more letters on my business card

So last week I officially became a certified hospice nurse, I passed the Certified Hospice and Palliative Nurse exam (150 questions, 1 hour, 92% correct). It wasn't too hard...I studied for maybe a total of 8-10 hrs over a couple of weeks, just read the curriculum book and study questions and reviewed a bit with another hospice nurse who took the exam the same day. All this gets me is a few extra cents an hour and the right to add these letters, CHPN, after the RN on my name tag and business card. The main reason I took it is just because it says, "I care about what I do so I took some time to prove it."

In other business of dying news, I'm changing my position! At the end of the month, I will move into an RN float position and out of my current RN case manager position. I'm pretty excited about it. While my 1+ year as a case manager has been an invaluable experience, the thing it mostly taught me is that I enjoy the nursing part more than the manager part of that job.  Our patient load is exploding, which means hours of overtime and often unexpected events or phone calls leading to looooong days. I've worked a few weekend triage shifts, where I just see patients with emergent needs. I get to swoop in, meet the patient and family, assess the most urgent issues or problems, and attempt to provide a solution. So that's what I'll  be doing as a float nurse. No more pages, phone calls, re-certifications, discharges, care conferences, etc. Just see my assigned patients for the day, chart on 'em, ensure appropriate follow-up from the care team is in place, close the computer, and DONE. Sure, the OT is nice on the paycheck but it's just not worth sacrificing my nights and evenings to charting charting charting. Plus, I'm really looking forward to the variety and new challenges of this new position. I perversely enjoy the challenge of "difficult" patients or "interesting" family dynamics when I know that it's just for that one shift. Also, after a year or so of learning a new thing, I tend to get a bit squirrelly...I start thinking, okay, this stuff is no longer terrifying or overwhelming, what's NEXT? That's a pretty cool perk about my job, and nursing in general, is that there are so many different opportunities, positions, educational chances, etc, that's there's really no excuse for boredom or stagnation.

and then I almost died..

Ok, so this "headache plan" of mine... Hm. The verdict is still out. The diet itself is kind of a pain in the ass to follow...I'm having a really hard time eliminating onions, citrus (esp lemons and limes in my cooking!), yogurt, and aged cheeses. I mean, life without cheddar? Are you kidding me? I even sunk so low as to Google "substitute for parmesan" because God knows nothing livens up a salad, veggies, or pasta like a kick of parm. It may be that none of those things are be a "trigger" for me, but the migraine book guy advises to cut all possible triggers out of your diet before adding them back in slowly, and individually. Which of course makes a bit of sense...but has HE tried cooking without lemons, limes, onions, yogurt, feta, etc? Obviously he must enjoy a rather bland diet. Other sources I've read on tyramine in foods advise limiting quantities of those items to small daily doses. Which is sort of what I've been doing, since I cannot find things like onion-free salsa and I drank half a bottle of "citrus zest" flavored sparkling water before realizing what I'd done.

But the diet modifications are like a trip to Disneyland (or in my case, a yarn store) compared to the caffeine elimination. I thought I was ahead of the game, tapering off my coffee habit over the course of two weeks. I cut down from about 16 oz each morning (with the occasional tea or soda here or there) to about 6 oz per morning, and then...NOTHING. Yesterday, Day 1 of the Great Caffeine Withdrawal, went sort of okay. I felt icky and foggy in the morning, took three Aleve (yes three, yes I know what the label says, trust me I'm a nurse) and actually made it through the day. I was a bit irritable and drowsy and had a mild lurking headache but all in all, I thought, hey, not so bad! Until this morning. I woke up with a vague headache behind my right eye (yesterday it was my left eye), feeling a little foggy and muzzy. Had a cup of peppermint tea and three Aleve (stop judging), and went about my day. Only today, the headache and irritability only got worse and worse. I made it home by 1:30, had some lunch, and had to lay down for a nap. I woke a few hours later with the same headache but worse, tried to eat dinner, but nothing helped. Finally Matt convinced me to take an Imitrex and I even took a couple of Excedrin Migraine too. Obviously they helped because I'm sitting in front of a glaring computer screen typing somewhat coherently at the moment and not sobbing and moaning in a dark room.

So yeah. Caffeine Cold Turkey plan aborted. On to Plan B: tapering caffeine slowly. Tomorrow I will try to switch to tea and see how that goes. After all, I have an unopened box of PG Tips and it would be a royal shame to let that go to waste.

Oh my aching head.

I hate it when there's a long pause between blog posts on a blog that I read, and when a new post finally shows up, the blogger spends an inordinate amount of time making excuses and apologizing for the silence.  So, I'm not going to do that. I haven't blogged in a while. Now I'm back. Make of that what you will.

So I'm trying out this new migraine plan, based on this book by David Buccholz, Heal Your Headache: The 1-2-3 Plan for taking charge of the pain. I can't remember where I heard of this book, just that I kept coming across references to it on various headache sites and finally thought I'd see what all the fuss was about. Thankfully, there was a Kindle version available because I am both impatient and lazy.  Keep in mind that I am full of snark and skepticism, and am the first person to mock "self-help" books and whatever diet plan is the flavor of the month. But I also have chronic headaches and migraines, and it sure would be nice to not have them control my life anymore. So I read the book. And, despite being soap-boxy and arrogant and overbearing, it pretty much makes sense. The author explains the three steps to taking control of your headaches: Stop taking "quick-fix" abortive migraine meds that are causing rebound headaches, eliminate dietary triggers, then try a preventative medication to raise your migraine threshold. The premise, while the author doesn't delve too deeply into the physiologic explanation, does make sense: you can't control external headache triggers (stress, sleep, barometric pressure), you CAN control internal triggers, such as diet and caffeine. And triggers are cumulative, so while peanut butter may not give you a headache one day, on another day when other triggers have accumulated peanut butter will be enough to hit your threshold, and BOOM. Headache.

I'll give this plan a try, since it can't hurt, and maybe it will even help. The diet is kind of hard to stick to: no caffeine, no citrus or bananas, no hard/aged cheeses, among other things. Eventually I'll try to add things back in on a trial basis, since I can't fathom an existence without onions, garlic, yogurt, parmesan, or lemons. So far so good, but it's only been about a week. I'm down to about half a cup of coffee in the morning, and I plan to taper that to nothing by the end of the week. I haven't had any headaches but it's early days yet. I have "cheated" a bit, but in tiny amounts. Like tonight I had caesar dressing on my salad, which usually contains some "forbidden" ingredients: anchovies, lemon, parmesan.

I'll try to post updates with my progress and results on here. I'm having trouble finding recipes for this diet, so maybe I'll post some of my attempts to modify recipes to fit the diet on here.

Night nurse

I often tell myself, or others, in a (sort of ) joking manner, that "there are no emergencies in hospice." It helps me keep my perspective and maybe even stress levels under control. But that doesn't stop me from waking up in the middle of the night, with a sudden realization that I forgot to chart something. In the persistent, niggling way that only middle-of-the-night-lying-there-in-the-dark thoughts will do, this thought kept circling through my brain, kept me awake, and finally insisted that I get out of bed. I logged into my work laptop and sent the order: I had forgotten to change the patient's bath schedule from once weekly to twice weekly. Phew, now I could rest easily. No wait...since I'm right here in the front of the computer, I think I'll check on the status of the other patient I saw yesterday. Oh, that reminds me, I might as well submit that supply order request now so I don't forget later. Which leads us to here, with me typing a blog post at 0430 in the morning. While there might not be any "emergencies" in hospice, there's a different set of priorities that can take on the same significance. A bath is definitely never "STAT," but to the exhausted daughter at her father's bedside, knowing that someone is coming today to give her dad bath because he's now incontinent and needs much more frequent cleaning might be the only thing giving her a little relief or comfort. The added stress that I feel, while not emergency status, is that if I don't remember to change the bath schedule, it just won't get done. It doesn't just roll over onto the next shift like in the ICU, family member can't just put their call light on again or the computer doesn't pop up a little reminder to the next nurse. So that's what wakes me up at night.

Maybe my old night-shift schedule is too deeply ingrained in my brain. This used to be the time when I would toast some bread or get my yogurt out of the fridge, sit down in front of the computer, and finish up my charting or complete my nursing shift note, reviewing my shift and making sure I didn't forget anything.

So there you go...that's what goes on in the mind of a hospice nurse in the middle of the night.

What's in your car?

When my hospice nurse orientation finished and I was officially "set free" to drive the streets of King County visiting patients, I was given my "car kit." It consisted of nursing supplies in four large brown paper bags. No good drugs or anything like that, we're not allowed to carry narcotics in this state. But since I'm on the facility team and almost all my patients are living in facilities such as Assisted Living or Skilled Nursing facilities, I rarely if ever need to bring supplies to them. For several weeks these brown paper bags lived in the back of my car, with adult incontinence supplies embarrassingly peeking from the top of them. Finally, a couple of months into the job, I got fed up enough with shifting them around to accommodate Costco trips to actually organize them. I bought some pretty-colored storage bins from Target and sat myself on the floor, surrounded by nursing supplies, and inventoried. I still don't actually need most of it, but at least now I know what I have:

• Adult diapers, large and extra large
• Bath wipes, x 2
• Dressing supplies, including gauze, abd pads, tegaderms, and even my very own suture removal kit and two pairs of bandage scissors
• Isolation gown, goggles, and mask
• Lotsa rubber gloves. Can never have too many of those
• Foley catheters, urimeters, leg bags, a urinal
  
• Various creams, lotions, skin care ephemera
• Two sizes of emesis basins
• thermometers
• A sphygmomenometer! And a stethoscope! Apparently I didn't really need to be using the set I'd purchased seven years ago for nursing school.
  
• Lab collection supplies

I feel a bit better now actually knowing what I'm carrying around in my car, should any of my patients need something at the spur of the moment. Typically I can order supplies for them and bring them on the next visit, but there's always the family who waits till the last minute..."Hey, you don't have any extra diapers on ya, do you ?"
"As a matter of fact, I do! Let me just run to my car..." Thusly averting a messy situation.

And also, when your little puddle-drinking poo-sniffing dachshund starts suffering from diarrhea which turns bloody, it sure was convenient to have rubber gloves and a stool specimen cup laying around with which to take a sample to his vet. I don't think that was the intended purpose of the "car kit," but hey, now the little guy is started on his course of Flagyl and hopefully he'll be back to his energetic puddle-drinking poo-sniffing self soon.

So, to answer your question, yes, those are adult diapers in my car. What's in your trunk?

Nursing from the streets

So here I am, a full-fledged Hospice Case Manager Nurse. A month out of orientation, on my own, managing my own case load, and I can still safely say that I pretty much love this job. I realized that I loved it on Tuesday, after a grumpy, rainy, 45-minute drive to Newcastle. I may be a day-walker now, a recovering night-shifter, but I have not and will never quite get used to having to get up early in the morning. So I grumbled and scowled my way through rush hour traffic, gripping my coffee, trying to hear the bossy GPS directions over NPR, and squinting through the blustery, gray weather. After two wrong turns and a U-turn I finally arrived at my destination, and found my way to my new patient's front door. I met the patient and his wife, answered their questions and explained how our hospice services could help them. Yes, they could call and speak to a nurse 24 hours a day if they needed to. No, we would do everything we can to keep him from having to go to the hospital ever again. Yes, if he wants to eat apple pie, let him eat apple pie (in small bites and sitting straight up, of course). The patient's wife sighed deeply and relaxed back into her chair, years faded from her 84-year-old face, and she finally smiled at me. "Thank you," she whispered. "Thank you for what you do."

So I got back in my car, and steeled myself for a 30-minute drive on the highways through the sheets of rain to Issaquah. But my grumpy mood was gone, and I didn't mind the drive.

The view from the other side

I'm five weeks into this new hospice gig that I'm doing, and although I'm still on orientation, I am here to report that I'm pretty sure I really love it. I almost admit that hesitantly, because I'm doing things that I always swore I'd hate, things I scoffed at, things I mocked and derided others for doing. Okay, maybe that's a little harsh, but you get the picture. Those things include: sleeping during the night, waking up early each morning, working five days a week, having to do errands and shopping on the weekends...I could go on. Because to be honest, I LOVED night shift. I loved only working three days a week, and I was giddy over being to go shopping or do errands in the middle of the week. The middle of the night, even. I could avoid traffic and most of all, CROWDS. I did the nocturnal thing really well, and the few early mornings I've been forced to contend with have left me grumbly, crabby, and generally miserable. To be fair, I probably induced the same feelings in those unfortunate enough to be around me in the early mornings.

Well, nothing drastic changed...I'm still not a morning person, and given my druthers (what the heck are druthers, and why is someone giving them to me? Like a present?) I'd be staying up late and sleeping in till past noon. Oh well. But I've adjusted to this new schedule, in part because I'm a creature of habit...I ADORE habit. And routine. It's just so comforting. So the regularity of this new schedule fits me well. And I guess I'll give Matt a little credit...since I've moved in with him, my old night schedule got progressively more annoying and inconvenient. I was only home with him a few evenings a week for dinner, and those nights weren't the same week to week, and it was frustrating. Now I get to be home every night, and every weekend, and it turns out that five-day-a-week things isn't so bad when the shifts are only eight hours long, leaving me with plenty of time after work to walk the dogs, cook an Indian feast, plant some vegetables, whatever strikes my fancy. I'm not advocating either schedule/lifestyle over another, I'm just saying you gotta find what works for you at the right time for you.

At this point, you'd be forgiven for thinking that I changed jobs simply due to shift and schedule concerns, and while that is a huge piece of my overall contentedness, the nursing aspect of what I'm now doing versus what I was doing is the main thing. But that's a big topic for another post, and right now it's easier to write about and be silly about simple things like sleep schedules.

I'm sort of concerned that I need to rename the blog, or start a new one...since I'm no longer literally "knitting in the dark." Now it's more like "driving during the day" but that isn't too catchy...I'll have to ponder that.