At the same time exhilarating and challenging is the access granted by nursing work. In ordinary human interactions, there isn't permission to poke and pry and invade personal space. But of course that's why patients come to hospitals: for nursing care. They expect it and automatically grant permission to anyone who walks in the hospital room door wearing anything vaguely clinical. And there are us rookies in our starched whites. Well, maybe not starched.

This is what surprised me about nursing work when I first started doing it (this is my second time around). I thought I was going into it to "do well by doing good". The surprise was the direction of the giving -- the giver turned out not to be me. Rather, the work of care-giving is a privilege; the trust and faith given to us turns out to be the true gift. To someone who hasn't been there these words likely have a simpering, Pollyanna quality; but everyone I know who actually does this work (my nurse, doctor, and therapist friends) know exactly what I mean. Even the ones who subsequently changed professions (several guys I know have ditched doctoring -- burnt out on it for one reason or another -- and gone into technology; I'm following the opposite path) don't hesitate to say that this privilege was the best part of the work.

So that's the exhilarating side. What about the challenge side? I'm still working on overcoming my tendency to see that person in the bed as a peer rather than a patient. I'm still learning that it's ok -- more than ok, it's required -- to walk in and lay on hands; to inspect and prod and ask personal questions. Imagine asking a complete stranger when they had their last BM. No, don't just imagine it, do it. Ask, I mean. And maybe even wipe their butt for them. Or do things that hurt. This is my challenge: giving myself permission. The patients have already granted it. Now it's up to me.

Infection transmission precautions are driving me nuts. Those bacteria have us whipped. We don't stand a chance. Biology always wins. No wonder so many of our patients get MRSA and C-Diff.

My mental picture of bacteria is the finest microscopic dust that wafts everywhere, weighs so little it travels effortlessly, on every surface, and settles everywhere. Doorways into patient rooms are no magic barrier; objects and people travel in and out and bacteria ride along. Walls and doors and building spaces are more cultural artifacts than biological barriers; we imagine that they create safety zones but the microbes are oblivious and ubiquitous.

While the evidence shows that dutiful handwashing does improve outcomes, it's only on a probabilistic basis, not an absolute one. Obstacles to effective infection prevention seem overwhelming. Everywhere you go, your hands and clothes and supplies and instruments touch infected patients and things that have touched infected patients, even when you wear the plastic gown and gloves. With my gloved hands I must touch my pen to take notes, and swabbing it after I leave the room feels like an inadequate precaution. There are disposable stethoscopes but the nurse I shadowed says the unit head doesn't want them wasted on nursing students so I use my own... and swab it afterward... which continues to feel inadequate. The idea that I'm bringing all these bugs home is troubling, too. It feels like the whole system is set up to fail. We joke that hospitals are dangerous places and, to stay healthy, we should avoid them. It is growing ever clearer to me how quite literally this is true.

I remember distinctly a comment made by one of my clinical instructors from the first time I went to nursing school about four years ago. She observed that I was having difficulty finding my "rhythm". In light of Prof. X's request that we use these journals for self-criticism (which reminds me of the coercion to "self-criticize" in China's Communist Revolution with Chiang Kai-Shek ninety years ago but never mind... :-) I am returning to that excellent bit of feedback.

"Rhythm" was a well-chosen word. When you're an expert, you know without hesitation what is your top priority, what to do now, what can wait, when something is a crisis and you must hurry and even more importantly when it's not yet a crisis but it could become one, and so on. All these things have to do with time management.

Music, too, is all about time. Skilled musicians (for a few years in a former career this was how I made my living, though having worked with a few geniuses I wouldn't have rated myself above "competent") always know where "one" (the first beat of every measure) is, i.e. their job, too, is about time. Finding that rhythm -- more a head thing than a hand thing -- is about a sense of mastery, of flow.

Exhortations from our professor about finding out when meds are due but not looking them up until time permits -- get our head-to-toe done first! -- are very helpful in getting us started in developing the time management instincts. Perhaps a better word than instinct is reflex. A reflex is an action taken as a result of a decision made at a sub-cortical level. When you know something thoroughly, you do it without having to think about it. You just know. That's where I strive to get to.

I feel like it's a long way away yet, but at least I have a sense of where I want to go. It will take years of practice to arrive at that sense of confidence, of mastery. But someday I will have that rhythm.

Nursing education is focused on the hospital setting with its enormous resources and fine-tuned protocols. What about nursing in other environments? I don't mean merely outpatient instead of inpatient, I mean nursing in its fundamental sense -- helping people directly, with the skill and experience of our hands and brains, with or without the infrastructures of these vast institutions, these monstrous machines -- in which we may or may not choose to be cogs.

I write a sort of a healthcare blog -- https://www.dan-keller.com/nursing/ -- take a look. In it, I ponder not only the minutia of nursing care but also the larger issues such as healthcare and peak oil. How will we keep ourselves healthy when we don't have endless petrochemicals for all the disposable plastics without which we could not function as we do today? Lest you dismiss me as yet another wild-eyed enviro-whacko, do a little objective research to see that these constraints will become realities before we oldsters reach retirement... let alone the youngsters who are my classmates. (Yes, I am older than most of my teachers, too... but that's a diatribe for another day.)

In one of my bloggings I propose a "reverse foreign aid mission" to Cuba. With almost none of the capital investments that characterize our medical system in the USA, combined with a degree of preventive care and community coverage for which there are no incentives nor even consciousness in our system, the Cubans -- spending pennies not billions -- have better outcomes than we do. How do they do it? With a little humility -- realizing that such a mission would not be to dispense largesse but to listen and observe -- we could learn from our relatively impoverished neighbor and begin to prepare for the hard times that most surely are a-comin'.

And what does all this mean for nursing? No doubt my agenda is different than that of many of my peers. My primary motivation is not a healthy paycheck and job security. I want to know how to work with people so we can all get well and stay well even without monstrous buildings crammed with expensive technology and endless regulations. Yes, teach me to be a nurse in an American hospital. But also teach me to be effective without all that. Let's get back to the future... It's surely getting back to us.

Listening is a challenge. I could not hear 9121's heart! (Room numbers changed to protect confidentiality.) And 9120's sounded like nothing I've heard before. My RN said it's breath sounds but it's definitely not; I don't think she listened at all... the sound is so unusual she wouldn't have forgotten. I can hear the lungs just fine; breaths are at 12-20/minute (normal) and match chest expansions. No way to confuse the two. The heart sounds like a moan, repeating at 60-80 BPM (normal heartbeat frequency is 60-100 BPM). There is no discernable S1, S2, etc., just that moaning sound. No lub, no dub. Yet both patients have pretty normal EKGs on the monitors (this is a telemetry, high-acuity unit).

9121 is obese which is why I couldn't hear his heart though I tried mightily. I listened in several places with my wonderful stethoscope's volume cranked all the way up. Plenty of bowel sounds but no heartbeat! Very strange! And frustrating. There must be one because the guy is alive... With whom can I discuss this? Not the floor nurses; they already have low opinions of students. Not G., my lecture instructor; he is harsh and judgmental and I can't risk jeopardizing my grade. Nor F., my clinical instructor; he would find fault and would ridicule... I saw him do this to another student. Not my classmates; I would be embarassed. Who can help me solve this? Anyway, I will not chart what I did not hear.

Still have occasional moments of, "OMG what (of the hunded possible tasks) should I do next?" but they last only five seconds. Nonetheless, even with only two patients (how does a real nurse handle five?) there is more than I can do. I did do two head-to-toe assessments... Good practice! The intimacy they necessarily demand creates opportunities for useful interactions. I still omit details, e.g. I forgot the bilateral finger pull to assess neuromuscular function.

One of my patients is Punjabi. She speaks no English. We communicate with smiles and gestures. She is sweet but in much pain -- bad cellulitis of her BLE -- she squawks when I touch her feet. But she also squawked when I did her blood glucose fingerstick which is not painful. I conclude that she has a low threshold of pain. Also, in some way I can't quite explain, the lack of a common language increases her fearfulness that everything will hurt and so it does. But really only the patient herself can say how bad it hurts.

O'Connor still has mostly paper (not electronic) charts. My fellow-students are grumbling. It's so inconvenient! We waste much time just trying to find the darn thing. Having found it, we often can't decipher the physician's illegible orders. But I grew up on paper charts and am reminded of how nice, in some ways, they are. No layers of login screens and menu drill-downs to get to what you want to read or write about your patient. Occasionally, without all the canned verbiage of computer-assisted records generation and the endless layers of access levels, I find myself comfortable with the low-tech, paper medium. Looking around to locate data, I appreciate how paper concisely conveys a patient's history and status at a glance. That technology has undergone a century of refinement. The electronic one is still young.

After all the flack in the press about the sorry state of affairs at Walter Reed hospital and the right-wing excoriations of our government's purported neglect of our brave men and women formerly in uniform (i.e. veterans) it was eye-opening to see how well, in fact, they are cared for. The quality of the facilities and staffs were impressive. Also interesting was the distinction that is made between illnesses that were acquired while conducting military duties versus those that came later. I would have thought that the distinction would be of little importance since health care is, for veterans, completely covered. However, there is some kind of implied value judgement; combat-caused disabilities and ailments are somehow more highly respected. Perhaps I'm imagining that... but why would the medical charts even bother to track this detail? Anyway, it's good to see that we take good care of our military people who have indeed given so much to their country; the sentiment may be corny but the reality is right there before us.

Also valuable in our first clinical rotation was our exposure to the renowned VA electronic medical record system. In the medical informatics world, much press has been devoted to its excellence and, based on what I've seen so far, it's well-deserved. Unlike other electronic medical record systems I've used, it's easy to get started and find your way around the VA's system. It has lots of detail and features but the basic function of simply looking up a patient is easy and can be done with a few mouse clicks. Medical informatics has been the focus of my career for many years and I'm looking forward to getting to know this system.

Of course, the most interesting part of any clinical work is the patients and the veterans are no different. It will be valuable to get to know a few and to explore their issues especially from the psych nursing point of view. In his introductory remarks, Prof. Y. said he expected that none of us would likely choose psych nursing as our focus. I don't agree. I could see myself doing that kind of nursing as much as any other. Why would we be biased toward, say, med-surg? Is it a matter of pay? Or of some unstated hierarchy? So far, I see no evidence of either.

I'll be blunt: the time doesn't feel very productive. We're doing a lot of sitting around and shooting the breeze. The good things that have happened so far (and I do expect more good things... please don't interpret this as pessimism) are:

• meeting new patients and seeing their issues (if not actually working with them on them), and
• seeing the VA and what it offers and how it works.

I am clear that my perspective is that of the intensity of med-surg clinicals; mental health is by definition less intense (no touching! your tools are your words not your stethoscope) in terms of the demands on the caregiver for clinical skills; e.g. starting an IV vs. a therapeutic conversation. This is not a value judgment; I do not value the IV over the conversation nor do I think that one is necessarily more skilled than the other. However, the IV is more of a clearly-defined achievement and career milestone.

Nonetheless I am interested in mental health as a possible career direction and appreciate your guidance and willingness to look at all points of view. An awful lot of what these nurses seem to do is push pills and I would hope to help steer things in other directions.

A couple of brief but illuminating patient interactions have given me pause. In the first, Mr. F., one of the more belligerent and combative patients, when I accompanied the CNA to assist with his hygiene care bellowed at me in his near-incomprehensible manner, "Who are you?" and then, "We don't need you here." In other words, go away. Knowing that he has severe cognitive and social deficits (a couple of my classmates, surmising that he accepts care only from females, described him as "creepy") I didn't take it personally. However, it was eye-opening to observe the degree of entitlement he feels; that he can command, and that the organization and its staff exists to serve him and to do so unquestioningly. Indeed, the CNS whispered, "Do what he wants, it's easier."

The second such interaction was with another patient, Mr. M., whom I have chosen for my case study and whom I asked to meet with me so I could interview him. Of course, he had no obligation to cooperate and indeed he peremptorily hobbled past me in the corridor, barely acknowledging my request, saying, "I'm busy now." His appointment was with a chair on the patio in the sunshine. Again, he was entirely within his rights, and again the unhesitating sense of entitlement was interesting to observe.

And why not? Why shouldn't these men have this sense of entitlement? They are veterans and the care they receive is part of a contract on which they have delivered and can now collect. Nonetheless, they have somehow become dehumanized in the process; they have become unable to see others as people but as automata to command. Like people I have seen with Asperger's syndrome, they have lost (if ever they had) any sense of empathy, of consciousness of the emotional internals of others. Such behavior would be less acceptable in an ordinary hospital; poor psychological function would get such patients relegated to units equipped for difficult people.

It may be their right and even their privilege to behave thus, but I do not doubt that the quality of their lives is diminished. Are these behavior deficits caused by disease processes (such as Asperger's) or does the healthcare/VA system itself somehow share responsibility? In what way might the system be to blame? And, having identified shortcomings, how might they be remedied?

The only direct cause that I can see is the Third World provenance of most of the CNAs (most are recent immigrants) and how naturally they are relegated to a kind of servant status. (My own experience here was to be treated similarly, an uncomfortable and unfamiliar sensation.) If indeed it is a flaw, it belongs not only to the VA system; it's structural in the labor market in America. Perhaps, like so many issues, much of the problem -- which appears on the surface to be medical -- boils down to economics, to an unspoken class structure in our society, with the VA system merely one of its manifestations. There is much to ponder!

I felt at least a twinge of disappointment at my inability to "connect" with this patient. I would have liked to have been able to work with him at least to some small degree in friendship or at least a sense of collaboration in working toward a shared goal. Instead, I discovered that he is simply not a nice person, unprofessional as that must sound. My concern regards not my own emotional needs which of course are irrelevant in a therapeutic context, but the obstacle to progress created by the disconnect.

The experience of working with this patient reminded me of my interaction with a nephew who suffers from Asperger's syndrome, the inability to empathize, to perceive emotions in others. On one occasion I attempted to feed the child. My concern was of course for his health and wellbeing. The revelation to me was his perception of me was not as a person but as a thing, a thing to be made to go away. Of course, this is a central feature of the syndrome. He shouted, "I hate you!" In people with Asperger's, consciousness of the internal states of others is absent. This direct experience of it was eye-opening.

My experience with this veteran was similar, and the lack of even a small connection made clear the depth of his disease and the enormity -- probably ultimately insurmountable -- of the obstacles to his healing. As a caregiver this disappointed me.

I have observed the professional distance maintained by some seasoned nurses that implies, "Hey, I'm doing my job and at the end of the day I get to go home. You can work with me or not, your choice," -- a kind of coldness that undoubtedly is required for long-term survival in this work. Remaining emotionally available and thus vulnerable would lead to burn-out. Nonetheles, this seems to me a little sad and must make the work less satisfying.

In sum, I would have liked to like my patient, the veteran Mr. M., but couldn't, and am disappointed that there appeared to be little opportunity to help him improve his mental health but only to proceed as a caretaker until someday he'll die at the end of an unsatisfying life. If all mental health patients were like that I don't think I'd choose it as a career. Fortunately, there are others with whom a human connection and progress are possible. Surely it is this thought that helps us all keep going.

Nursing is, of course, about people. As a student on this rotation I had the luxury of being able to take time to listen to patients talk about more than the immediate medical issue at hand. Working Emergency Dep't nurses cannot do this; they do not have the time even to do the head-to-toe assessments we were taught in school; they can do only "focused" assessments -- look at the thing that brought the patient in and never mind whatever else may be going on. Emergency care demands a unique mindset.

I like to say that nursing is better than doctoring because:

1. The MD gets ten minutes with the patient; the RN gets an entire shift.
2. The MD treats the disease; the RN treats the patient.

But in the E.D. nurses must behave like doctors: talk only while multitasking (thus only briefly); focus only on solving a single problem, not on the big and complicated needs of a human being.

Nonetheless, I am enjoying this work very much. Perhaps it's the variety and the pace; this a good job for someone with attention deficit hyperactivity disorder. And I wonder whether there is at least a small component of voyeurism. I continue to marvel at the access granted by nursing into private lives. Relationships are revealed: a worried parent reassuring an equally worried child, a family that delivers a worsening elder and then disappears, a migraine sufferer accompanied by an office coworker who is both concerned and annoyed, a celebrity with a heart condition and his boyfriend who both pretend he has no drug problem, and many more. Working in the E.D. has been a remarkable experience and a rare view into the lives of others.

Here are some of the astonishing (to me, anyway) things I've been able to do on this rotation: start lots of IVs (I'm learning not to get blood all over everything), insert Foley catheters (I'm not good at this yet; it seems to always want to slip into the vagina not the urethra), CPR chest compressions (until the MD said, "You can stop now, he's dead"), interview a 5150 patient who was having auditory hallucinations (his talkers weren't saying nice things to him), comfort a frightened and lonely 86-y.o. lady who asked point-blank whether she was going to die (the answer was no, not right away) and who appreciated that someone was for once taking some time to talk with her.

How lucky we are to be able to do this work.

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