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May 30, 2008

Differences In Practice

We are in Newport, Rhode Island, for the weekend. Jess worked last night, and after she slept a few hours, we boarded up and headed out. Newport is less than two hours away from New Haven, so it's a good drive. We are staying in a very nice little inn. It's not really a B&B, or even a legitimate inn; we think the building itself is a number of apartments, but when I called one of the B&Bs in town, they handed off the phone to another lady, who was looking for some boarders. Still, it's great, its $150 a night, and we can keep Zuri here. Even if we'd stayed at the cheap Motel 6, it would have been $105 a night, plus a $10-20 dog fee, and we would have had to pay $30 for doggy day care for Zuri. So this works.

At any rate, this is a nice town. It has a long history of really rich schmucks building ji-normous mansions for "summer retreats," so everywhere you look, there's some massive relic. The downtown area is nice, though, lots of interesting architecture, wood building dating back to the 1700s. We came in mid-afternoon, so we haven't seen it all, but it's promising.

New Haven is actually a great location to travel to in New England. We have close access to Rhode Island, New York City, Boston, and other areas, and even going up to Maine isn't that far. I hadn't ever imagined that I'd be living somewhere that was only a couple of hours from Newport or NYC. It hasn't really sunk in yet (although it's starting to).

We're both quite happy to be done with the week. For one thing, we finally got paid today, and how great that was. It was pretty awesome to see how well we're getting paid, not to mention the fact that we're not even paying rent or utilities here. Also, it's been a busy week. Jess has been taking care of the sickest kid on the unit, pronounced so by surgeons there, and was even doubled with that patient. She's been pretty worn out by those nights. I'm proud of her.

My last evening, when I wrote the previous entry, went sour about four hours after I'd finished with the entry. I was pretty bored all evening; I even wrote all my notes and had all my charting completely up to date. Good thing, because at four, after being turned, my non-intubated patient suddenly decompensated and quickly went into full-blown pulmonary edema, complete with pink froth and everything. This is where I experienced a sharp departure in the way things are done at the Y and how they were done in the Big D.

First and worst, I had to page the doctor. There are two teams of doctors on the unit, but don't ask me where they are most of the time, sitting in the cafeteria for all I know. So, I paged the doc (an intern--don't get me started on that), and he returned the call quickly enough. I explained that my repeatedly intubated CHF patient had O2 sats in the low 70s and that he should probably come and check it out. Apparently, I wasn't clear enough, or I didn't sound urgent enough. He ambled in fifteen minutes and two pages later, after my patient had gone from comfortable on a simple facemask to barely conscious on 100% O2 through a non-rebreather. Yet he made no decision, instead allowing the resident who actually followed him in to order Lasix, which did nothing. The resident decided then, without further interventions, that intubation was needed.

Granted, intubation was probably inevitable. Still, these doctors should have known that the man's kidneys were useless, and that what had worked for him previously was dobutamine. In hindsight, I wish I'd remembered that I'd discussed his recent dobutamine drip during my report with the day nurse and had brought it up at this point; on the other hand, it's not my job, it the doctor's job to know what has been working medically with patients like this.

At any rate, while nothing else went wrong at this point, it was completely different than what I'd always done up to that point. At the Big D, I'd be busy getting my sedation and code drugs together, as the respiratory therapists and unit doctors prepared to intubate. So, I'm asking the doctors (yes, the idiot intern and his resident friend) what they wanted for intubation, only to get a scornful look. These doctors don't intubate, as it turns out, nor do the RTs. All intubations are done by anesthesia, all of them (maybe not in a code?). So, another five to ten minutes pass, and finally the anesthesia team shows up. Wanting to make myself useful, I positioned myself at the head of the bed with my saline, ready to push drugs. No, not the thing to do, as that only brought me another scornful look.

So, in the end, I just stood aside while it all happened. Even the RT did very little. Granted, it turned out to be a very calm, almost serene intubation, but I always liked the adrenaline rush of a good intubation. The unit team, meanwhile, barely was even aware of the intubation, they sat outside the room on the computer, looking perhaps at CNN, something that was more interesting than patient care. When the paralytic the anesthesiologist used for intubation wore off and the patient's respiratory rate was 45 times a minute, I really had a hard time getting them to write orders for versed and propofol. In fact, I only got a verbal order out of them, and had to get the oncoming day doctors to actually write the order. Needless to say, I wasn't too impressed with this team, as in, what Caribbean island did you get your medical degree? WTH?

Anyhow, I left the room, the charting, everything, a monster mess. I tried to get it all together, but this happened right at a quarter after six, and I couldn't finish everything. I probably didn't make good friends with the oncoming day nurse. All in a day's work, I guess...

Anyhow, it's just nice to have it over, to be in a different place, even different state. Really, the nice thing about traveling is even when you find yourself in a big cluster, it's only a matter of time (thirteen weeks or less) until it's all over and you walk out of the place free and clear. Unless you get fired, then there's even less time.

Not that I want to get fired. No, I hope that doesn't happen.

Until next time, be safe.

May 28, 2008

Three Weeks Down...

It's crazy. It feels like we just started (which I guess we did), and yet we are already three weeks into our 13-week contract. That means only two and a half months remain before we either re-sign here at the Y or go to another contract. I remember how fast the last two months at Big D went by, and I can imagine that these next ten weeks aren't going to last long. We're already having to think about where we want to be by early August, and even in January (we're hoping for Phoenix for that time of the year). I guess that is part of the job, continuously preparing yourself for the next stop.

I've spent the last week taking care of stable doubles, which for non-nurses means two patients who are stable for the most part. I've kept hopping, if nothing else because of busy work. I've already had several alcoholics, reminds me of the Big D and my typical patients there. I've had the crazies trying to get bed, the big folks cyring in the middle of the night because they're starving. Yeah, it's like being at home.

Last night, though, I finally had some actual sick patients. I even had a patient on a ventilator, something different than what I'm used to. Same tonight, I can't believe they'd let me have two vented patients in a row. Thing is, here they don't like to give sedation to their vented patients, which just makes me cringe. So I maxed out my PRN meds last night, and tonight I started my patient on Propofol, the nectar of the gods. They're a little more comfortable thanks to my nursing concerns.

I'm staying surprisingly busy these nights, each night steady all the way to the end (with the exception of tonight, of course), even with fairly simple patients. I think the real issue is supplies, as I have said before; not knowing where things are can slow me down tremendously. Also, procedures are different here, and I have to approach them more slowly. Finally, there is no IV team, so I find myself spending a lot of time practicing putting in IVs, which I'm terrible at.

Jess is having her issues as well, in particular that she feels that she is very dependent on her coworkers. I have to convince her that it's not a bad thing to have to ask a lot of questions, especially with a single eight-hour orientation shift to prepare us for our units. She's doing fine, though.

Our two night trip to Rhode Island is coming up quickly (this Friday). I'm finishing my 5th shift in a row tonight, then Friday we head to the smallest state. We'll spend two nights in Newport, which from all descriptions is a great little city. Everyone seems to have something good to say about it. We're pretty cheap, though, since we've yet to receive our first paycheck, so it's looking like we'll be camped out at the HoJo or maybe Hotel 6. Even those places are more than $100 a night. B&Bs are in the $200 and greater range, especially those that allow dogs.

Another cool trip is in early June. I've joined a Meetup group for photographers, and a ton of people (photographers and their families) are meeting in Mystic, CT, for a big shoot. These meetup groups are great ways to meet people in the area. That will be a lot of fun, I think.

Until next time, be safe.

May 25, 2008

In The Numbers

So, I've finished my first week off of orientation. For the most part, it's been fine. I haven't wiped out anyone, and there haven't been any bloopers or blunders yet. Although during all three shifts, I felt as though I were completely discombobulated and rushing around like my head was cut off, looking back it wasn't all that bad.

Probably the most difficult issues I've had to deal with was finding stuff. This might seem like a minor detail, but it's huge, really. Patient care is often the same no matter where you are; assessments, med administration, all that jazz is pretty much going to be similar regardless of the unit. However, when you can't find the most basic supplies to do the most basic procedures, it puts you back considerably in time.

Paper charting is also difficult. I'm getting the hang of it, but frequently someone comes up and points out that I've not been charting an entire section, or mischarting. Really, paper charting cuts down on the amount of charting to be done; computer charting allows much more anal charting. My hand hurts after writing a bunch of pointless, never-to-be-read nursing notes by hand, though.

The folks on my unit have been particularly helpful. I haven't felt isolated or left to myself, as I've always had people around me who are willing to assist. It's been great. I haven't met any younger people to hang out with, not that I'm really expecting to. Travelers don't often become particularly good friends with staff nurses, it seems, if only because of the short time that they will be spending on the unit. Still there are some cool people, who have offered up advice on where to go and what to do in this area.

Speaking of this area, Jess and I took our first day trip. Some friends of mine was in NYC for the week, so we went to see them. We were pretty excited to go to NYC, but it started raining as soon as we arrived. We did our best to enjoy the day, even though it was pouring until around 5 pm. We ate some excellent Indian food at a little cafe, we dunked through the rain to a few different bars and coffee shops. We sat and people-watched in Grand Central Station. Eventually, the rain stopped and we walked through Times Sqare down to Penn Station and Madison Square Gardens. I didn't manage to meet up with my friends due to complicated circumstances conspiring against that, but it was still a good trip. Even better, it only took an hour and forty-five minutes by train.

I've also gotten some fishing in. I had to go down into the New Haven ghetto (yes, it certainly exists) to find a bait shop that is open, but then I was able to fish off a small pier for free. I managed to catch a 12-inch striped bass, which is less than half the size they allow you to keep (I kept it anyhow, since it was my first fish up here; I tried to eat it, but that went badly). I should get in some more fishing later this next week.

This morning, I'll get some sleep after I get off of work, then Jess and I are touring the area around New Haven. We are planning on getting lunch at a nice place, then maybe going on a wine tour. We have most of next weekend off, so we are planning on visiting Rhode Island. That will be a great trip. Even better, we'll get our first paycheck in a month and a half on the 30th. That will be superb (it's a little tight right now).

May 19, 2008

Our First Week

Our first week was pretty uninteresting, being mostly packed with orientation events.

We had Sunday off, which we spent checking out the New Haven area, visiting the Yale campus, that sort of thing. We hadn't moved into our apartment yet; due to a housing issue, the apartment wouldn't be ready until that following Friday. In the meantime, we were put up in a first-class hotel suite, complete with a huge flat-screen TV and a full kitchen.

For my first piece of advice to potential and practicing travel nurses, always tell everyone who asks (the travel agency, your recruiter, any housing folks) that your dog weighs under 50 pounds, no matter how much they weigh. Obviously, if you have a 150-pound dog, you may want to consider a smaller dog, because you won't get away with it. Our dog, Zuri, weighs somewhere between 50 and 60 pounds. Unfortunately, this was over the 50 pound arbitrary weight limit set by the apartment. It doesn't make any sense; after all, a 5-lb mini turd-dog can shred furniture and excrete an apartment to a premature remodeling just as fast as a 55-lb dog. Anyhow, Jess had mentioned Zuri's weight issue to our recruiter, and the apartment complex they normally put travelers in was putting up a fuss about her weight. So, Zuri went on a Photoshop diet; I changed her weight on her last vet form to 48.5 from 68.5 (which wasn't accurate anyhow), faxed the form to our recruiter, and suddenly we had an apartment waiting.

My second piece of advice is that your recruiter is the single most important decision you'll make as a traveler. If you have a good one, things will get done. If you have a bad one, they won't. If you have a great one, then everything will get done almost in miraculous form. Your choice in recruiter is more important than the company your choose to go with. If you are looking for a recruiter, I would definitely recommend ours, Dee Leon with Crosscountry. Just tell her we sent you over.

Anyhow, we started our orientation that Monday. It was an excruciating experience. Corporate hospitals literally can talk about how great they are for days on end. They brought in vice presidents to talk about the "Y Way"; they had three hour classes about diversity, customer service, all that needless junk. My favorite part was a horrifying video about being a customer service star. Essentially, they showed some poor Downs kid working as a bagger at a grocery store, who through impossibly PC mumbo-jumbo pleases all the customers and brings in tons of happy business. In other words, when it comes to customer service, if the retard can do it, so can you!

So, we endured three and a half 8-hour days of hospital orientation before we even set foot on the unit. Jess and I tossed down $600 for three months of parking, which fortunately will be reimbursed. I learned an archaic computer system that will be replaced in two weeks. Yet, everytime I started to grumble, I remembered the loads of money I was being paid to do it, and that I hadn't had a paycheck since early April, and it all seemed better.

Finally, I found myself on the unit. It turns out to be a great unit; the people seem nice for the most part, and helpful as well. The rooms are big, and it seems quite modern. Of course, having spent the first three years of my nursing career in a single place, suddenly being outside of my known territory (in terms of knowing where supplies and equipment were, the codes of the many locks and safeguards, even where a bathroom was) shocked me a little. Probably the most immediate issue was the fact that this particular unit (and hospital) have paper charting, where I was used to computer charting. While there seems to be considerably less charting with paper charting, it isn't nearly as quick and easy to do as computer charting. A big difference was that there was only one assessment area for the full day, rather than for each four hours. Any changes simply were added to previous notations. That was a bizarre concept for me to grasp.

Anyhow, I only ended up with around 12 hours of orientation before I started working. I had a full 8-hour day shift where I figured out a lot of the protocols and ways that things were done on the unit. By Sunday night, though, I was in the numbers and working independently, although I had a designated helper should I need assistance. Having only a day of orientation felt a little alarming, but It seems like everyone is helpful enough on the unit that I shouldn't have too much trouble.

Sunday night was interesting, but that is another post. I have to hit the sack in order to get up in the morning and go to NYC (the real reason we're up here in New England, to check out all these great places).

Who Am I, And What Is Travel Nursing?

I guess I should introduce myself. I'm Aaron. I've been a MICU (Medical Intensive Care Unit) nurse since the start of 2005. I became this after graduating from a previous undergraduate program with bachelors in biology, which yielded squat as far as jobs go. So, I backpacked Europe and Chile, did poorly paid and relatively horrible jobs for a few years, and ended up going through an accelerated, second-bachelors nursing program at Duke University. In the end, I ended up with the same education as nearly every other nurse out there (including associates degrees) except with a much larger student loan load than most others. At any rate, I landed in a MICU.

Who am I? Well, I love travel and photography, and I run a website that blends both. My escape plan from nursing (you need one of those; if you don't have one, get one) is to invest in a microbrewery and run it. I've been married since March of 2007. That's me in a nutshell.

Travel nursing is fairly easy to describe. For those unaware of the medical profession, there is a massive nursing shortage which will only get worse in the next decade as an entire generation of nurses retires. As a splendid side effect of this, hospitals need to fill short-term holes in their staffing. Therefore, they are willing to pay large sums of money to people willing to sign an average of 13 weeks in a contract. Some contracts are shorter, some longer, most are 13 weeks. This means for 13 weeks, a nurse will work in a unit or floor or whatever. They will actually be employed by an agency rather than the facility, and will usually have their housing paid for. Other financial treats include travel expenses, insurance stipends, housing stipends when travelers share apartments (such as my wife and I--we get free housing and a big chunk of change), and much more. The offside is that you have to be willing to give up the security of a normal job, be willing to step into the role of a nurse with as little as a single day of orientation, and be able to move around alot. Which for my wife and I hasn't been a problem yet.

There will be much more of a description of our own definition of travel nurses to follow. I'll put up good links as well.

Start Of A New Life

Becoming a travel nurse, at risk of sounding dramatic, has been a life altering event for my wife and I, in the same league as starting nursing school and getting married. We'd both worked at the Big D for three years. There, I put in my three days a week of fairly predictable work, with the occasional extra shift thrown in. On my days off, I had a routine that I followed most of the time. We had our restaurants, our shops, our coffee joints, our bars that we patronized most of the time. It was a life in the rut.

Big D was paying us tuition reimbursements each year for three years after graduation. The week after I received my third and final installment (which like the rest was taxed at a 46% gift tax rate), I put in my resignation. We'd chosen a travel company, had spoken to a recruiter, and planned our destination by that point, but it was an incredibly liberating feeling to fly that coop. February was mostly over by then, and March exploded by. The next thing we knew, March 27th arrived, and I was walking out of the doors of Big D for the last time as an employee (as far as I know). I was accompanied out the door with an interesting peer review, undeniably the worst I'd ever had, which I won't describe any further; suffice to say, someone had a chip on their shoulder and finally an opportunity to exploit it. That sort of soured my exit; I'm glad I had three good years there to balance that out.

At any rate, news of positions for the both of us came just before that, at a hospital I'll call The Y. This was exciting, since it was not only a similarly sized hospital as Big D, as well as a teaching hospital, there were positions for both of us, so we could endure the orientation together, would have better chances of good scheduling, and could even carpool. Finally, The Y was right in our desired region, New England, and even our requested state, Connecticut. It was close to NYC and Boston, just down the road from New Hampshire and Vermont, and even Maine. Of course, we jumped at the opportunity. Jess got into a PICU position that they opened up specifically for her. I was able to get into the MICU. So, we were definitely happy about that.

In the meantime, we had a lot to do. First, we moved from our apartment. This was a very stressful event, in particular packing up our junk. We got rid of all of our furniture except our beds, first trying to sell it on Craigslist, then just giving what remained to whoever wanted it. I sold my car, as we anticipated buying a crossover SUV to travel with. We literally donated or trashed at least 3/4 of all of the rest of our stuff, and we still packed a moving truck full. Everyone should move every two years, just to clear out some stuff. Finally, after loading the truck, we spent a few days with friends, then headed south to Jess's parent's house, where we deposited half of our remaining belongings in their attic (again, a stressful event). A few days later, we flew out to visit a good friend and her husband in Phoenix.

This was the start of our week-long Southwest Roadtrip. After a few days in Phoenix, we rented a car, and drove north through Flagstaff to the Grand Canyon, where we bid farewell to our friends. From there, we headed up through Monument Valley and Valley of the Gods to Bluff, UT. From a little backpackers hotel, we made a daytrip to Mesa Verde and Four Corners. The next day we drove north to Canyonlands NP, where we made a 9 mile hike through rugged canyons and desert environments on nothing but breakfast and a couple of bottles of water. We staggered into Moab that night, where we wolfed down burgers (not my wife, she's a veggie) and beer at a microbrewery and slept like planks. The next day we hiked the full 11.5 miles of the world-famous Slick Rock MTB trail, this time more prepared with food and water. Finally, the next morning we visited the Arches NP before making a 6-hour drive to Denver and my parent's house. You can see all of the pictures on my Photography Website by clicking here.

We spent a week with my folks in Longmont, then flew back to SC to Jess's parents, where we stayed at for about 10 days. We had a lot to do, getting paperwork in order, sending off forms, buying a RAV4, and doing a lot of fishing. After the first of May, we headed back north, passing by North Carolina to visit our friends. We spent a night at the beach, a great part of North Carolina. Then we headed north. We planned on traveling through Virginia Beach, passing through Maryland along the coast to go through Delaware in its entirety. However, we made a last minute decision to go up I95 through Washington DC and Baltimore instead, which turned out to be a bad decision. We hit construction just short of DC, which slowed us down enough to hit Baltimore just at rush hour. The 50-60 miles through DC and Baltimore took us 3 hours to drive through. We were stressed, angry, and exhausted by the time we reached the northern tip of Delaware and our hotel. The next day, we took the long route through rural Pennsylvania and New York to reach our destination of New Haven, CT.

Hence, our journey begins. A month and a half after my last day at the Big D.

Introduction To This Blog

So, here is the introduction of this blog. My wife and I just started as travel nurses. This blog will chronicle the experiences we have, as we uproot and try something very different from the lives we'd be living. For personal reasons, at this time I will not be naming hospitals or people; I will refer to my "original" hospital, where I worked the first three years of my nursing career, as the "Big D." I will refer to the current hospital as such, and to hospitals where I've finished an assignment by names I develop after working there. This policy of self-imposed privacy could change in the future, I don't feel like dealing with it now.

As for authors, I will be the primary author. I will try to convince my wife to write as well, and will pick up other hopefully as they start out as new travel nurses. This blog is simply to describe the experience of becoming a travel nurse--its trials, tribulations, and benefits.

I hope you enjoy.

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