Barkley & Associates Nurse Practitioner Review Course

 Yes, the time has finally arrived- preparing to take my NP board exam!  I've been studying for the exam using the materials I received while attending the Barkely & Associates review course.  I took this 2 day course several weeks ago along with several other NP students in my graduating class.

I will first start off by saying that I've taken review courses before- once for the GRE and once for the NCLEX and because of those experiences, I had low expectations for this course.  Well, to tell you that I was pleasantly surprised would be an understatement!  Thomas Barkley, the owner of the company, taught the 2 day course at a hotel in Philadelphia and he did an excellent job!  He was engaging, funny, direct and covered a lot of material in a short time.

Each student received a manual the same manual that he reviewed during the course and what has now become my bible for the board exam.  Barkley & Associates students have a 99% pass rate.  He highly recommends studying from only his course material for the test.  There is also an option to purchase the CD's of the live course, which some of the students did instead of the live course and some did both.  In addition, you can purchase practice tests which give you the correct answers and rationale for each question and a breakdown of what you missed based upon the particular topic. 

I would highly recommend a review course to anyone preparing to take the NP board exam and based upon my experience, I highly recommend Barkley & Associates (this is not a sponsored post). 

Healthcare Startup Interview

Remember how I mentioned that my ultimate dream job would be to work for a healthcare startup?

Well, a couple of weeks ago I landed an interview with a 13 person healthcare startup near Philadelphia.  Coincidentally, I found out about this company while preparing for a NP interview at a hospital in the city.  I was very interested in what this company was doing to prevent 30 day readmission rates.  So, I went to their website and discovered they were looking for someone with clinical experience to join their team.  I knew I was underqualified for the position, but decided to give it a go anyway- nothing to lose, right?  One of the founders replied to me within the hour of emailing my cover letter and resume and we set up an interview for the following week- score! I was excited but also very nervous.  I knew this interview would be unlike any other that I've experienced before.

Before the big day, I spent the prior week preparing.  I read up on the company, the legislation surrounding 30 day readmission and any tips that I could find when interviewing with a startup.  I'm glad I prepared as much as I did because I relied on that information for what became a 3 1/2 hour interview with 4 members of their leadership team- yikes!  By the end, I was absolutely exhausted.

Even though the experience was tiring, it was also exhilirating and I learned a lot about the startup world.  No, I wasn't offered the position but it was for the best.  For a number of reasons, it would not have been the right fit for me at this time in my life.  Although, I was glad to hear that it came down to me and another candidate.  In the end, they chose the other candidate because he/she had more project management experience.

If you're thinking about taking the plunge into the exciting world of healthcare startups or are preparing for an interview- I'll share some of the interview questions that stood out to me.

1.  Tell me what's important to know about you?
2.  Tell me about a time when you failed.
3.  Hypothetical:  Tell me how you would handle xyz situation?
4.  Do you consider yourself tech savy?
5.  What are your passions?
6.  What book are you currently reading?
7.  How would handle working in an unstructured environment?  (basically, how self-motivated are you?)
8.  What's your experience with analyzing data and drawing conclusions, etc.
9.  We're going to move quickly on this position- if you were offered the job, how quickly could you let us know if you'd accept it?

Those are just a few of the questions that stand out- believe me, there were a lot more!  

Have you ever worked for a healthcare startup? I'd love to hear about your experience. 

Reflections about NP school

Guys- tomorrow is my last day as a NP student at the University of Penn.  Tomorrow will be the last day I sit in this classroom.  I have no plans at this point to return for my PhD or DNP, but perhaps in 10 years I will have forgotten the pains of graduate school and I might take the plunge again.

As I reflect upon my own experiences in school there are a few things I would have done differently.

1.  Become involved in a grad student association.  GSO is the organization I should have joined when I began the program.  I decided early on that I didn't have the time for extras in my life because between school, work and family I was already juggling enough in my life.  Organizations such as this one can enhance the grad school experience.  There were definitely networking opportunities that I missed out on.

2.  Select a specialty early on and stick with it.  When I began my clinical rotations I did not have a preference aside from the fact that I wanted to work in the ICU setting.  My first rotation was in the Neuro ICU followed by a rotation in a Cardiothoracic ICU and my last clinical was in a general surgery practice- inpatient.  While my experiences were varied and I did learn a lot- I feel that my job search would be easier had I chosen a specialty and chosen my clinicals in that area only.  For example, had I chosen cardiology I could have worked in an inpatient/outpatient setting, a clinical in a cath lab and a rotation in a CCU (coronary care unit).  What I am finding is that even though I have worked for several years as an ICU nurse, many of the job openings in my area require experience within that particular specialty.  So, to make a long story short- my advice would be to select a specialty and stick with it throughout all of your clinical rotations.

3.  Connect with your classmates.  Luckily, as a result of this program, I feel that I now have new friends for life.  A group of us worked together very closely on projects and complimented each other very well.  We've shared our disappointments and celebrated our successes.  They have made school fun- good friends are essential.   

Do you all wish you would have done things differently while in NP school?

Last Day of Clinical

Hello friends.... I hope you're still out there because it's obvious I have not been as religious about updating this blog as I would have hoped.  Life just seems to get in the way sometimes and that has definitely been the case this summer. 

Great news- today is my last day of my clinical rotation as a NP student! Yay!  To say that I am excited would be an understatement- I'm elated!  

For the past 8 weeks I've been working with a NP who works for a group of general surgeons. She has been a wonderful role model and I hope to not forget the valuable lessons she has taught me.  I'd like to share them with you so that if you're also embarking upon a career as a NP perhaps you will find this information helpful in your own practice.

1.  Be thorough.  Be thorough in your assessments and in your documentation.  Do not rush through seeing a patient just because you want to finish rounds- take your time.  Review all of the necessary info: vital signs, lab work, progress notes, imaging studies, etc.  You'd think this would just be common sense but I've worked with providers who are careless in their clinical practice and just want to finish as soon as possible. 

2.  Spend time educating patients.  Patients appreciate it when you take the time to listen to them and educate them about their management plan.  Time and time again, patients thank my preceptor for her effort to explain things in a way that they can understand. 

3.  Play well with others.  Again, common sense here but we all know at least 1 or 2 providers who have a bad reputation because of the way they treat other people.  It is important to get to know your colleagues and to establish a good rapport.  Medicine is a team sport- not one provider can do it all alone.  We rely on each other in order to provide the best care possible to our patients. 

4.  Know your limitations.  As a NP, and especially as a new NP, there will be things I just don't know.  I know the learning curve will be steep.  It's important to know my limitations and to seek help when I'm unsure about something.  Just last week, one of the surgeons suggested to the NP that she place a catheter in a patient where a different surgeon on the same service operated.  She told him that she was not comfortable with that and felt it more appropriate for a surgeon to perform this procedure in the operating room.  Sure enough, a different surgeon agreed and took the patient to the operating room later that day for the procedure. 

My preceptor has taught me a lot and I am very grateful for her as a mentor.  I feel that I've learned a lot on this rotation about the role of a NP. 

As far as my own job is concerned, I'm still on the hunt.  For now, I'm just going to focus on finishing the program, studying for the board exam and enjoying the last few weeks of Summer. 

Univ of Penn Graduation

Over the break- you might be surprised to know that I graduated.  Well, not technically but I did attend the School of Nursing commencement ceremony and walked across the stage.  Most of my classmates participated in the ceremony which made for a very nice night.

These lovely ladies have become wonderful friends.  We've endured many projects, presentations and they've made it much easier to handle the stresses of the NP program.  Love these girls!

Laura Bush was the keynote speaker.  I thought her speech was inspirational.  She was genuine and her Texas drawl reminded me of my Texas upbringing- a bit of nostalgia.

Even though graduation was not the end of my graduate education, I can finally see the light at the end of the tunnel.  

Back from the break

Ahh-- sitting in class, once again.  The break from school and clinical absolutely flew by.  I was in denial that class began this week.  As I sit here listening to all of the projects and papers, etc. that will be due over the next couple of months I'm feeling slightly overwhelmed and yet still in denial. 

I have two weeks of class followed by eight weeks of clinical and then a final week of class and then the fun ends on August 8th!  Yay! 

My last clinical rotation will be both inpatient and outpatient with a large general surgery practice.  I'll be working with a NP who has been with this group for many years.  I am looking forward to working in an outpatient setting.  The only experience I have with the outpatient world are a few volunteer shifts at a charity clinic in Austin.  It will be a nice break from the hospital. 

I will try to do my best at keeping you updated on the NP student happenings during my last semester.  Also, if you would like to contribute to the blog and share anything as it relates to the NP world- just send me an email:  I would be absolutely thrilled to hear from you. 

Photo above from a trip to Longwood Gardens


I am thoroughly enjoying my break between semesters. I know the time will fly by so I'm trying to take advantage of every second. The kids and I are playing a lot every day, I'm cleaning out every closet in this house (exciting, right?) and I'm running Ragnar Cape Cod this weekend.  I've never run a Ragnar Relay but I'm excited about the adventure- running at all hours of the day and night, sleep deprivation, sharing a van with 6 people, no shower and porta potties for 200 miles, sure- sign me up!

Hope you all have an adventurous weekend!

Floating Doctors

Plans are in the works to join Floating Doctors this year.  I will keep you posted on the details because I really want to spread the word about this amazing organization.  Plus, my family and I are going to be working hard to fundraise for them.

I've always wanted to join a medical mission and my brother in law who will begin his 3rd year of internal medicine residency went to Panama last year and worked with Floating Doctors.  He came back dedicated to help and to do more.  He twisted my arm and now I couldn't be more excited to join him later this year.

Resume Writing

I spent most of the early morning yesterday rewriting my resume.  Luckily, my latest edition was fairly up to date but after doing a bit of online research, it was apparent that I had to change my strategy.  I am no longer applying to RN positions, but to NP postings- it's a totally different story.   

The other issue that I found tricky is how to really sell myself even though I have absolutely no experience as a nurse practitioner.  Oh, and not to mention that I haven't even completed the Acute Care NP program- that happens in August of this year!

One thing that I learned, thanks to NP Career Coach is that including my clinical rotations and a few specifics about each rotation is important, including the total hours at each site.  This information gives my future employer an idea of my interests and capabilities.  So far, I've almost completed two very different ICU rotations.  My next clinical rotation will be at a much smaller hospital working with a NP who sees patients both in the inpatient and outpatient settings.

Also, making and keeping connections, like in most fields is important and I am finding that to be very true in health care.  My former preceptor was the NP director at her hospital and the clinical faculty at my current clinical site is also the NP director at this hospital- jackpot.  So far, I think that both of these connections will pay off immensely.

The director of the NP program I attend sends our class daily emails about current job postings, some are local but most of them are outside my area.  She sent a job posting on Friday that sounds like a great fit so I wanted to send in my resume as soon as possible.  I have a feeling that the job market is fairly competitive but I am hoping that the connections I've made will help.   

a nurse practitioner career

I only have two more weeks left in this semester and I could not be more excited about taking a break from school and clinical.  During my break, I am going to get very serious about my job hunt.  I have already looked around in my area and there are a few positions that look interesting to me.  If I were to expand my search to Philadelphia then the options are almost endless, but I think I want to stay closer to home- we'll see.

I find it very timely that MidlevelU is dedicating several blog entries on how to begin the job search.  I have found the information to be very helpful.

I also came across this graphic below about 'How to Become a Nurse Practitioner' and thought I would share.  Even though the NP profession is more prevalent that it was even 5 years ago, I still find myself explaining the NP role to people I meet.  This graphic is a great snapshot of the career. 

How to Become a Nurse Practitionerthe
Courtesy of:

Heart disease and Red Meat

Just thought you guys might want to read this article before heading out to dinner this weekend for a big steak dinner.

I was born and raised in Texas and believe me, I have had my fair share of red meat.  I eat it probably a few times a month now (no great BBQ in New Jersey) but I might even eat it less frequently now.

History and Physical

Monday morning was our last SimMan practicum of the semester.  I was not very nervous about it this time but it turns out that perhaps I should have been.  I prepared by brushing up on my cardiac assessment and 12 lead EKG interpretation skills.  This time, instead of a team of students, there were only 2 of us.  Nicole was my partner- she's wonderful.  What we thought was initially a myocardial infarction (heart attack) ended up being heart failure.  Fortunately, we did figure that out based upon his diagnostics and decided to give him Lasix and put him on a Milrinone drip to support his heart and blood pressure.  

What was disappointing to me about our/my performance of this SimLab was that we did not pick up on his heart failure much sooner.  We failed to do a thorough history and jumped quickly to the physical exam.  If we/I had spent more time asking a detailed history, we would have found out that the patient has a history of stage IV heart failure.  I think we were a bit distracted by his need for almost immediate intubation.  We should have thought to call his 'wife' into the room for a more detailed history.  Overall, we managed to diagnose him correctly and ordered the proper treatments.  

This experience reminded me of something my brother-in-law once told me, he's an internal medicine resident in Baltimore.  He said that a physician once told him, "Nine times out of ten, if you do a thorough history and physical, you will correctly diagnose your patient."  Of course, there are always exceptions but this statement definitely held true during our SimLab. 

I hope that when I begin my career as a NP, that I will not forget this valuable lesson.  Never underestimate the importance of a detailed history and a thorough physical exam. 

RN experience before NP school

  Image via Ecophon Acoustic

Is RN experience before NP school a must?  Before I share my own opinion, I will first start out by saying that there are two camps and most people are not interested in hearing what the other camp has to say about this topic.  So, the purpose of this blog entry is not to persuade or dissuade anyone, but to simply share my own experience.

There was nothing that I learned in nursing school that could have prepared me for what it would be like to be a bedside nurse in a busy trauma hospital in the ICU.  Nothing can prepare you to take care of someone who was just shot in the face several times.  Nothing can prepare you to see a mother who kissed her son goodbye that morning and is now seeing him for the first time in the ICU after a motor vehicle collision with a severe traumatic brain injury.  Nothing can prepare you to witness a husband making the decision to withdraw life support from his wife who he has been married to for a lifetime.  Nothing can prepare you to see a 25 week old fetus be delivered stillborn because the mother was in a terrible motor vehicle collision.  Nothing can prepare you to manage two patients who are hemodynamically unstable.  Nothing can prepare you work closely with dysfunctional families.  Nothing can prepare you to be in a heated disagreement with a physician.  Nothing can prepare you to multitask, problem solve and troubleshoot like someone's life depended on it. 

So, what's my point?  My point is, that the skills I learned in nursing school meant almost nothing to me.  What has been most valuable to me are the skills that I learned as a bedside nurse.  It was through those experiences, those countless hours working in a hospital with physicians, with patients and with families that will be of value to me as I begin my career as a nurse practitioner.  What I have learned from a textbook or in a classroom is important, but the real value comes from within the hospital walls- from experience.  

Healthcare Startups

Healthcare related startups are hot topics these days.  With the influx of several million newly insured patients as a result of the Affordable Care Act and an ever aging population, finding ways to innovate and improve our current system is garnering a lot of popularity and attention. 

My ultimate dream job would be to work for a healthcare startup.  I think that helping to create something that improves lives or makes access to information or access to healthcare easier would be a pretty exciting contribution to society. 

I enjoyed reading this article and learning about the 13 companies that Startup Health selected to invest in and take to the next level.

It's exciting to be involved in an industry- healthcare- that is finally creating ways to innovate and improve.   

What's in my Lab Coat?

Okay guys- stop with the jokes already-- this is a serious post about what I’m packing in my lab coat pockets these days when I am at clinical. 

Well, before I continue, I have one confession-- I hate wearing my lab coat to clinical.  I wore it during my first clinical rotation in the Neuro ICU but in the current Medical/Cardiac Surgery ICU where I’m rotating now, only the attending wears a lab coat.  The fellows and the NP who is also my preceptor all wear black scrubs.  The med students and I wear the green operating room scrubs.  I definitely prefer the green, so comfy I could wear them to bed scrubs over any white, but very dirty if you look closely lab coat any day. 

So, what am I carrying around in my green scrub pockets?  Glad you asked.

A pen: no explanation needed.

A penlight:  I used this penlight several times/day on my Neuro ICU rotation.  I still use it daily in the Cardiac Surgery ICU but it definitely needed a battery change after all of those pupils I checked on the stroke patients.

Littmann Cardiology III Stethoscope:  When I first started out in nursing school I purchased a budget friendly stethoscope that seemed to work just fine.  After I began my first job as a bedside nurse, I noticed a variety of stethoscopes and wondered if the ones that looked more expensive were actually worth the money.  After borrowing this one from a fellow nurse it was obvious that this Littmann Cardiology III stethoscope was definitely worth the investment.  I am a firm believer in the value of a great stethoscope.  I can appreciate heart mumurs much more easily and can hear breath sounds loud and clear- it's a definite must in my opinion.  

Pocket Medicine Handbook:  I use this book daily at clinical.  It is well organized and incredibly easy to use.  If I have a basic question about management of common diagnoses found in the ICU or even on the floor, this quick guide gets me on track. It covers everything from infectious disease to status epilepticus.  It also fits easily in my back pocket.

Cardiac Surgey Manual: When I started working in a cardiothoracic ICU several years ago, my preceptor recommended I purchase this book so that I could familiarize myself with how to take care of patients immediately post-op cardiac surgery.  At the time, the book overwhelmed me and I don't think I spent as much time reading it as I should have.  
Now, as a NP student in the Cardiac Surgery ICU I use this book daily.  It is written by Robert M. Bojar, M.D. a cardiothoracic surgeon.  He goes into just the right amount of detail about every pertinent topic as it relates to cardiac surgery.  He even includes sample ICU order sets for the management of these patients immediately post-op.
Even though this beast (820 pages) doesn't fit into my scrub pocket or lab coat pocket (if I wore one)- I always keep it close by. 

How about you, what do you keep in your lab coat or scrub pockets?

AANP National Conference

So far, the only professional NP organization that I have joined is the American Association of Nurse Practitioners.  I receive their daily emails and will often read the articles that they post on FB.  This organization is very active when it comes to NP policy and legislation- something I would like to become involved with in the future.

Each year, the AANP hosts a national conference.  This year, the conference is in Las Vegas.  The schedule looks extremely comprehensive and covers everything from dermatology, to the Affordable Care Act, a critical care workshop and everything in between. The student rate for the conference is a huge steal at only $75.

If I can work out the logistics, I would love to go this year.  I think it would be a great learning experience and a wonderful opportunity to network with many experienced nurse practitioners. 

Have you ever attended the AANP national conference?  Should I really make it happen?

The Perfect Job

Because I will complete the Acute Care NP program this summer- August 8th to be exact, I have been thinking a lot about where I would like to work.  Also, someone asks me almost daily when I am at clinical if I already have a job lined up.  The answer is no and this question has me second guessing whether or not I should already be scheduling job interviews.

I'll be honest- I am not passionate about any one particular area of medicine.  I either like or dislike them all equally.  I've spent most of my RN career as a bedside nurse in the ICU and I thought that perhaps I would end up in the ICU as a NP, but that specialty area is looking less likely.  I can see myself getting burned out after a few years. 

This week I spent my clinical time working with 2 NP's on the cardiac surgery service.  These NP's manage the patients pre-operatively in the clinic and post-operatively once they've been transferred from ICU.  They alternate their weeks- one week outpatient and one week inpatient.  We saw a few patients in the clinic and I really enjoyed the variety.  I also enjoyed getting to the know the patient in a normal setting, in street clothes rather than intubated and sedated in a hospital bed.  It might have helped that the patients we saw in clinic were kind and pleasant people.

This group of cardiac surgeons also employ 2 PA's and 1 RN first assist who work in the OR full time.  I talked at length with one of the PA's and she loves her job in the OR.  She worked in a community health clinic for several years but burned out quickly.  I've been in the OR several times to observe and while it is usually interesting, I could not see myself working in that setting exclusively.

So, after learning a bit more about my preferences and what I find interesting, here is my 'perfect job'

1.  Outpatient, inpatient and assisting in the OR- the specialty is secondary (don't have a preference)
2.  A competitive salary, of course.
3.  I don't mind working some weekends- but prefer only working 4 days/week.
4.  Off on holidays
5.  At least 3 weeks of vacation time/yr- more would be better.
6.  A short commute.

There you have it- the 'perfect job.'  I know I may not get everything on my wish list but a girl can dream, right? 

There are a lot of NP job postings in my area- so I might just have a chance.

Any words of advice when trying to land my first job out of NP school?

A Professional Poster

I recently completed a major project in my class- a professional poster.  I am surprised that with all of the technology available today that an old fashioned poster is still a popular way to share information.  I thought I would dread this project but I actually enjoyed the process.

I chose the topic of Mannitol vs. hypertonic saline and its effectiveness at decreasing intracranial pressure in the patient with traumatic brain injury.  There are several randomized controlled trials but all of the sample sizes are small (around 20-50 patients).

The results of the studies I analyzed concluded that both drugs effectively reduced intracranial pressure.  As expected, mannitol increased urine output more than hypertonic saline and hypertonic saline increased serum sodium.  Currently, the 2007 Traumatic Brain Injury Guidelines do not recommend hypertonic saline in this patient population but perhaps the updated guidelines will include this drug.

A few things I learned from this poster presentation:

1.  Use bright colors and interesting photos.  Presentation and styling are just as important as content- if not more so.  I kept my poster very simple but should have jazzed it up to attract more attention.

2.  Less is more.  When it comes to text on a poster, the rule of less is more definitely applies.  There were posters that read like research papers and included every detail.  I chose to present my information in succinct sentences or phrases, rather than pages and pages of text. 

Overall, I enjoyed the process of putting together a poster and if I have to do it again someday, I would do a few things differently.  

Balancing School, Work and Family

Today, I'm privileged to be a guest blogger at Midlevel U.  I'm blogging about balancing it all- school, work and family. 

If you have not checked out Erin's site, you must do so today.  She shares interesting insights about her experience as a family nurse practitioner.  If you are interested in a career as a NP or are currently a practicing NP, you must check it out. 

Thanks, Erin!

'Outside Hospital'

The attending in the ICU right now at my clinical site is absolutely hysterical.  He's cynical, sarcastic and witty-- a great combo in my opinion.  He's old enough to be my dad and reminds me of Ben Stein.

Today he was sharing this video with a few of the physicians and nurses.  As soon as I watched it, I knew I had to pass it along- too good not to.


A little R&R

I've been MIA on the blog lately but I have a couple of good excuses.

Jason and I took a trip to California over the weekend for a dear friend's wedding.  It was a beautiful ceremony and we just danced the night away- something I haven't done in a very long time.
I used this wedding as an excuse to buy a sari and I loved wearing it.  

The trip was too short and now I'm back in full swing with kids, grad school, clinical and work-- the weekend escape from real life was much needed. 

Before our trip, I spent most of my 'free time' working on an academic poster for class.  I'll unveil my poster in a later post but rest assured that the wedding was a lot more fun and exciting. 

US Healthcare in a graphic

We were discussing the topic of the state of the US healthcare system in class today.  

I was browsing the web and found this graphic that puts into perspective the state of our healthcare system based upon the article by Steven Brill.

All I have to say is wow-- let's get moving and try to make some progress on this monster problem of a healthcare system we have created. 

Cardiothoracic ICU

I started a new clinical rotation this week.  It's at a nearby trauma center working with a NP in the cardiothoracic ICU.  The unit is a 30 bed shared ICU- medical ICU and cardiothoracic ICU.
There are 3 cardiothoracic surgeons who average about 4-5 cases/day.  So far, the patients I have seen have been post-op aortic valve replacement (AVR), aortic root repair, coronary artery bypass graft (CABG) and total arch repair of a type A aortic dissection.

This clinical has taken me back to my days as a nurse working in a busy cardiothoracic ICU.  Some days I enjoyed being a 'heart' nurse and some days it was just too stressful and physically exhausting.  It also didn't help that the ICU intensivist was a former cardiothoracic surgeon and one of the grumpiest and most miserable people you'll ever meet.  Nope- don't miss it.

Working in the unit as a NP student is much different and I'm enjoying it.  The NP on this service was a former RN on the unit and when she graduated, the surgeons offered her this position.  She is very good at her job.  The ICU intensivist and a ICU fellow are always around for extra help or back-up when needed, which is also wonderful.

Although, I must say that I do miss the warmth and friendliness of the people I worked with at Christiana hospital in the neuro ICU.  It's funny how traveling only an hour south can make such a difference.  Ah-- gotta love the east coast. 

image from:

Pocket Guide- a health risk?

(My apologies for the poor image- a few technical difficulties)

I recently purchased this pocket guide for my next rotation.  Before I ripped into the package, I read the warning on the plastic wrap.  Wow! I have never seen this kind of warning label on anything I have purchased before, especially a book.  Amazon did fail to disclose this potentially fatal health hazard in the description. 


Well, I decided to take my chances.  I'll be carrying this green book of kryptonite with me on my next clinical rotation- a combined Medical ICU/Cardiothoracic ICU.

Who knew that becoming a health care professional could be hazardous to your health?

Time Magazine Article

Some of you may have already read this incredibly comprehensive article about the state of our health care system.  Steven Brill does a great job of exposing the various reasons for our astronomical cost of health care in this country.  The article is lengthy but worth your time.  Warning-- it will anger you.

Getting pimped

 Oh yes, that's right-- my favorite part of my neuro ICU rotation.  No seriously, it is.  Let me explain. 

There is nothing that motivates me more to know my stuff than when an attending is asking me question after question after question about a patient, medical condition, lab work, etc.  Luckily, the attendings in this neuro ICU are not as brutal as I have witnessed back in my days as a nurse working at a trauma center in Austin, Texas (how I miss that city).  I remember med students and residents getting eaten alive in front of a small audience-- so painful to watch. 

The 'pimping' that occurs on this rotation isn't nearly as severe as it could be.  Today I was asked to perform a neuro exam on a patient while the attending observed and asked questions about the cranial nerves I was testing, motor strength, sensory, etc.  I feel I did decent job- not perfect- but pretty good.  She then proceeded to ask pointed questions about the patient, diagnosis, etc. 

For all of you out there just dying to know the components of a neuro exam here they are:

Elements of the Neuro Exam:
1.  Level of consciousness; mental status
2.  Cranial Nerves
3.  Motor: strength, bulk and tone
4.  Sensory
5.  Reflexes

Easy right?  Try doing it in front of a small audience. 

Looking forward to the 'pimp zone' tomorrow.

A little Wharton and Penn insight

My husband graduated from Wharton's Executive MBA program a few years ago.  It was a crazy time in our lives.  He was working long hours at his normal job and then on weekends and weeknights he would attend class, study or meet with his group.  We thought that having our 3rd kid halfway through the program was in ingenious idea (3 kids in 3 yrs almost to the day).  I was still working as an ICU nurse in Philly and taking the required pharmacology class in the NP program.  We soon realized that we were going to or had already lost our minds.  I quit my job, took a few semesters off from the program and stayed at home full time to quell the madness within our four walls.  I loved it and it was the only way our family would have survived all of the demands we placed on ourselves. 

Ok- I digress- now what was the point of this?  Oh yeah- it's to share an article from Knowlege @ Wharton. It's a great article which discusses the issue of independent NP practice and it's economic impact. 

Quote from the article:

"Physicians may be facing a losing battle. "That horse has already left the barn," says Linda Aiken, professor of nursing at the University of Pennsylvania School of Nursing and director of the Center for Health Outcomes and Policy Research. "With Obamacare coming in and millions of people getting insurance, there is no other way to provide them with reasonable access in the short term except to expand the role of NPs and physician assistants (PAs). It takes 20 years to train a doctor, so there isn't any alternative." According to an article titled, "Broadening the Scope of Nursing Practice," published in 2011 in The New England Journal of Medicine, "between three and 12 nurse practitioners can be educated for the price of educating one physician, and more quickly."
"Doctors have always been wary of others poaching on their turf," says Lawton R. Burns, Wharton professor of health care management. "And highly trained nurses are always looking for more recognition, responsibility and autonomy rather than being under a physician's thumb. It's these types of dynamics that pose a challenge to health care reform."

Things are getting heated, people.  Thoughts?

Aneurysm Coiling

 Image via Yale Medical Group

Last week I had the opportunity to observe an endovascular aneurysm coiling performed by a neuro interventionalist. 

I've always wanted to check out the happenings in interventional radiology and this was such a cool procedure to watch. 

I sported the full lead apron including a thyroid collar.  The apron must weigh at least 7 lbs and weighs significantly more after hours of wear. 

The procedure was fascinating.  The coolest part for me were the 3D images that were produced in real time of the cerebral arteries.  The images looked something like this:

 Image via

It was also interesting to watch the platinum coils being deployed into the aneurysm.  I am still fascinated by how a metal coil/coils into a weak portion of a cerebral artery works- but it does. 

I spoke at length with one of the NP's that works for the practice and she only had wonderful things to say about her role.  She sees patients both in the inpatient and outpatient setting.  Her schedule includes 4 10 hr days one week and then 3 10 hr days the next.  In my brief interactions with the physicians, they seem wonderful to work for and she agreed.  Sounds like a pretty good gig to me.

First job offer

I was in clinical yesterday and as I was leaving, the neuro/critical care attending offered me a position in their Neuro ICU when I graduate.  I was flattered.  We talked a bit more about the position but did not go into details.  This job would be a perfect fit, except that it is a 45 minute drive from where I currently live and that would be the limiting factor. 

As I've gone through NP school I've sometimes questioned my ability to function as a NP.  I've done well in school and know that my bedside experience has been incredibly valuable, but sometimes I doubted my ability. 

I was admittedly nervous about starting clinical but after several weeks of working in the unit I can really see myself feeling comfortable working as a NP.  I know I still have a lot  to learn and I recognize my limitations but I no longer doubt my ability to practice, safely and competently.  It is a great feeling.  Above all, I am so glad I chose the NP route.  I am happy with my career choice and know that I will enjoy my job once I graduate. 

Alright-- we're off heading out for a weekend of skiing.  Wish us luck-- it will be the first time for our kids. 

Have a wonderful weekend!

image: skiing wallpaper

Forbes Article

 This article in Forbes magazine is a must read.  Do it. Read it now-- and then come back to my blog. 

With the ever growing patient population as a result of ObamaCare the demand for competent health care providers will continue to increase.  My goal is not to begin the debate MD vs. NP or NP vs. PA-- no way-- not going there.  What I will say and I am only sharing my opinions is that there is a place for everyone in health care.  As the article points out, nurse practitioners, nurse anesthetists, nurse midwives, physician assistants, pharmacists and psychologists all have a place in medicine.

When it comes to incredibly complex medical issues I feel that an experienced physician is the most qualified person to provide medical care (of course there are exceptions, as with everything).  But, nurse practitioners provide competent and safe health care in a variety of settings: outpatient, inpatient, ICU, minute clinics, long-term care and the list goes on. 

The much larger issue that is a topic of heated debate is whether or not to allow nurse practitioners to practice independently.  This would mean that a nurse practitioner could open his/her own practice without the need of a collaborating physician.  Each state currently places their own laws and restrictions on who is allowed to practice medicine independently of a physician.  Some states already allow this independence.  Independent practice is the core issue.

The state of California is already working to pass legislation that will expand health care access not only to nurse practitioners but to physician assistants, optometrists and pharmacists.  

As a future nurse practitioner you might think that I would be a proponent of independent practice but I see both sides of the argument and am still on the fence.  As a new NP, I do not feel comfortable or confident opening a solo practice, seeing my own patients and essentially running a small business.  I don't want that kind of responsibility and stress.  Perhaps in the future, this would be an appealing option and something I would consider so yes, I am glad that the NP profession is making strides in this direction.  

Dr. Adalja is a proponent of independent practice:

"Expanded scopes of practice, in which a non-physician renders care independent of a physician, not only expand access to health care and have the potential to decrease the cost of healthcare, but also reflect a respect for the free market system."

What are your thoughts on the topic?  Is independent practice for NP's the way of the future?

(the photo above is of a favorite spot in Costa Rica.  It reminds me of warmer days- a great reminder in the middle of February)

Wernicke's Aphasia

My preceptor and I took a trip to the ED last week to examine and admit a patient to the Neuro ICU.  I love going to the ED because you never know exactly what you're going to get.  Plus, it's usually chaotic and incredibly busy.

The patient was in the hospital 3 weeks earlier for an ischemic stroke of her temporal lobe and had since been discharged home.  She was sitting at the table when her son noticed that she was having difficulty speaking correctly.  The CT scan of her brain showed a hemorrhage into her old infarct.  Her blood pressure was sky high when she presented to the ED. 

What I found most interesting about this patient when I assessed her was her receptive aphasia.  In my experience, expressive aphasia is what I have seen most often.  Patients have an inability to express oneself or a lack of verbal expression.  Instead, this patient was talking a mile a minute with full facial expression and verbal inflection.  She was laughing after her sentences and seemed to just be enjoying every minute of our conversation.  The only problem was that she wasn't making any sense.  You could understand the words she said but none of the words together made sense.  Our conversation went something like this:

Me:"Can you tell me your name?"
Patient: "Oh, famous tell candy young did soccer eating horses in."  She would go on and on like this.  She was smiling, laughing and appeared to be having fun.

I had only ever read about Wernicke's aphasia in a textbooks or heard about it in class. Seeing a patient present with this type of receptive aphasia is something I won't forget for a very long time.

"Patients who recover from Wernicke’s aphasia report that, while aphasic, they found the speech of others to be unintelligible. And, despite being cognizant of the fact that they were speaking, they could neither stop themselves nor understand their own words." -citation unknown. 

It isn't rocket science-- it's brain surgery

Clinical was interesting and challenging this week.  I really enjoyed it.  I was even able to take a trip to the operating room with my patient to observe her neurosurgery.  In an effort to maintain patient privacy, I'm leaving out all of the interesting details but here is the gist:

My patient came to the ED where they found an right cerebellar intraparencymal hemorrhage on her head CT.  When I assessed her at 0600, there was a change in her neuro exam.  She was more lethargic and unable to follow commands upon exam.  Mannitol IV was given and then she was taken for a follow up head CT.  The head CT showed worsening edema and obstructive hydrocephalus.  She was then planned for a R cerebellar craniectomy w/evacuation of her hemorrhage.  I asked if I could accompany her to the OR to observe the surgery and my preceptor made it happen.

Ok guys-- brain surgery is crazy. The patient was placed in the prone position (on her belly) and the neurosurgeon got to work.  He reviewed her two previous CT exams prior to starting the procedure.  After the skull was removed and the dura cut away, the cerebellum was easily visible.  It was huge and bulging.  He then opened a hole into cerebellum and then next thing I see is a huge gush of dark, dark red blood.  It was the hemorrhage- it was cool to see it just gush out of the cerebellum.  He cleaned it out nicely and by the end of the procedure, the cerebellum was normal in size.  Instead of replacing the skull, he placed a plate over the cerebellum to protect the brain and then closed her up.  She was taken back to the ICU.

I was thrilled to be able to observe the procedure and hope that when I go back to clinical next week that she will be back to baseline.  Neurosurgery is pretty cool, although I hope that I never have to be the one on the table getting my brain operated on. 

NP school: the interview

If you are thinking about a career as a nurse practitioner, you probably wonder if you'll be accepted after going through the process of applying. 

I thought I'd share a few inside tips about my own interview at Penn

I was admittedly nervous for the interview but felt confident about my interviewing capabilities.  I dressed for the occasion in a black skirt and light blue button down shirt.  It was the middle of the summer and I definitely worked up a sweat before I arrived.  I brought along a copy of my resume and essay, just in case.  

I sat down with the Associate Program Director for a one-on-one interview.  The interview lasted approximately 45 minutes and in my opinion, was incredibly thorough.  She started off asking general questions about my work experience and then followed up with scenario related questions.  You know-- the ones where you're asked to give an example of a time you showed leadership capabilities as a bedside nurse?  Or, tell me about a time that you advocated for your patient in a difficult situation?  Also, if I were to ask your co-workers and managers, what would they say about your strengths and your weaknesses?  Gotta love that question.

Then, we talked about the NP role in general and I used this opportunity to tell her why I wanted to become a nurse practitioner.  I also asked specific questions about the program at Penn.  Do not forget that even though you are the person being interviewed that this is also your chance to ask your own questions about the program.  It's important to know if a specific program is the right fit for you.  I wanted to know their board pass rate and which clinical settings/locations do they use, among a few others. 

I do remember the last question she asked which I was not expecting-- it went something like this:
"Do you read nursing or medical research?"  Me:  Oh, yes, definitely. It's important to stay updated on the latest practices because as you know, medicine changes so quickly.
"Ok- can you tell me about the research that you've read recently?" Oh, wow-- did she really just asked me that. (Think, think, think,- sweating again) Luckily, I did recently read a research article about robotic prostatecomy- don't ask me why- but it saved me, thank you, prostate.

 A few take home points from the NP interview:

1. Think through the scenario questions before the interview.  Be prepared to sell yourself.
2. Don't forget to 'interview the program' 
3. Understand the role of the NP and current legislative issues. 
3. Read up on some latest nursing/medical research.

So, there you have it- my interview experience.  I hope this helps you if you're thinking about applying or are preparing for an upcoming interview. 

Neuro ICU Clinical: a typical day

Hi there!  Wow-- it's been quite some time since my last post.  Well, that's because I've barely been able to keep up with all of the demands- school, work and clinical but I'm trying my best.

Here is a typical clinical day in the Neuro ICU:

0600-0730:  I arrive on the unit and am given 3 patient assignments.  I assess my patients, look up their recent labs, talk with the night nurse about any events and record the info on the ICU flowsheet that is then used for rounds that morning.
0800-0900:  Attend morning report.  Morning report consists of the trauma/surgical/neuro attendings, residents and students.  Each patient is discussed- the new patients in detail and a quick update is given about the existing patients.  I did present a new patient the other morning and it went well-- although you could hear the nervousness in my voice-- ugh!
0900-1230:  Morning rounds with the neuro attending, the NP, PA, bedside nurse and respiratory therapist.  Rounds are incredibly thorough and a complete neuro exam is performed on each patient.  We discuss each patient head to to toe, new orders are written and any issues are discussed.
1300-1400:  I usually follow up with my patients if there were new labs that were ordered, etc.
1400-1430:  Lunch
1430-1600:  I assess my patients again in preparation for sign-out.  My NP preceptor will usually select a topic that we discuss ie: ventriculostomies, head CT's, etc.  On several occasions I've gone to the ED with the NP or attending to assess a new stroke patient.
1630:  Sign out

I've enjoyed the Neuro ICU but over time I can see how difficult it would be to manage this patient population day in and day out.  I've only been there for a total of 8 days but almost that many patients have died or have become severely disabled as a result of their brain infarct/injury/hemorrhage.

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