TagNurse Practitioner

Major John P. Pryor, M.D., U.S. Army, Killed in Iraq

I was wide awake this morning at 0230. As is normal, I rolled over and blindly reached for my iPhone, figuring that if I couldn’t sleep, I would at least make good use of my sleeplessness and catch up on my RSS feed reading.

The moment I read the post title, which simply said something about a New Jersey trauma surgeon dying in Iraq, I knew I would be in mourning when I was fully awake. I hadn’t even read his name and my intuition was going off.

From HUP’s website:

Dr. Pryor is a trauma-critical care surgeon at the University of Pennsylvania in Philadelphia. He completed medical school and general surgery training at the University of Buffalo, in Buffalo New York, and completed fellowship training in trauma surgery and critical care at the University of Pennsylvania. He is currently the Trauma Program Director for the Trauma Center at Penn, and the Director of the Office of Life Support education for the Division of Trauma. Dr. Pryor is also a Major in the United States Army Reserve Medical Corps. He served two active duty tours as the trauma surgeon for the 344th Combat Support Hospital in Abu Ghraib Iraq during 2006, and then with the 1st Forward Surgical Team (FST), in 2008.

Pryor-1
John P. Pryor, M.D.
Trauma and Surgical Critical Care

Major John P. Pryor, M.D. was a prominent trauma surgeon at the Hospital of the University of Pennsylvania. MAJ Pryor, while serving in Iraq, died on Christmas Day during a mortar attack.

Dr. Pryor, I would realize later, was a guest lecturer for my Acute Care NP program, and spent time with us in the lab teaching central lines and chest tubes. It was unnerving to find photos of Dr. Pryor among those I took during my time at Penn, finally understanding why the post title, read in the middle of the night, struck a chord.

Lab 2003 001
Invasive Procedure Lab with Dr. Pryor
UPenn, Adult Acute Care NP class of 2004

Lab 2003 020-1
Dr. Pryor (left)
Me (center) with hands raised
after successful chest tube placement


Although I did not know Dr. Pryor personally, his confidence in the classroom and his approachability made the sections he taught some of my favorites. His death is a loss for the students he taught, the patients he treated, the staff he worked with, and the soldiers he served with.

My thoughts go out to his family, Army unit and professional colleagues.
Story at MSNBC.com here.
Story at MyFox Philadelphia with video here.

Grand Rounds 4.48 at Six Until Me

For those of you who are unfamiliar with the blog Six Until Me, you should take the time to check it out.  Not only is the author, Kerri, a gifted writer, she brings something a bit unique to the world of blogging, a patient’s perspective on diabetes.

I have not one, but two friends who use insulin pumps.  One just happens to be a newly graduated pharmacist.  I thought both them and Kerri yesterday whilst discussing back pain with a patient who also uses a pump.  It constantly amazes me how other bits and pieces of my life, like watching J9 (the new pharmacist!) change her pump and patiently teach me while she did it, roll into my world as a nurse and as an NP.  Because I could talk to this patient about her pump, she felt more comfortable with me helping her with her other medical problems.  Instant credibility.

So, Kerri, thanks for your blog and great job with hosting Grand Rounds this week and including me!

J9—thanks for teaching me.  I miss you btw.

UPDATE:  My world constantly amazes me.  Just saw another young patient on a pump, talked to her about online resources and gave her the address to Six Until Me.  How cool is that!

NP vs PA, what is the difference?

What is the difference between a PA (physician’s assistant) and a NP (nurse practitioner)?

I get this question A LOT. Surprisingly enough, it is not just from those outside of the healthcare realm, it comes from my peers as well.

As I was looking for some sassy graphic to go with a post about my first few days in my role as an emergency room NP, I came across this link comparing not just NPs, PAs, but Physicians as well. Although I think a lot could be added to it, I wanted to get it posted here so I didn’t lose the link.

As I need to get in the shower for my 3rd shift at my new job (wooHoo!), I will leave it at this, and throw a gigantic “you are it!” to anyone that has better links. Every time I say I am going to look something up, or post something later it doesn’t happen…..so I won’t say it!

Anyone have any vitamin C? Don’t think hand washing is gonna keep me from catching what my pathetic immune system has been exposed to this week.

Tattoos, Preconceived Notions and Cultural Diversity

About a year ago, I had a poly-trauma patient (MVC) who happened to be a tattoo artist by trade. As the stereotype goes, this guy was a walking advertisement for his craft. He happened to be in his mid twenties and co-owner of a very successful studio.

My Artwork

As fate would have it, this patient had a mother who did not leave his side and after a few days the uncomfortable patient and his hovering mother began to wear on the nursing staff. The nurse who had been assigned to him for the past three days or so was in her mid 50s and bombarded me with the examples of why this patient was being so difficult. (picture a very annoyed, frazzled nurse who had a heavy patient assignment)

Her biggest bitch? They were putting * gasp * Tattoo Goo on his abrasions!

“Emily, I need you to go in and explain to them why they aren’t allowed to use that stuff!”

I stood there, shook my head a bit, and told the nurse I would talk to the patient. In grateful relief she strode away to check on her little old ladies with hip fractures as I went in to “deal” with this annoyingly needy trauma patient.

As I entered the semi-private room, located at the very end of the hall, I was immediately struck by, not the patient, but his demented elderly room mate who was loud. The patient’s mother was at his side hovering as mother’s do, when they know their child is hurting but there is little they are able to do to help.

After saying hello to both of them, and introducing myself, I addressed the mother first. My initial question? Who did your tattoo? This woman had obviously been through a lot over the past week or so, but took pride in her appearance. She accentuated her ample bosom with her choice of clothing which in turn displayed a gorgeous tattoo on the top of her left breast. After hearing my question, she smiled from ear to ear and began talking about how her son was the artist. The pride in her voice was unmistakable.

Small talk ensued about his tattoos, his shop, my tattoos, and eventually his car accident.

It took all of about 15 minutes for me to figure out that he wasn’t sleeping, his pain was not quite under control, he had no appetite so he wasn’t eating or drinking in adequate amounts, he didn’t remember when he last had a bowel movement and he was somewhat concerned with all the abrasions over his tattoos.

Last I checked, these were all NURSING DIAGNOSES. Why did this take a phone call to the Nurse Practitioner to figure out?

Although his nurse was one of our more experienced on staff, she walked into the room with a whole boat load of preconceived notions about the patient and his mother. Both were very tattooed, spoke freely about “partying” together and even being at a coke party a few days before the accident. The nurse couldn’t get past the way the mother was dressed or her seemingly overly interested body language/doting towards her son.

This guy was broken from head to toe. His injuries would have warranted a lot of narcotics in any other patient, but the perception of “drug abuse” led the nurse to under-medicate him. This was her first mistake based on judgmental notions.

Her second mistake? Not taking the time to figure out what could be done with the noisy room mate. She didn’t explain to the family that he was being transferred out of the hospital that morning. After letting the two of them know this small piece of information, the relief was almost palpable.

Mistake number three: not telling the family to bring him anything he wanted to eat. They simply hadn’t been told that this was an option. This not only made him more interested in food, but gave his mother something productive to do so she felt like she was helping.

More mistakes? Yup. Number four: the nurse didn’t take the time to explain that his irritability was not only related to his pain, and lack of sleep, but also because he hadn’t “taken a shit” (my words exactly) in days. Oh, yeah, and the narcotics are going to stop you up as is immobility! By gaining his trust in the first few minutes of conversation, he eventually admitted that getting on a bedpan and needing someone else to wipe his ass was humiliating. Duh! He is a mid-twentys, otherwise healthy guy. It is humiliating for anyone, but especially men his age.

I talked him into a suppository.

The Tattoo Goo? For those of you unfamiliar with the stuff, I wish I could prescribe it to all my trauma patients sporting superficial abrasions. For those of you who have never gotten one, or have never seen one being done, tattoos are nothing but abrasions with color injected into them. Tattoo Goo is a vitamin rich salve that speeds tattoo healing and in the process helps to minimize scarring.

Tattoo Goo Tin .75 Oz-1

Tattoo Goo ‘The Original’ INGREDIENTS:

Olive Oil, Beeswax, Cocoa Butter, Wheat Germ oil, Tocopheryl Acetate, Lavender Oil, Sunflower Oil, Rosemary Extract,, D&C Green 6

By judging this patient by his age and appearance, the nurse not only gave SHITTY nursing care, but missed an opportunity to learn about the craft of an amazing artist and business owner.

Such a shame.

Epilogue:



After writing very specific pain medication orders (meds around the clock), diet orders and abrasion care orders (ok to use Tattoo Goo) I took a moment to reeducate the nurse in a very tactful manner. The next morning, upon entering the patient’s quiet room (I had requested that he be left without a room mate if bed assignments allowed) I was greeted with smiles from a well rested mom and patient, and was told how right I was about taking a shit! He felt much better and even ate all his hospital food breakfast.

I am happy to report that the patient was discharged 36 hours later which was days earlier than predicted.

Moral of the Story:

Over the years I have heard horrible “tooth to tattoo ratio” comments during rounds and have witnessed the unnecessary defacement of tattoos in the surgical arena. ie: Belly tattoos which were STAPLED closed off centered ON PURPOSE. The reason? “That’s a stupid place for a tattoo anyways,” per the offending surgeon.

We need to realize that tattoos are artwork and a very personal form of self expression. They are an investment just as any other piece of art that hangs on a wall or sits on a shelf. They are usually one of a kind and have deep religious, spiritual and personal meaning. Just because someone has “fuck you” tattooed to their knee caps doesn’t make them a horrible person who deserves shitty care or attitude.

Cultural diversity doesn’t just refer to different shades of skin color, religious beliefs or languages spoken. It also refers to differences in life style choices which may not be something we necessarily agree with.

Tattoo4

If I am your patient someday, take care of my tattoos, don’t pray over my bed and don’t be offended if I come out of anesthesia cussing like a sailor. I may be an Ivy League educated white girl from the mid-west, but I am also a tattooed atheist who believes in freedom of choice in any manner of contexts.

Speaking to the Masses

After being away for Paramedic School, I returned home to the pile of mail I was dreading. Fortunately, in it was the information on the AAOS conference in February. Interesting to see my name in the program as a speaker. Guess I grew up at some point and didn’t realize it.

By the way…anyone know anything about pelvic fractures????? j/k

Aaos Program

Always a Nurse: Beach First Aid in Hawaii

Yesterday while at Sharks’ Cove, I wandered up to the car to get my towel and rinse off by myself. Three girls hobbled by, two helping the third who was limping in the middle. They were all islanders, 13 and 14 years old. A second girl had blood all over her thigh. I dug the first aid kit out of the dive bag. I was lucky that Patrick had mentioned it’s existence earlier. I bought it for him as a Christmas gift a few years ago.



After pulling it out, I threw my cover-up on, grabbed a towel and walked over to where they were rinsing off in fresh water. I introduced myself, told them who I was and offered to help. They were actually being fairly calm and supporting each other in ways only teenage girls can. I looked at their wounds and offered to patch them up.



It is amazing, but not surprising what ocean waves and volcanic rock can do.

The one girl had a gash about 5 cm long down her thigh, the other, a deep gash in the callous of her heel. Butterfly Band-Aids to the thigh, regular ones to the heel after washing them both out with the bottled water I had. Abby, Gabby, and Molly were their names. They all swore they thought I was only 21 years old. They were astonished when I told them I was 31. It made me smile, but be glad I was no longer that age. The other interesting thing was that I introduced myself as a Nurse, not as a Nurse Practitioner. It just seemed to require less explanation.



The girl with the thigh wound really needed some stitches. She had so little body fat that it went deep enough to hit fascia but was deceiving because of the lack of obvious subcutaneous layer. It was gaped open about a centimeter and will leave a bad scar if her father, who showed up a few minutes later, decided not to take her in because of lack of insurance.



When finished explaining to the dad what I thought, and giving my infection teaching in a subtle way, they thanked me and hobbled off. While throwing out the bandage wrappers and folding up the towel, an older islander woman, who would be called abuelita in Mexico, wandered over in her very large floral print dress and said, “That was very nice of you to do.”



Apparently she had been watching me. It is funny how much helping like that just becomes an extension of who I am, even when I least expect it.

Flight Nurse Emily

As of 6 Aug 06 I am Flight Nurse Emily. *the crowd goes wild*

Actually, I am feeling quite reserved about the entire thing for some strange reason. Everything I have done since 1997 has been preparing me to get to this point. My last flight as an Army Medic was the summer of 1999. Can that really be 7 years ago? Damn…

I have blown the dust off of my old paramedic books and my acute care cheat cards. I haven’t had the heart to pull out my mini-flashlight and other gadgets. I am to afraid of getting so excited I will just begin twitching uncontrollably.

So, before I leave my current role as an Ortho-Trauma NP, I want to finish a few miscellaneous projects and I need to clean out my desk.

The most interesting thing about leaving, however, has been the reaction people give me when I tell them.

“I am leaving on August 6th.”

A look of confusion, “What do you mean leaving?”

My shoulders shrug. “Well, I took a position at AeroMed as a Flight Nurse.”

“OH MY GOD! That is great!”

Hmmmmm. Not quite the reaction I expected. I thought I would get a bit a disappointment and maybe some, “oh what will we do without you?” Definitely not the case. I finally realized it is because of two things:

1) Being a flight nurse is just short of being a Blue Angels pilot in the coolness factor

2) It fits me so much that it just makes sense to people

An eerie sense of relief and calmness has settled over me. I just didn’t realize how much stress being in this position, because I knew it wasn’t me, had accumulated.

So, although I will be giving up my prescriptive authority and NP pay (about 13K and 4 weeks of annual vacation), I will be given a much more broad scope of practice.

Back to Mach 2 with my hair on fire….

It is about time.

Great Week

Never in my entire life have I had not only things go well for me, but for everyone around me as well.

Kevin found out he got into CRNA school…at UPenn no less.

David got offered a position at a company making a lot more than he was at his old company…and will be getting the BlackBerry, Laptop AND company car!

Found out that Mark will be getting promoted here SOON! The most deserved promotion ever. All I have to say: “it is about fuckin’ time.”

Even closer to home:

Patrick passed the next step to becoming a federal officer. This most recent step was the ever nerve wracking polygraph which I have had friends say is the worst thing they have ever gone through. I am so proud that he has stuck with this long drawn out process. All he has left is the background check and the wait to see if he gets a good offer.

Oh, and last but not least, I had my second interview for my flight nurse position on Friday, which went well…

…they offered me the job over the phone 15 minutes after I left the hanger!!!!!!!!!!!!!!!!!!!!! Okay, so I just realized that the first time I posted about this job was in November…..geesh.

Now when people ask the question, “Are you the flight nurse?” they will actually be right.

Okay, short but very exciting post. Thanks everyone for your words of encouragement. it is good to know you all are there! Just wish like hell we could all share a celebratory cocktail.

I will give you all a bit more detail about the interview tomorrow. I am going to bed!

Nite.

Credentials

You know, I almost didn’t add that gaudy list of credentials to the post about my issues with the Army Reserves. All of my professional accomplishments have been influenced by my Army experiences in a very positive way and I wanted to give credit where credit is due.

It is funny. When I was at UPenn, I used to laugh at the pretentiousness of the presenters when their title screen had all of their e-i-e-i-o behind their name. I am almost embarrassed about mine to the point that I rarely use it. I am very satisfied with using Emily, NP and leaving it at that.

For those of you who have considered taking a certification exam–please do. The tests are challenging, but there is a sense of pride that goes with obtaining them. It is outside validation that you do have expertise in your chosen field of nursing. Nursing is a profession, not a job. We should strive to always get better, learn more, and advance our specialties.

AeroMed Interview

The good news is that I survived the interview. The bad news is that they gave me a written exam with a SHIT load of cardiology and pediatrics on it.

Have I expressed my deep and unmoving dislike of cardiology??? Kiddos? No problems. I suck at the pedi portion, but that is just lack of exposure. Cardiology I have a difficult time getting. Guess I will be getting over that fast if they offer the position to me.

Hey, is it a good sign when the Chief Nurse stops taking notes on those required HR questions to just sit and listen to you?

Is it good when she makes a point of taking you into the COO/Medical Directors office to make introductions and he shuts the door to do an impromptu interview?

The kicker? He asked why they hadn’t heard from me earlier.

Keep those fingers, eyes, and toes crossed Mark!