of a patient- and that partner is so alive, so intelligent, and so present, and then you look over at the patient helpless in bed, struggling to remember his name...
And then you see the way that partner looks at your patient, as the doctors and nurses place the ECG electrodes on that patient's body - you see that partner's eyes, and you look at their wedding rings, and you realize that the sweating, hyperventilating *person* in the hospital bed who can't even tell you his/her name at that moment because they're so out of it is *everything* to this person in the room, who stands in the corner, out of the way, strong, keeping it together, letting us do our work, stabilize, extend life another minute, hour, day.

I lost it for both of us. I had to leave the room and duck into the closet. Trauma has never bothered me, but that look in her eyes cut me right to the soul.
I fought tears, and lost.

A fellow MEPN (and good friend) asked me, "Did you see her eyes?"
"Yes. That's why I had to leave."
He nods. "I had to leave, too."

We just stood there, hugged each other for a bit, sighed, and went back to taking vitals.

Later that day, I found out that another patient had received a final cancer diagnosis, and that it was not only extremely early, the prognosis was very good, AND it was treatable. She hugged me and we jumped for joy together.

A nurse practitioner friend of mine told me that not a day goes by that she doesn't give bad news, good news, cries, laughs or hugs a patient. And she says if you can't feel, it's time to leave the profession.
I think I understand why.

Remember: there's a life in front of you. There's a person in that bed. We are so much more than the sum of our diagnoses.

Wednesday, March 12, 2008


Each day, I am stunned by the joy and the suffering that exist intertwined in this world.

Working in healthcare weaves me into the fabric of other people's joys and sorrows in a way I did not fully grasp when I thought about becoming a nurse. It is a reality I am coming to inhabit over the course of this MEPN year. Last quarter in my labor and delivery rotation, I helped coach a woman through her labor and the birth of her first baby, then helped her learn to nurse her child. In my community health rotation, I filled syringes with liquid morphine for the family of a hospice patient to squirt into her mouth to relieve her pain in the last two days of her life. I've walked with patients in the hospital halls, I've bathed them, I've accompanied them to frightening tests and procedures, I've celebrated with them when they're ready to go home and to re-enter their lives on the outside of the hospital. Until recently, I had no grasp of the power and the gravity of playing that part in a person's story, nor of how grand and improbable our stories can be.

I used to think that most of life was mundane, habitual, full of errands to run and tasks to accomplish, only occasionally punctuated with moments of joy or of tragedy. Increasingly, I see how precious, how fragile, and how impermanent life is; intertwined joy and tragedy, all the time, if we're paying enough attention to notice. I don't know if all budding nurses encounter suffering and joy, their own and others', in such intimate and constant ways as they come into their new roles, or if they also struggle to understand how we are to interact meaningfully with it all. What colors this year most vividly though, far beyond any lecture or clinical skill, is my effort to fully face the depth of wonder, beauty, sorrow, and pain in my patients' and their families' lives. It has been a year of striving, sometimes desperately and often clumsily, to sort out my place amidst the messiness of life, as difficult, as poignant, as radiant, and as tenuous as it is.

Sunday, February 17, 2008

Past Midway

As of now I have finished two and a half quarters of the MEPN year. Probably a good time to provide an update on how things have been going.

In short, school and my induction into the nursing profession has been fantastic. The first quarter was the most stressful, the second quarter was the most difficult and most rewarding, and the third quarter has been somewhat chaotic. But all phases have been extremely valuable and I can barely comprehend how much I have already learned.

Learning happens at a fast rate with the combination of focused classwork and rich, intense hands-on experience in the hospital with patients and other professionals. Nearly every one of my precepting nurses has been extremely willing to teach and happy to work with me. They have given me great latitude and trusted me to do sensitive, complex work with vulnerable patients.

The classroom experience has been mostly good, but frustrating at times. Usually over issues of disorganization, including schedule/curriculum/experience changes. Guest lecturers have been very high caliber professionals, and have given extremely valuable information on all sorts of topics. Lisa Day, our q1 Pathophysiology and Pharmacology instructor, was fantastic and a steadying influence on us all.

My classmates are good people. Collectively we have a tremendous amount of talent, energy, and drive. I feel we have something to offer to the nursing profession. We take this very seriously, and I have faith we will all be competent, diligent professionals.

Currently, I am in Psychiatric Nursing. My clinical rotation is in the Forensic Psych unit at SF General Hospital, my old stomping ground as a volunteer. I really love that place, there is just something special about it. Forensic Psych is absolutely fascinating. Our patients are jail inmates, or otherwise facing new charges. It is difficult for me to describe these people now because A) I have little understanding of mental illness and treatment thereof, and B) their symptoms are extremely varied. But the observation and interaction with these patients, sometimes one-on-one when the deputies and other nurses and docs aren't around, has been mind-blowing. More on this later as I gain understanding and experience.

After another 3 weeks Psych is finished and Spring Break begins. Q4 begins in late May, with Labor and Delivery and Issues in Nursing. In June I graduate, then study for and write my NCLEX in June, to become licensed as a Registered Nurse. And HOPEFULLY I will get a job which starts in July.

My goal is to work in the Emergency Department at SF General Hospital, Highland Hospital in Oakland, or Stanford Hospital, in that order of preference. I will work full time for one, maybe two years before scaling back to part time work and returning to UCSF to begin work on my Masters. After two years of school and work I will complete my Masters and seek licensure as an ACNP (Acute Care Nurse Practitioner). Hard telling what will happen at that point. Depends on job opportunities in San Francisco and elsewhere, as well as personal life factors.

Tuesday, December 11, 2007

A Day at an Abortion Clinic

REFLECTING ON: Observing at an abortion clinic and confronting my previously unchallenged ideas on the subject...

Having not donned my forest-green scrub top in a while, at 5:30 yesterday morning, I found myself again feeling like a complete fraud as I dressed up to “play nurse”. I moved slowly as I pulled up my multi-pocketed, khaki scrub pants, and closed my eyes for long periods of time. At the end of one sleepy head nod, I opened my eyes to stare down at my left sleeve: the iron-on UCSF patch—my official sponsor. I wondered if or when I ever was ever going to feel confident or competent as a nurse. Such is the life, I suppose, of a student in an accelerated program.

My destination was a San Francisco abortion clinic where they perform abortions for patients in their first and second trimesters (up to 22 weeks). As someone who had never been to an abortion clinic in any part of my personal or professional life, my expectations were distorted by the vague abstractions of what I had heard in lectures, seen in the news, and read in books. Though it was vacation, I had chosen to volunteer at this clinic for this very reason: my total lack of actual experience with the subject. In addition to educating myself, my decision to volunteer was intended to confront my fears regarding abortion. In being totally honest with myself, I realized that I wanted nothing to do with the abortion process. My natural inclination is to run away from situations like these due to some misplaced instinct to survive. I have quickly realized, however, that being a nurse often requires me to walk towards these less-than-comfortable situations in order that I better serve my patients. How can I be objective and caring if the greater part of my brain is sorting through basic instincts? So I take a deep breath and take a step closer to my fears.

Although these greater, mostly inexpressible thoughts were swirling around my gray matter as I got ready, I could verbalize one constant preoccupation: I was nervous and concerned that I wouldn’t be of any use. I suppose “being of use” isn’t so much the point during a day of observation, but I always like to show that I can be helpful. Part of the “disease to please” I suppose, where I always try to find someway to help. Later, after I had observed eight abortions, I was glad to just sort through my thoughts.

While on BART and Muni, I spent my time reviewing pregnancy and abortion terminology as well as the pharmacological actions of Mifeprestone, Misoprostate, and Methotrexate—drugs used in medically induce abortions. Memorizing things like these is a part of my “comfort-routine”, where I control for as many variables as possible. Memorizing facts, though challenging and requiring discipline, is easier than wrestling with the swirling and unpredictable emotional variables. I can memorize what is known and understood. In contrast, I can only blankly repeat sentences when something is beyond my mind’s grasp. As much as I crammed, there was no way I could prepare myself for truly understanding the mechanics of abortion.

I foggily made my way through the hospital’s labyrinth of hallways and, after ringing a doorbell, stepped into the clinic. Luz, another nursing student in UCSF’s MEPN program, was already there. Everyone was friendly and this surprised me somehow. I even heard one of the nurses say, “Oh good, the students are here.” Reflecting back, my surprise was the first clue to my true, thoughts on abortion. If I had been completely honest with myself, I halfway expected that everyone in the clinic would be quiet and forlorn, perhaps in constant state of mourning, because after all, weren’t they killing babies here?

And with that flash of thought, I was truly taken back. Floored really. Completely and totally shocked. Did I really just think that? But I had always flown the pro-choice flag…and now…shit…was all my talk just lip-service and yet another unchallenged idea in my personal cache of thoughts that define me as liberal and open-minded? Am I really that naïve? In the abstract, I had somehow rationalized that there was a clear delineation as to the point where life began and ended such that each of these medical professionals, with exacting precision, were able to determine beyond a shadow of a doubt when and how life began so as not to destroy any potential, any thought, any love, or any laughter…as if the next great Mozart or Martin Luther King might be at the clinic in fetal form, or perhaps just a really good kid. I don’t know…starting out with thoughts like these, I knew it was going to be one hell of a day.

At the nurse’s station, I stood next to Luz, blankly repeating words and sentences to myself. Luz seemed more at ease than I. Madison, an experienced nurse at the clinic, approached us while tossing up a coin, which I knew had something to do with me. Without asking, I called heads, won the toss, and was asked to choose my preceptor: Madison or some other woman. As I hadn’t met the other woman and I liked Madison’s style—direct, thorough, and smart—I chose Madison.

Madison shot out a million words a minute and walked about just as fast. Talking while walking seemed to synergize her speed, making her blurry on any photograph. One minute we were in the med room drawing up a cocktail of fentanyl, versed, and atropine and the next we were whirling passed the nurse’s station and reviewing patient information. She explained that the fentanyl, an opiate, is for stopping pain; versed is a central nervous system depressant used to relax the patient; and the atropine, a parasympatholytic, is employed in order to maintain the patient’s heart and breathing rate, as well as for prophylaxis against a vasovagal response. Madison had not only told me the pharmacological action and reason for each drug, but she had also managed to summarize the procedure, and even began to discuss abortion complications—all in about 3 minutes. My head was spinning when we entered the procedure room where there was a already a patient prepped and ready to go. I would need more time to take it all in.

As I learned and asked questions, twenty-three abortions would take place that day. The patients ranged in ages from 14 to 30 years and their fetus’ gestational age ranged from 7 to 14 weeks. I observed no immediate complications.

Ella was our first client. She was thirty-three, married with two kids and didn’t want another. She told me as much while I sat with her during the pre-procedure counseling session. She had had this procedure once before and somehow seemed cheerfully resolved to go through it again. Her “cheerfulness”, I admit, was my bias, but I can only report what I see. Who knows how she really felt?

In Ella’s chart, we would write that she was a G4P2—gravida 4, para 2, indicating that she had been pregnant a total of four times, and had carried two of them to at least 20 weeks. This fetus was 14 weeks. Ella’s confident body language and willingness to look at medical personnel in the eye seemed to indicate that she was at peace with her decision. Somehow that put me at ease, too, which allowed me to pay close attention to the tools and mechanics of her abortion.

The procedure took place in an older operating room with wall-to-wall tile. The room was extremely cold and in the center of the room was Ella, lying on the operating table with her legs propped up, spread, and secured by the stirrups. She was draped with the infamously small hospital gown, but probably didn’t care about the cold because of the fentanyl. Behind the table sat the equipment that monitors each patient’s oxygen saturation, respiration rate, heart rate, and blood pressure. At the foot of the table was a draped cart of sterile tools. Under the drape was a bowl for betadyne, which is used to clean each patient’s vagina inside and out. Near the bowl was the speculum, a vice-like tool that is inserted into the vaginal canal so that the clinician may have direct access to the cervical canal and uterus, where the fetus is developing. Next to the speculum was a wrapped sterile cloth that contained several sterile dilators—10-inch metal rods of increasing diameter that would probe from the external to the internal os of the cervix, allowing for full access to the uterine cavity. Depending on the age of the fetus, the clinician will use either a manual or electric vacuum, either of which would require a plastic tube, the cannula, to be attached to it. The cannula is inserted through the cervical canal and into the uterus. One one end that is insertedinto the uterus, the cannula is beveled and the other is attached to the vacuum. The cannula serves as the primary tool for terminating the fetus and is guided into the uterus via an ultrasound image. The ultrasound is live, essentially showing a video of the procedure’s main event: destruction of the fetus. The amniotic sac is more salient in earlier pregnancies, with a small but distinguishable fetus growing at one side of the placenta. The head is just barely visible, as well as small arms and legs. If the fetus is in the second trimester, like Ella’s, the fetus’ spine is obvious, and upon careful examination, one can even see a tiny fluctuating blur of black and white: the beating fetal heart. The plastic cannula would normally be invisible on an ultrasound image, but is obvious because of its barium coating. Once the cannula is placed into the uterine cavity next to the fetus, it is twisted and pumped up and down while connected to suction. The fetus, placenta, and amntiotic sac are being speared, broken apart, and then sucked into the vacuum container. The clinician performing the procedure will make several passes with the cannula in order to ensure that all of the contents are aspirated. Then, to further ensure that there are no more fetal contents within the uterus, another tool, the curette, will be employed. The curette has a handle similar to a screw-driver with a long metal rod extending from it. At the end of the rod is a metal loop that is used to gently scrape the uterine walls to ensure all fetal material has been removed. Both of the physicians that I observed carry out this part of the procedure described the sensation of scraping the empty uterus as “grainy”. Once empty, the uterus shrinks back into its flattened position, the walls of which are now flush unto themselves, with no fetus present. On the ultrasound, the physicians described the flattened uterus as having two parallel “silver” lines that represent the uterine endometrium.

Ella’s abortion followed this precise operation. No complications. No pain. She was groggy from the medicine, but after recovering from the procedure, she left the hospital and was driven home by her sister. In the recovery room, she smiled at me, ate crackers, and talked easily with the nurses and other patients. Again, I found myself surprised by the ease in which she and everyone around her had adapted to the events I had just witnessed. This included myself. I did keep my surprise quiet for fear of being branded a heretic. I suppose if I had I been injected with a fentanyl cocktail, I could have watched a train wreck while singing “Frère Jacques”, but I hadn’t, and nor did I have the years of experience that could allow me to fully gain professional distance and objectify the patient while sinking into a rhythm of automaticity.

I had a strong emotional reaction. What I had observed was this: one minute there was an observable human figure on the ultrasound and the next there was not. In the interim I observed blood being suctioned from Ella’s uterus and into glass jar that had a cheesecloth filter for catching solid tissue. At one point, the electric vacuum became clogged and the doctor had to withdraw the cannula from Ella. A scant amount of blood dripped from Ella’s vagina to the blue drape beneath her. Clearly, there was tissue obstructing the beveled end of the cannula. The doctor brought it to a bowl and tapped the cannula twice on the bowl’s edge. A clump of tissue loosened and fell; the doctor returned to the procedure and all eyes were back on Ella except for mine. My gaze remained fixed on the bowl where saw a small, dismembered arm with a hand. I counted five fingers and noticed the arm was bent at the elbow.

I strained to hide a flash of grimace. My eyes watered for a second and would have betrayed me had I not looked with feigned interest at the vacuum. Ella had her eyes closed anyway. Nobody in the room was looking at me. My nostrils flared and I thirstily inhaled air. All I could think was, “Get it together Nat…we’ll work this out later,” which I repeated at least seventeen times. My eyes returned to the arm and I noted veins below translucent skin. It was the left arm. I thought I could see the head of the humerus. It was approximately 5 cm long.

The facts were comforting to me. I looked around and noted instruments and where we were in the procedure. And with that, I moved from being emotion-filled to diagnostic-filled, which I found as alarming as first seeing the arm. The sting of what I had just seen was still with me, but was sublimated into fascination by examining the anatomy of the fetal remnants. My head was in two places at once.

Upon leaving the operating room, the emotional pull returned, forcing me to bend my mind around what I had just seen. This was heavy, heavy stuff but there was no time to think; there was another procedure to perform. I was on Madison’s schedule now. The rest of the abortions were for fetuses 8 weeks or less, which somehow seemed more acceptable to me. I couldn’t see the fetus as well, and they weren’t as developed as the 14 weeker, so it wasn’t as hard to watch. There were no more tissue obstructions either.

In between patients, Madison and some of the other nurses expressed their disbelief that some of their patients actually wanted to take the fetal remnants home with them for a funeral. Madison was clearly frustrated, “I mean, I can see wanting to have a funeral if it is a medically necessary abortion and you wanted the child to begin with, but for an elective abortion? I just don’t get it. And besides, most of our girls are on Medicaid…so you’re telling me you can’t afford an abortion, but you can afford a funeral?”

“Maybe they’re trying to show somebody,” I said, surprising myself. I had turned a corner and tried to picture the life of the person who had been on the operating table outside of the procedure. “Maybe they’re trying to let someone know that this is what they had to go through.”

“True,” Madison said, “there’s a million reasons to get an abortion, and we only see part of it. I guess the bottom line is that everyone should have access to it, regardless of their reason or means so they can be safe—it’s going to happen no matter what. I know we sound callous, but don’t think for a second that we don’t love what we do. It’s important. Women need to be bale to safely choose this procedure.”

Clearly, the day one decides to have an abortion shouldn’t be a happy day in anyone’s life. But for Luther, it clearly was. Although all the nurses had discouraged Susan from having her partner in the room while the procedure was taking place, she was adamant about having him there. “I didn’t get pregnant by myself,” she insisted. At with this, everyone acquiesced, and he was fetched from the waiting room. It was late in the day and this was the next to last procedure. When Luther came into the operating room, Susan was already laying back on the table. Her face had changed as soon as he entered the room: passionate to impassive in two seconds flat.

When I first saw Luther, all I could think was that he was a grubby little boy. Mannish in stature and size, I suppose, but his body language put him at 17 tops. His sweats were crusted up with dirty liquid stains and a distinct odor followed him into the room. I recognized the smell immediately—that of a dirty, neglected home. I had been in hundreds during my days as a social worker and group home counselor, and most of them smelled the same: stale cigarette smoke, dirt, must, and sweat all combined to create one of the most pungent smells in my memory.

Luther was taking off his hat as he entered, which I offered to take from him. He handed it to me and was signaled to sit down next to Susan. When he spoke, his words were saccharine, “It’s gonna be alright baby, baby—you’ll see. All these people are gonna take real good care of you.”

It sounded like bullshit to me. His words were hollow and unconvincing like those of a bad actor. Luther looked around at the staff after each sentence, as if looking for approval, and spent very little time looking at Susan. As the procedure progressed and the staff would offer encouraging words, he would mimic them like a myna bird, “It’s going alright baby, baby…just breathe baby, baby.” And although he said all the right things, I couldn’t help but think he was quietly celebrating because I could see him smile. A new feeling overwhelmed me during Susan’s procedure: that she was brave.

Perhaps Luther was relieved to not be a father at such a young age. God knows I was relieved to hear that an old girlfriend’s pregnancy test came back negative when a much younger Nat went through a pregnancy scare at age 18. So perhaps he was happy, but Susan was clearly not, and I think she wanted him to see that. Later, Madison told me she noticed the same thing, “I hate it when they perform like that.”

While Susan was in recovery, I realized that I had not given Luther back his hat. I went to find Luther in an otherwise empty waiting room and before I even got to the door, I noticed a new smell: the small room reeked of marijuana. Nobody had been smoking in the room, otherwise there would have been smoke, but somebody had clearly smoked recently and brought the smell in with them. When I looked at Luther, his eyes were bloodshot. I held up the hat, and said, “I have your hat.” Luther stood up, breathed heavily, and then sat back down, clearly overwhelmed. I tossed him the hat and said, “Good luck. Take care of Susan.” His head darted back to the television without another word. Stoned was no way to start out as a father.

Now I was relieved that Susan had the abortion. She knew she was doing what was best for her, Luther, and her unborn child. Having seen the situations that unwanted children can be born into, and the havoc that being brought up in a poor, neglectful, and/or abuse-ridden home can do to a child, I am certain that some people are better off not having been born. It hurts me to say it, but I think it’s true.

The gross reality of the abortion procedure leaves a lot for me to reconcile. Am I justifying a form of murder? Perhaps, but when exactly does life begin? Is it with the first mitotic cell division or the first heart beat? Is it the first lucid thought? A lot of unknowns. And what would happen if the child were to be born? Have I grown so self-absorbed to think that humans are so important that every single hint at a life should be preserved when there are millions of already born humans that don’t even get their basic needs met? More unknowns, though I’m inclined to answer yes to that last question.

I suppose it doesn’t really matter how I answer any question, because the reasons that a woman has to get an abortion are her own, and determining their “validity” is as difficult to ascertain as determining when life begins. The reality of the situation is that the procedure will continue to take place, whether legal or not, and to provide women with safe options is of the utmost importance.

My head was still spinning when I got on the bus to go home. It still is.

Friday, June 29, 2007

First Day At Clinicals

REFLECTING ON: First day of clinical rotation of first quarter at UCSF, written to fellow classmates...

Just got home a second ago and this is where I am at: I feel tired before I've even begun. Thoughts started percolating about this whole experience so I thought I'd share...please feel free to chime in and reflect too.

As the scrubs hit the laundry basket, the gargantuan-ness (I made that word up) of what I've/we've chosen to take on hit me like an anvil. Despite the fact that I got this week's "to do" lists almost done, I've got my PDA crammed with our schedule to keep me on point, I got books (and even feel like I really dig Patho), and maybe I've got some knowledge about some things in the past, really, when I stop to think about where I'm at right now, I have got no clue.

Clinicals really brought home the reality of this situation.

While on the oncology floor this morning, immune-compromised patients strolled by us, each with about fifteen IV bags filled with chemo, I became pretty damn humble. One patient shuffled on by with her nurse and managed to wave and smile at us. Yeah, I've got good intentions, but I felt like an impostor in my scrubs. You know, kinda like dress up or Halloween. No matter how I try to build myself up in my mind right now, somehow I cannot believe I'm going to be a nurse!

I also can't believe I'm seriously considering buying a fanny pack. Seriously. Though it's ridiculous, the whole fanny-pack thing is an appropriate metaphor in this whole MEPN situation. Two weeks ago, I wouldn't have ever thought that I would DREAM of buying a fanny-pack. I have never liked fanny packs. Even in the early eighties, when I was like five, and fanny packs were considered semi-socially acceptable, I thought fanny packs were silly. Now I think I need a fanny pack and what's worse: I want it to match my scrubs.

I left the comfort of my previous identity and hung it up on the coat rack as I walked into UCSF.

Yes, I know there's a learning curve. And yes I get that I'm really only expected to be a glorified volunteer in the beginning. But that somehow doesn't change the fact that I am really starting to realize the gravity of our work. It's simultaneously intimidating and awesome.

Some part of me keeps on reminding me that starting from scratch is good. You know, like doing pull ups or eating Brussel-sprouts. Builds character--or so I'm told.

I guess that's just it: I thought I was done with my character. I thought I knew who I was. I was competent at what I did--some might even say good. Now I know nothing. Now I am rebuilding my character, or more appropriately put, adding on to what I once thought was finished.

This will be good. Just not always so comfortable.

I am humbled and honored to be in this program with all of you. Truly.

Have a good weekend.