I have no idea what I'm doing...
That's what I thought to myself on my first night in the ICU. I was still a student. I can't remember what it's like not to be a student. Healthcare is like that. I know - you know.
Prior to this I had a background of 8 years as a neuroscience step down RN with three certifications and several awards for clinical excellence under my belt. But to get through school I had been a Supervisor for while, on night shift. Stroke, seizure, post op spine - that was my area. But the other stuff I was a little rusty on. I was about to start my last clinical rotation as a AGACNP. In critical care. Something I felt adjacent to, but still a stranger in a strange land about.
And I was so fortunate. I had managed in a very competitive environment to arrange my own preceptors for all three rotations. It had gone really well so far. Was this the moment it all fell apart? Was I in over my med-surg head? I thought back to everything I had already done as part of this challenging DNP/NP program. Three years of full time course work without a break, Fall, Spring, Summer. Lather, rinse, repeat. Exam after exam. OSCEs. Procedures. Exams again. Gotta keep a better than 80% average, or you are out. The bain of every student in healthcare. Less than a 'B' is a fail. Every missed test question could be the end of your career no matter how long and how hard you worked to get there. Failure is literally not an option.
My first clinical rotation started with 180 hours in outpatient urology with someone who was a colleague at my RN hospital job who graduated with her AGACNP from the same program I was attending. Did she have to precept me? No. Did she because she's a kind and wonderful person (who promised me that I would pay it forward) - yes. She worked Mon-Fri at a couple different offices in the largest urology practice in the Southeastern US. I absolutely loved that rotation. I learned a lot, the patients were so grateful for the care, and I noticed right away the amount of respect she commanded as a provider. The MDs in the office were collaborative but she had a lot of autonomy. She got paid a percentage of all the patients she saw/billed (RVUs) on top of a great salary, took minimal call and each day either lunch was catered (by device and drug reps) or she could go to the doctor's lounge in the hospital and get lunch. She went to exotic locales for paid-for conferences. She loved her job. It was eye opening. I could see myself in that role. I was encouraged to apply at graduation. And I seriously considered it.
My next 180 hours was with an internal medicine physician at my hospital. Amazingly nice guy. Excellent teacher. I got "pimped" on rounds every damn day in the beginning because he challenged me on high yield topics, and often I was tongue tied or not keeping up.
At first.
Then I dug in.
I made copious notes.
I drilled common differentials and treatment plans and got up to speed.
By the end when he tested me on the top 25 problems (chest pain, syncope, abdominal pain, shortness of breath), what the differential was for those problems (STEMI, GI Bleed, pneumonia) and the plan to treat (cath lab, CT Abdomen, antibiotics and so much more) I could rattle them off. And then he recommended me for a job. With internal medicine. And I planned to take it.
In my first semester of school I networked like an obsessive. Linked In. It really does help you. For all those NP students looking for preceptors (not the kind you pay) - it's my best suggestion. Find the people you work with, and see who THEY work with, and network. I asked another DNP in critical care, who was a colleague of a colleague about precepting me in critical care. He kindly pointed me to the DNP who arranges clinical rotations in critical care. Again - both of them graduated from my program. They knew I was in a serious program, they knew I had a good reputation at the hospital where we all worked, and while the coordinator told me there was a long waiting list - he put me on it.
And then we had face time during a rapid on my unit. And a few more times during codes. And people I knew talked me up to them. And they saw me round during my internal medicine rotation. And in the Fall before my last year of NP school I got the shot. I got a clinical rotation for my last summer semester for 240 hours in the ICU with a nightshift NP.
We met, we were sympatico. She wasn't bothered that I was not a critical care RN. She set the expectation that I would work my ass off. She did not mind I had a lot to learn. What she didn't tolerate was laziness. If we saw a patient I wrote a note (in Word) and she would pick it apart ruthlessly. Until I got better at writing notes.
So in my last semester I showed up.
To be a nocturnist.
An intensivist who works through the night.
And I fell in love with critical care.
And I knew nothing. And then I learned, and I learned some more.
And by the end of the 240 hours I was encouraged to join them.
I graduated in August, I took and passed boards in September and applied. To be fair I gave internal medicine a shot too, and applied with the understanding that the job was basically mine barring an interview with the CNO of the organization - but the ICU team interviewed me first, and offered me first. After weeks and weeks of credentialing it all began. And that's how it started.
Next installment - how it's going so far.
I can relay my latest and greatest situation - where I got pimped on rounds - probably because I suggested we give bi-carb to an acidotic patient when it wasn't (really) necessary.
And I once again was spending time reading more Marino (that is Paul, not the first of his name, patron saint of ICU) on acid/base and electrolyte imbalances in intubated septic patients....