More exploration of comfort theory

Case study (entirely fictional, but based on my experiences)

Tracy, the operating room nurse, quickly reviews Mrs. Brown's chart noting the surgeon's orders and pulling out the consent form. She sits down on a stool next to Mrs. Brown puts her hand out to shake and introduces herself and states her role. Tracy has only a few minutes to do a visual head to toe assessment and ask a handful of questions of Mrs. Brown, but she wants her patient to be comfortable. Tracy sits to put Mrs. Brown at the same level; she ensures the environment is quiet and that Mrs. Brown is warm enough. Tracy asks Mrs. Brown to verify her identity and confirms her preferred name, Blanche. Tracy asks if Blanche has anyone waiting for her today. Tracy then explains her plan to communicate with them during surgery. Allergies are confirmed, including a a specific question about iodine and latex just in case Blanche forget to mention any sensitivity to those. Tracy asks Blanche to state in her own words what surgery she is having and has Blanche confirm her signature on the form. This allows Tracy to verify that her patient understands what surgery is to be performed; it also allows the patient to ask questions if she doesn't understand the medical terms. Tracy then does a quick inventory of Blanche's physical status, asking questions about belongings, metal implants, ability to move and any pain. This allows Tracy to do a visual head to toe assessment to understand how to best care for Blanche in the OR. Now Tracy teaches Blanche about what to expect in the OR. She assures her patient that even if she is cold or many people are talking, Blanche only needs to say something to get more warm blankets, to know that Tracy will be there for her. Tracy also mentions things that Blanche may see when she wakes up from surgery. Telling the patient to expect a catheter and orange-tinted skin helps to alleviate anxiety post-operatively. As Tracy is instructing Blanche about the catheter she sees a frown cross the patient's face. Tracy then informs Blanche the reason for needing a catheter during surgery. Since Blanche's surgery will be longer than 3 hours and she will have a large abdominal incision, a catheter is necessary so she will wake up in recovery comfortable and not have to worry about getting up to the bathroom immediately. As soon as Blanche is up walking the catheter will be removed. Blanche's frown eases a little, but she asks if she can be put under anesthesia before the catheter is placed. Tracy assures Blanche that she will not be awake for the catheter placement. Blanche's expression relaxes and Tracy asks one final question, "Do you have any questions for me?" Blanche thinks for a moment then says "No." Tracy states that any time Blanche does have questions she can ask anyone. Tracy then says she will see Blanche in a few minutes and leaves to help prepare the OR.

Using Kolcaba's taxonomic structure for the concept of comfort (1991), we can see that the nurse accomplishes physical ease and social relief. The nurse sits to be at the same level as the patient, limits the environmental noise and makes sure the patient is warm enough. These actions directly contribute to the patient's current physical ease. The nurse also asks about any pain the patient may be experiencing. Knowing about current pain sensations can allow the nurse to address these in several ways: she can ask the surgeon or anesthesiologist to provide an analgesic and she can take special care when moving the patient during the positioning in the OR. These actions also contribute to physical ease immediately and post-operatively. The nurse also tries to contribute to future physical ease through teaching: informing the patient of things that may be anxiety producing following the surgery can help reduce physical discomfort in recovery. The nurse responds to the patient's discomfort about the catheter when she notices the frown. Addressing the patient's concerns allows the patient to achieve calmness about potential unpleasant body sensations. When the nurse informs the patient about her plans to communicate to the family she contributes to social relief. Many patients are concerned about the anxiety their family may be experiencing. Informing the family of the patient's progress intra-operatively can meet the patient need to reduce their family's anxiety. Another way the nurse contributes to social relief is informing the patient that she will be available to the patient during a time that the patient may feel most alone - in the chaotic, noisy and cold environment of the OR. Finally, giving the patient some control over her situation by ensuring any questions that patient has are addressed can reduce anxiety and allow for a greater sense of physical and social ease.

Applying comfort theory to The Death of Ivan Ilyich by Leo Tolstoy

Note: I have an eBook so page numbers may be off, I included page numbers as they were reported in the Kindle application which says the book has a total of 57 pages.

Before Ivan becomes ill, it is clearly shown that he is especially fond of improving his social comfort. When changes occur in society via "new and reformed judicial institutions (p. 11)", Ivan becomes one of the "new men ... needed (p.11)." He enjoys affairs, visits from people of rank and carousing. He always remains proper "with clean hands, in clean linen, with French phrases, and above all among people of the best society and consequently with the approval of people of rank (p. 11)."  So when he becomes ill, Ivan's thoughts are most concerned with approval from those he considers leaders in society and his own family. His "chief occupation was the exact fulfillment of the doctor's instructions (p. 25)" to ease his social discomfort of having this illness. He was able to "force himself to think that he was better (p. 25)" as long as his social comfort was stable. If he had an unpleasant encounter with his wife or a bad day at work his awareness of his discomfort was immediate. He even blames the negative social interactions and the people causing them as "killing him (p.25)." These bad encounters cause him to be angry and he feels the anger is uncontrollable and contributing to his illness. He feels alone and that none care about what was happening to him; he feels as if he were some obstacle inconveniencing his family (p. 26).

If we apply Kolcaba’s theory of comfort, focusing on the social relief aspect, it is easy to find many examples throughout the story where social interactions could have been different, leading to a more socially comfortable Ivan. It is important for Ivan to feel he is important to his family and to himself. Without the approval and support of his family he feels alone, his social needs are not being met. Ivan needs a calm environment with calming family and friends. His wife and daughter are “in a perfect whirl of visiting (p. 26)” but he feels they do not understand and are “annoyed that he was depressed and so exacting (p. 26).” If these two, who are constantly around Ivan, had been more calm and less irritated at Ivan’s pain, it is possible Ivan may have experienced more social relief. It is apparent that many of Ivan’s social comfort needs were lacking, especially from his family. Ivan has many social needs that could’ve been met better by many of his visitors. Speaking with him, rather than about him would’ve helped Ivan feel more important to his friends and family, meeting Ivan’s need for social comfort.

Truthfully, I’m not sure Ivan would’ve had his needs met, he appears to be a very unhappy person to begin with. He pursues status and material belongings more than healthy social interactions. The interpersonal relationships he does have are all based on gaining more status rather than making connections. I tried to show how social comfort might have improved Ivan’s comfort, but I really doubt anything would have worked better than Gerasim in providing Ivan with any comfort. But even Gerasim’s comfort was more social than physical or environmental. Gerasim provided social comfort by being present with Ivan, not making demands, and allowing Ivan to keep him from his other chores (p. 37). Gerasim was calm and attentive; he met social needs for Ivan when nobody else in his family could. He enabled Ivan to feel that his comfort was important to someone.

When things go well...

...it may still seem like you got run over by a train.
In the room early to look over things and to make sure I can go see the patient as soon as I clock on. Get to the induction room and I am too late. Anesthesia is talking to the patient, not noticing me, and discussing an epidural. I wait a few more minutes to see if they will notice me and let me have a few minutes. Then the surgeon walks in. Well, I am not going to be talking to the patient any time soon and there is lots to do in the room still. I go back to the room and help my stressed out scrub start getting the room open. She's stressed because they put her in the room at the last minute and it's a big set-up with lots too do. I tell her to relax. The patient is getting an epidural so she has time to set up. I also am willing to let them know we can't bring the patient back until we are ready. Get more equipment and supplies and we get her scrubbed in. Others who don't have cases in their room, or they are are turn-over team or the induction room nurse help. I go to interview the patient. The family is outside the patient area waiting. They are taking pictures of everyone who is helping, including me. I take a few minutes to talk to the family about what I will do for them (call every couple hours with an update). I also let them know that even if they leave the waiting area, messages will be communicated when they return.
Anesthesia is done and I let them know that we can't go back until I talk to the patient. And yes, we are ready to go to the room.
That was the easy part. The start of cases can be very busy for the circulator, today was no exception. It was worse than usual because once we finished one part I had to move equipment out of the room. Then there was the pagers. Oh my goodness I hate doctor pagers! I would answer one page and sit down to do charges or charting and another pager would go off.
Well, by the time this case finished I was tired. So even when things go well, sometimes you are exhausted by the end of the case.

Working with the robot

Robot really is a misnomer. It is more like remote manipulation. Whatever.
I was in the robot room today. The really small robot room. The room is small, not the robot. About 15 minutes before the day was supposed to start my scrub calls me: the bus is running late, she might be a little late. She gives me a list of things to open, doctor uses the 3rd arm and we need the extra drape and another sealing cap. Got it. I go through the supplies and instruments. Make sure we have everything we need - and we don't. CS sent us two different manipulators, both are large. I need other sizes. No trocars in the supplies and the laparoscopy cart is missing the 5mm sleeves. Call CS, get the other manipulator sizes, get the sleeves from the other laparoscopy cart, open the whole room and my scrub walks in only a few minutes late. She grabs suture and scrubs in. I get her gowned up and go talk to the patient. Sweet couple, nervous but ready for the day. Doctor shows up and that ends my interview.
That really bothers me. I really need to not let it, but it does. Doctor walks in and all conversation stops with anyone else. I understand that the patient knows the doctor better than me, or even our anesthesia staff, but it's just rude. I have important things I need to know!
Get back to the room and get the robot draped and the camera draped. We are golden. Room's ready a few minutes before our goal time. I am even anticipating some of the things I will need. I actually felt really good about the set up. Get the patient in the room and things come to a screeching halt after the surgeon starts. OK, not a screeching halt, but it took a while to make incision. The phrase, I will be rude here, is "Tell her partner she needs to use the strap on more often." Just a joke, but the surgeon had a really difficult time getting the manipulator in the virginal orifice. We all laughed a little to ease the tension. They really are a sweet couple.
Otherwise, the case went well. Got relieved for lunch as we were finishing and came back to chaos. I felt lost. It took me a few minutes to remember all of the things I had to gather for the previous case then I was off and running. Turnover was a little long, but when you have relief staff I expect turnover to run a little longer.
Second case started out great. Then trouble crept in. I looked up from my charting and a fountain of red was giving the surgeon a reason for using the bipolar cautery non-stop. Got that under control, but the adhesions and the bleeding had shaken the surgeon a bit. Called in some help. Ended up with 5 surgeons and finished the procedure as planned.
Really, it was a good day. It's possible it's because the surgeon is really nice, generous with her praise and thanks. Even when things were going tough she was nice. She's awesome with the patients and I am sure she explained to our first patient's partner why it took us a little longer to get done.
Tomorrow is a Whipple. Maybe I can read a bit of my book on making leadership matter for school.

A day in the life of surgery

I was all set to work hard, turning the room over multiple times and getting through 5 quick cases. Well, the best laid plans...
First case went well, started just about as early as is possible. Except our OR lights quit working on us and I had to call engineering to come try to fix them. Called my facilitator to send for the next patient and come to find out s/he is not in the hospital. Can we get a hold of them? No, tried 4 times. Maybe they are on their way in? Finally we get the correct number and they didn't even know they were having surgery today, and they didn't have a ride to the hospital. Well, then let's start calling the next patient in early. Again, no pick up. We're done with the first case now and no next patient. The day is looking like it's getting longer.
Finally as we roll the patient to recovery we find out the 3rd patient is on their way in, will be here at the time they were supposed to check (in an hour) and the rest of the patients have been called moving their check-in time up. 2nd case is cancelled (so sorry, try again some other day when you have a ride and know you are having surgery).
I get a little break even after taking a copy of my degree to HR.
I go interview our next patient, who has been rushed through check-in and who has yet to talk to the pre-op nurse. I take my 2-3 minutes and go get the room ready. For some reason the pre-op nurse took quite a while to get our patient ready. Maybe the patient was chatty, s/he did seem to want to talk to me a bit.
Finally we are moving along again but in a different room because engineering is going to need at least 2 hours to fix the lights, it's not just a burnt out bulb apparently. Finish this case and go to lunch while another team, in another room is supposed to do our now 3rd case. Again, long delay in getting the patient into the room. I finished lunch and relieved the circulator so he could get lunch right before his relief arrived.
As the surgeon came in, I asked if I could send for the next patient. Yes. Went to the induction room and saw that patient. Nice quick interview, get my local and go open the room. Room is completely set up except for scrubbing in to set up the instruments. The facilitator scrubs and we finish getting the room ready. Surgeon walks in and about 3 minutes later our patient is in the room. Like a dream, like it's supposed to be done. Took all day, but we finally had a case go smoothly. For our part.
Still got done more than 2 hours before original schedule said we would, but it sure was a struggle.
As I said, the best laid plans...
Everyone was in a good mood, so no scalpel throwing - not that I could ever see this surgeon doing so, he's a real nice guy. Other surgeons, though, might have been having a bit of an issue with rising blood pressure. I just tried to make sure my part of the whole circus was done, left it up to everyone else to do the same. In the end, it was a nice easy day, long breaks and only 3 cases instead of 5.

Comfort theory - a bad example within perioperative nursing

As part of the assignment to explore comfort theory without our clinical practice, we are supposed to write a contrary story of comfort. Again I have no specific story to tell, but can glean a few tidbits from things I have seen or experienced (by doing). Enjoy.

Again, I do not have a good specific story to tell related to what comfort theory in the perioperative setting is not. What I can do is provide examples of behavior by some OR nurses that I believe does not promote comfort.

Bringing a patient to the OR can seem like a production line at times, to the staff and especially for patients. In light of this kind of feedback from patients, I question our push to get the next patient into the room as quickly as possible after completion of the previous case. This push to hurry comes through during our interview with the patient. I see nurses talking to patients rather than talking with patients. I see nurses ignore the questions on patient faces - patients want to ask but they can sense the hurry the nurse is in and don't want to interrupt. I also see nurses do an interview in such a way that they do not provide the patient the opportunity to ask questions during or after.
Being a new nurse, I am sometimes too eager to teach a patient about things. This has, on several occasions, brought about distress in the patient. They don't want to think about the drain, or the reasons for needing such a thing.
Catheters are a huge issue for patients. I must inform a patient if there is a need to place a catheter. It's an unpleasant procedure and a catheter can be very uncomfortable to have in place. Many patients ask "Why do you need to give me a catheter?" and ask if we can just skip that part. This does give me the opportunity to teach them the reasons for why it is needed, but it can still be distressing to patients. (Luckily, they get to be under anesthesia when I place it, that sometimes comforts them.)

At my place of work we are supposed to have the ability to "Stop the line" at any point in the process of getting a patient to surgery or even once a patient is undergoing surgery to make sure that safety is maintained. I once had to stop the line as the patient was rolled into the OR because we had just discovered a contaminated set and our Central Services did not have a ready replacement. I am sure this was distressing to the patient to lie on a stretcher in that cold, noisy room for 15 minutes while we scrambled around to get a replacement.

Sometimes a patient wants to know that you are the expert in that particular surgery. I can't lie to a patient, but telling a patient I am new is not the right answer either. I have to deflect the question, skirt around the answer the patient wants, instead I have to say that "We" do many of those surgeries here every month (or something along those lines). I can tell sometimes this is not what the patient wanted to hear.

Patients in surgery struggle with many emotions, most related to the loss of control of what is going to happen to their body. Nurses who do not keep this in mind while interacting with the patient are doing the wrong thing to provide comfort.

Comfort theory - a good example within perioperative nursing

We are exploring comfort theory in class. Our assignment this week is to post an exemplar story about comfort in our clinical setting. Here's my attempt at  this: 

I don't have a specific story of comfort to write about. I will try to gather the ideas that I believe have helped to provide comfort to patients in my nursing care. The most difficult part of providing comfort to a patient coming to the OR is that each of their experiences and circumstances make their situation unique. I must tailor my brief time with them while they are conscious to provide the best care (and comfort) I can.

Perioperative nursing is quite different from bed-side nursing. We have limited contact with conscious patients; rather our patients must trust us to care for them when they have lost all ability to care for themselves while under anesthesia or sedation. Patient advocacy is one of our biggest responsibilities. Some patients are well-prepared for surgery or are in such a state that surgery is something to "just get done with it." Other patients are not ready for the loss of control that they must experience just getting to the OR. We take their clothes away, we pry into their private information, question after question after question. Does anyone read the chart?
Interviewing the patient preoperatively is one of the most important forms of advocacy I do. I do an extremely brief head to toe assessment, gathering information about my patient in a multitude of ways. Some of the ways in which I comfort a patient during my interview are interesting to consider:

I introduce myself so I am no longer a stranger,
I assure the patient that I will be caring for them during surgery,
I make sure the correct patient is getting the proper treatment,
I make sure to verify important information about the patient (i.e., allergies),
I also make sure to ask about particular concerns, just in case the patient forgot (i.e., allergy to iodine or latex)
I make sure that the patient has an adequate understanding of what surgery they are having,
I inform the patient about the environment of the OR (cold, bright lights, narrow table, noisy, etc.),
I assure that patient that if they need anything at anytime they only need to say so,
I also inform the patient about what to expect in those first few minutes in the OR (i.e., lots of people talking, attaching monitors, placing SCDs, safety strap),
I then instruct the patient about what to expect when they wake up (i.e., hair removal, tubes and drains, catheters, funny looking skin from dyed soaps).

For the most part, patients seem to be calm and ready for what's next by the time I am finished with my interview. Some aren't, especially when I start seeing them get nervous about what it will be like after surgery ("I'm going to have tubes/a catheter?"). These patients are sometimes the most challenging. I try to pay attention to their expressions and tailor my instruction to what they can emotionally handle at that time. Some patients will state "The less you tell me about what you're doing the better." These are a rare exception, but it does cut my interview down significantly. Just as rare is the patient that thanks me when I am done for telling them everything.
The last question I have for my patient is, I think, one of the most important. It can also convey comfort because it lets the patient take control: Do you have any questions for me? If the patient does, I can offer them answers that usually provide further comfort (or find someone who can). If they do not have any questions, then I assure them that at any time if they do think of a question, they are encouraged to ask. I think giving the patient some sense of control of their situation can provide them with a great deal of comfort.

And now I return, an essay on leadership

It's been over a month since I posted, I realize that. It's been a busy month or so, getting ready to start my masters' program, etc. I feel a drive to get back to blogging though, so expect to see more activity. To start, here's an essay I had to write in class about leadership:

What do you think makes a good leader?

A good leader has the ability (vision) to see the ways that will lead the team (organization, class, group, etc.) toward the goals that have been given to or agreed to by the leader (and hopefully, group). Often leaders have some behaviors that are commonly found in those who manage people, but good leaders seem to always have these behaviors: integrity, fairness, honesty and a good grasp of how to best treat people with respect to get their cooperation or buy-in and enthusiasm for their work and goals. Some of the best leaders usually have the ability to figure out the strengths of those they work with and how to best utilize these (resource management).

What I have found makes a good leader for me is trust in that person to keep my best interests in mind when recruiting me to their cause. Knowing my values is not necessary, but not requiring me to do anything that is counter to my values to achieve the outcome desired by the leader is necessary.

A supportive manner is usually present in the best of leaders. Support to achieve the outcomes that are best for me, my patients, my family, the organization (this really can happen).

Excellent communication skills, the ability to express ideas in ways that inspires the team. Clear, open communication about organizational processes - keeping the team together on where they are going and how it is better for the team and our patients. Being consistent in how they treat their team, as a group and on an individual level. Nonjudgmental unless absolutely necessary for safety or discipline situations, but it should always be fair, non-biased.

I invite feedback and input. I only had a few minutes to write this essay in class, so I know I missed a huge number of ideas that could easily help me describe what I feel are the basics for a good leader. Some of the above stems from bad leaders I have had and me identifying that essential characteristic (or characteristics) missing that make our relationship rocky. I have had too many leaders that I have struggled to have any kind of trust in, maybe it's me, but I know that I have had leaders I trusted and those experiences helped me identify the reasons why I am not trusting a particular leader.

Thursday - Visiting Versailles

Thursday we went to Versailles.
We had our route planned. Ride our train into Paris, change to another train to take us back out and to Versailles. Getting from our train to the other was the most challenging part of this commute. Again, th

e tunnel systems of the trains and subways of Paris are amazing. Reading the French has become easier after 4 days, but their assumptions can still leave one wondering which branch to take when the sign 100 feet back indicated the way. We made our train, found some seats on the upper level and relaxed for the 45 minute ride. AM took the opportunity to snooze. I tried to take pictures of the changing scenery. The parts of Paris we have seen so far are old, with buildings that are sometimes hundreds of years old. The most modern skyscraper (the only skyscraper) was Montparnasse Tower. As the train left this part of Paris we saw some interesting mixes. The buildings became newer and taller - a more modern part of Paris? Then we left that behind and started to see the more rural, and charming, parts of suburban Paris. I am sure that each of the stops had their own names, probably from the village (or villa) that formed that particular community, just like Goussainville. But unlike our ride to Goussainville, this way had many more interesting stone houses and older apartment like buildings. Goussainville is in an area that is more industrial, somewhat like Tukwilla, warehouses, large buildings of industry. The settlements along the way to Versailles were more rural, more houses, more people living in the area. I would've liked to have stopped to look around, but we wanted maximum time at Versailles, and we had no idea if there would be anything of real interest, facilities or when the next train would come by (though that last bit would've been easy enough to find out).

Arriving at Versailles came quickly, at least more quickly than I had expected. It was the end of that particular train line, the train stopped, everyone got off and the train was cleaned and restocked before leaving. We headed straight out

of the station, took a look at a convenient map of the village (really a small city) and started in the direction of the palace.
We had left Goussainville rather late, so upon seeing cafes we stopped for food. The food was again delicious, though AM didn't care for hers so much. Buckwheat savory crepes, cooked a little crisp. We continued on to the Palace and were in for amazement. As we approached, it became evident that this place was huge. It really was a small city of it's own! They have been renovating the outside and the gilded ornamentation was outstanding. I was, of course, taking pictures every where of everything. As we got close enough to note where we were supposed to enter I ran into some trouble: the camera wasn't working right. I could take a picture, but then I couldn't take another without turning the camera off, then back on. We did some trouble shooting, including looking up info from online. Tried a new card, tried a new battery, took out the 3V battery that I never knew about and tried cleaning and placing it back in. I couldn't get the screen in back to come up, no menu and I couldn't tell if the pictures I was taking were actually being saved...my camera was in a coma. We determined that the 3V battery was probably dead, a replacement might solve our problems. We went into the palace, directly to the gift shop, in the unlikely hopes that they might have a selection of batteries available. No luck. A storm was approaching so we ran inside the start of the tour to keep dry. Inside AM ran for the audiotour while SK and I stood in awe, snapping pictures everywhere. I continued to take pictures in the hopes that they were being saved, but it was inconvenient to turn the camera off, then on again each time, so my picture taking dwindled significantly. We couldn't go to the garden (rats!) because of the storm. That was one of the reasons I wanted to come to Versailles, to see the gardens! I did get to glimpse them through the windows and doors occasionally, but it would have been nice to walk along the paths and get lost in the labyrinths of topiary.
Inside Versailles has been made into one long museum, gallery after gallery of wall art, statues and historical notes. SK and I had long lost AM. Most of the exhibits are appropriate and chronistic, some though seemed anachronistic and out of place in this Renaissance/Victorian palace. The chandeliers made of melted plastic black or red knives forks and spoons was really interesting, but seemed odd to be in Versailles. The giant shoes made from cooking pots and lids were again interesting, but really seemed out of place in the Hall of Mirrors. It was crowded inside Versailles, I am sure many people were staying inside to keep out of the rain.
After the amazingly appointed Hall of Mirrors, which also had the best views of the gardens I had seen, we went through a series of rooms, including the bedrooms of the Kings and Queens who used this palace. More odd art work, including crayfish on a settee. I felt awed by the history of the rooms, the people who used to live here. SK and I wandered through an area that had an amazing display of porcelain containers. The colors were vibrant and the details interesting. These seemed more appropriate as a gallery in Versailles than the odd new stuff.
One odd art piece, interesting, but still off, was a pair of lion statues covered in crocheted doilies. I understand the craftsmanship and appreciate that, but why? Somehow SK and I missed a whole wing of the palace, AM got to see it though. SK and I take a little more time than AM (in fact it kind of goes like this - AM speeds through, cramming as much as possible into as little time as possible; I take lots of pictures, read a little of the signs of those pieces that really interest me, but move on quickly, keep moving most of the time; SK wants to read everything-just about-on every piece, lots of stopping and standing). We were outside waiting for AM for maybe 10 minutes when she caught up with us after seeing the last wing.
We then tried to find a cathedral in Versailles, and a place to sit for a bit, as well as a camera shop and a new battery for my camera. The pastry shop was very interesting, with an interesting proprietress who spoke a little English, Spanish and of course French. She was really nice, helpful and friendly. She didn't think her English was very good, and she didn't always have the word she was looking for, but I encouraged her that it just takes practice. She did't think there were any shops with the kind of battery we were looking for, but we could probably find it in Paris.
After sitting, eating, drinking tea we headed toward the station to get a train back to Paris. AM did check out the cathedral, which was just behind our pastry shop. I had an interesting conversation with the proprietress. She claimed her English was not very good, and sometimes she did not have a word for what she wanted to say, but I encouraged her to keep practicing, that's the best way to get better. She admitted that her Spanish and French were better. I then tried a little Spanish as well. She was not the first person we had met that spoke more of a different language other French and English. She was very nice, helpful and seemed to enjoy our company and business.
We then started back to the RER station to return to Paris.
Again, the ride back was quite pleasant, seemed shorter than I had expected.
Once back in Paris we were in for a repeat of the night before. The streets were crowded with parties. Bands were playing on almost every corner. It was one giant party outside. We found a cafe in a small little back road that wasn't packed and stopped for dinner. Watching the crowds from a distance was nicer than being in them.
We stayed late, waiting for the trains to not be so crowded. When we finally travelled home there were Metro security at every station, the trains ran slow as security got on at every stop. I was going through some pictures on my iPad and security from outside told me to put it away. I didn't understand why until the lady in front of us explained that there were thieves about. She even tucked her jewelry under her shirt and moved her purse to a position that would make it harder for a thief to grab from her.

Makes me appreciate my own neighborhood - no need for security guards, usually.

Tuesday in Paris - Buses, roads, rivers and boats

Tuesday We tried to get up early, well I did, but this morning it was SKs turn to delay our departure. He was exhausted, still, and when I woke him up he seemed a bit confused. He admitted he had been dreaming were we in Paris...oh, wait, we are. Today we decided to take it a little easy on the feet that are not used to walking so much. We did Les Cars Rouges, a hop-on, hop-off tour of part of Paris. We got on at the base of le Tour d'Eiffel, it took us around to the other side, stopped for a few seconds for the photo op and to pick up more passengers. As we head away from the area of le Trocadero, I notice a restaurant that SK has been looking for. The streets of Paris are amazing. There are the small, charming alleys, roads with rows of buildings with many windows and roofs bristling with chimneys. There are huge avenues, where cars careen chaotically from one side to the next, the monuments ignored by the motorists. Huge monuments line massive squares, that in earlier ages provided armies an area to parade. The traffic is amazingly horrific. Cars zip by, cutting each other off, motorcycles and scooters rush to the front, bicycles are out there too, zooming by. The bus stops and starts sporadically as the lights change and we move forward to the next intersection. The Place de la Concorde is breathtaking in is grandness. It is huge, with huge monuments, including an obelisk that was a gift to France from Egypt. We head north along la rue Royale toward the place de la Madeleine and l'Opera. Both of these buildings are amazing. The church is surrounded by pillars, somewhat like the Parthenon. The doors are so amazingly huge. You could ride giraffes through the doors and there would be plenty off room for fancy , really tall headdresses on the giraffes. When we had noted the building on Monday, the doors were closed, today they were open and we wanted inside. We never did make it back. Maybe next time. We wind through the narrow streets of Paris, entering the chaotic roundabouts, turning until we find our exit to the next destination. The Champs Élysées is a parade route from the kings of France. It is wide, tree lined , lined with shops of every kind and leads straight to the Arc de Triompe. It's huge, magnificent, grand, amazing. And how do you get to it? We didn't stop to visit, though I would like to do that if I return, and I found out later that you have to use an underground tunnel to get to the Arc from the outer walkways. From the Arc we returned down the Champs Elysees and stopped at Les Invalides where there are museums of the Navy and Armed forces. The buildings are beautiful, the statues commemorating heroes of war from around the world are golden. From there we returned to La Place de la Concorde and around to the road leading back along le Riv Droit (Seine River) passing by le Louvre and toward Notre Dame. Another amazingly huge building. The details are amazing and plentiful. We then returned along le Riv Gauche, passing by le Musee d'Orsay. Le Louvre is HUGE. We walked around most of the building the day before, but would wait until Wednesday to go inside. The Musee d'Orsay was where we had encountered the ring-finders. Now it was crowded with people going into the museum, no ring-finders in sight. We returned to the Tour d'Eiffel and decided to get some lunch. We tried to find La Terrasse, but found another cafe instead. One suggestion made by one of SK's coworkers was to order a "pichet" of wine. A bottle of wine is usually 75 cl (or 750 ml) and contains about 6 glasses of wine. If only 2 people are drinking the wine, that's quite a bit of wine. A pichet can be available in multiple sizes, usually 25 cl or 50 cl. SK and I enjoyed the 50 cl size, and usually ordered that or the 25 cl size during lunch. You have to ask for water at meals, it is not automatically served. The Parisiennes tend to order bottled water, Evian is popular. We tried a few of the mineral waters, AM didn't like them much. I found them flavorful, some more pleasant than others. Most of the water is also carbonated. I preferred the "still" water. Almost every sit-down cafe serves crepes or sandwiches. Take-away stands will sell wonderful ham and cheese warmed baguette sandwiches. After lunch we continued our sit down tour of Paris by taking the boat tour. The boat was boarded at the foot of the Tour d'Eiffel. We traveled west along the Seine seeing beautiful buildings and sights. Many Parisiennes sit along the banks and wave to the boats as they go by. We turned around and returned along the left side of the river.

Wednesday in Paris - Cathedrals, ruins, museums and subways

Wednesday We tried to visit the insides of places today. We visited Notre Dame, the Museum of Public Health in Paris, the Museum of the Middle Ages and the Louvre. Notre Dame is amazing. It is old, it is beautiful, it is full of detail and history.We spent a good deal of time here, walking around the outside, walking around the inside, being awestruck by the age and beauty of the place. It also holds a bit of sadness. Sadness that we have spent so much time, energy and resources in making such places to continue the brainwashing of people. I tried to ignore that part and just enjoy seeing such new (to me) things. Of the three museums, I enjoyed the displays, and the fewer people, of the Musee de Moyen Ages. The Musee d'Assistance Publique de Paris was a lot of pictures, very few artifacts. The few they had were really cool. The early EKG machine was an amazing contraption. It didn't state it on the description, but I knew that it required the patient to sit with their feet in buckets of water to help the machine pick up the electric currents of the heart. The instrument sets were filled with recognizable instruments (to me). There are very few buildings which have air conditioning. Most of the museums were so warm we were getting over heated. It was refreshing to go back outside into the 80 degree weather. The Musee de Moyen Ages was inside a building that harkens to an older time, though I don't think it was actually that old, maybe it was. It was filled with artifacts, paintings and armor from long ago. Some of the items were amazing. We were there late and SK and I were hurried out without seeing the last half. We discovered that le Louvre was open late tonight, so we decided to brave the lines. Before leaving for le Louvre, we tried to find an ice cream shop SK was told about. After wandering around a bit, we did manage to find the shop, closed. Nearby shops that were still open sold their ice cream so we managed to get a scoop to share. It is very good ice cream. Taking the hop-on hop-off bus we made it back to les Invalides (where the bus stopped for the night). We walked across the bridge to le Tour d'Eiffel, then decided to find La Terrasse. I remembered to look at the details while on the bus and found it fairly quickly. It still involved much waling. The food at La Terrasse was, as expected, wonderful. We then tackled le Louvre. Finding simple cool drinks and restrooms in Paris proved to be challenging at times. AM took off into the museum, SK and I looked for some ice tea and a rest room. We found a wonderful tea shop, with a magnificent selection of teas both chauds and froids. Thinking back, I believe this shop was the one I was directed to at a later date by the Mariages Freres tea shop when I asked for iced tea to go. We refreshed ourselves then tackled le Louvre. Getting in required a security check. Then we had to decide what to go see first. As it was we only saw part of one wing, and even that we rushed through, stopping to snap a picture or two or discuss the history of a piece of art. Our time frame was to meet AM outside in 2 hours. This concept of giving ourselves a half hour, an hour, 2 hours in a museum seems nice, but really is impractical when you are talking to an artist who has studied the history of many of these artworks, and someone who is trying to live a dream of visiting such a wonderful place. We had a limited amount of time, and we managed to see some of the highest priorities. We missed seeing the David sculpture, never found it among Michaelangelo's collection because it was in a different gallery. I can tell you, the best part of the Louvre was having along my own student of art who talked to me about the history of certain themes and art styles, the ages of sculptures, the influences of this art style, why this particular artist was so innovative... After le Louvre, we found our way back to the Metro under a very art nouveau sign. It was during this trip "home" that I had an experience that I had heard about in other countries, never really wanted to experience myself, and now, having experienced it, never want to experience it again. As we waited for the Metro (subway) to take us to a station near Les Halles so we could transfer to the RER to Goussainville, the crowd grew continuously, a few people here and there until the platform was full of people. When the train arrived there was a massive push of people through the open doors. We had arrived early so we were near the front and were shoved right onto the train. We had only one stop until ours so we tried to stay together near the door. People kept pushing their way onto the train until we were packed so tight you could barely breathe. At this point I was getting very uncomfortable, strangers touching me on all sides, can't even turn around, if someone managed to open my backpack and take something out, I wouldn't be able to do a thing about it...I can barely breathe we are packed in so tight. I almost started to try to get back out before the doors closed, but the alarm sounded and the Metro is automated, so they warn of injury if you try to get through the doors after the alarm sounds, and people were still trying to push their way on! The doors closed and we started moving. I had a hold of the pole, so I could maintain my position, not that it really made much of a difference, I wasn't going anywhere the people were packed to tightly. During the short, which seemed very long, trip to the next station my mind wandered to wondering what could happen if the train got in an accident at this point. All these people panicking if the lights went out, or the train suddenly stopped or broke down...PANDEMONIUM would surely erupt. I really didn't want that to happen, not with me right in the middle of all these strangers who wouldn't understand me as I tried to calm the chaos. Yes, I don't ever want to be on a train that is so tightly packed with people again. I would rather walk to the station I want, or wait until the crowd lessens so the train is not so crowded. At the Les Halles station we pushed our way off the Metro and tried to get oriented. We identified the "Sortie" toward the RER platform and headed in that direction. The crowd thinned out and we were suddenly alone in the subway tunnels. That seemed to indicate that the RER would not be quite to crowded, that was a relief. The rest of our trip home was uneventful, though I noticed transportation security at every station, including our own. They seemed to be providing a presence, and to prevent the young men who are constantly hopping over the ticket taking gates. We made it back to the hotel without further events, except we walked around the field since the puddle was big from earlier rains. I found a slab of marble that had been tossed into the grass. The slab had shattered, so I picked up a few pieces to bring home for KW.

Monday in Paris - Overwhelming, wandering, streets, buildings and parks

Day 1 in Paris
Our room came with the remains of a previous tenant. The poor moth probably died of starvation.

I was up very early, local time, about 3 am. I had been sleeping for nearly 10 hours and I was excited and hungry. I occupied my time, waiting for it to be a more appropriate time to wake the others by eating a the rest of the mini beigne du caramels I had bought the evening before. I figured out how to get onto the WiFi, started journaling and checked my email. I finally got a little sleepy so I decided to see if I could sleep just a bit more. That's when the storm hit.

Loud cracks of thunder to drown out the road and airport noise. The rain is amazing, it filled the streets with at least an inch of water. I opened our little door/window to let the fresh air in, watch the lightning and rain. We don't get these kind of storms very often in Kirkland, it was a treat. As the storm started to die down I showered since it was getting close to the time I would need to do so to start our day at 8 am. I was still hungry, so I was planning to be down at breakfast by 7 am when it opened. At one point during my shower, SK was moving about in the room, then suddenly the lights went out. I was in the middle of washing my hair so I had the water off and didn't notice right away. As I was rinsing out the shampoo and I could finally open my eyes I saw that it was very dark. As my eyes adjusted I could see a little and I finally noticed that light was coming from the door. I yelled out to SK and asked if he had turned off the lights to the bathroom. He said he didn't think he had, but when he flipped the switches my lights came back on. I finished my shower and proceeded on to the rest of my day. But more adventure would happen before we even left for Paris. As a note, I am aware of the custom in Europe for bathroom use: the shower was not very conducive to relaxing in a warm stream of water. It is designed to be held with your hand. The idea is that you rinse off (get wet), turn off the water and lather up, then rinse off. Repeat if needed. I immediately figured this out upon inspection of the shower the night before. I explained to SK that this is what should be done. We had been told by another friend, AP, who was born in Israel that this was common in Europe. We left our room, making sure we had our key card, and wandered down to see if breakfast was ready yet, and make sure that AM was.

After showering, we headed down to breakfast. It hadn't started yet, in fact the lobby was blocked off by a metal door. We knocked on AM's door on the way back to our room and found her to be just getting up. So we decided to return to the room to finish getting ready. The key card wouldn't work! We went back downstairs to wait for the reception desk to open. Why we didn't think about calling? I don't know. Maybe we were still adjusting to being up at the opposite time of day and our brains weren't caught up. Breakfast was warm mini baguette, warm croissant, warm chocolate pastry, sliced emmental cheese and ham (the French seem to love their ham), sliced cucumbers and tomatoes with some plain yogurt dressing. A coffee machine for fresh cafe au lait or express, and the cafe cappuccino turned out to be more mocha-like. I grabbed a couple packets of soft cheese and a madelaine to take along. I did end up eventually eating the madelaine and one of the cheese packets, the other decided to spread itself across the inside of my backpack.

Monday morning, after these fine adventures, we headed into Paris to see what we could see. Getting into Paris was no problem, we knew where the RER station is and there is only one that stops in Goussainville.

We needed to find our way to the places that had our tour packages so we started for those first. AM had a very handy app that would map out our route, works for any of the transportation systems. Sometimes, though, it will lead us in the wrong direction, or we are interpreting it wrong and head off in the wrong direction. The transportation systems in Paris are amazing. They have surface street buses, a subway system (Metro), the regional train system (RER) and high speed trains. They also have taxis, rickshaws, bicycles for rent everywhere. The system of tunnels that need to be navigated from getting off a train to getting on the next is absolutely confusing. The signs, for the most part, are good, but there seems to be less assurances along the way that you are going in the correct direction.

The French often run through these passages trying to make their next train. There are lots of stairs, few elevators, some escalators, especially for the really long ascents/descents. The tunnels are not spotless, but for the most part they are not terribly abused. We managed to get off our train and have to figure out how to navigate this maze of tunnels to get to our next train, or up to the surface. We did some quick option consideration and then tried to find our way to the next transportation. What a maze! Up and down, twists and turns, it just kept going. Finally we felt the fresh air of the surface and found ourselves on the streets of Paris, overwhelmed by the sights already.

After a flurry of picture taking, we started moving in the direction of our destination, which was supposed to have our 5 zone pass for 5 days so we could use the transportation systems without having to buy extra zones every time we needed to get back to our hotel room. We eventually found that, but only after stopping at each new site and taking many pictures.

We got our passes, but they ended up being for 3 zones. Grrr. We then headed for Hard Rock to pick up our Paris Pass that gets us into everywhere except the Eiffel Tower and includes the hop-on hop-off bus tour and the boat tour.
We then found a need to eat. The food is incredible. We haven't had a bad meal, or snack yet. We stopped at a Starbucks and got some French chai tea. Ok, really it was the same, but you can't get chai tea from most French cafes, restaurants or snack stands (known as brasseries). The cashier was very nice and gave us a card so that if wee buy 10 drinks while in Paris we get one free. So much for rude French people!
We then started wandering around trying to see the sights. The skyline of Paris is unique (to me). The roofs bristle with chimneys. I've seen this before in movies that show the buildings of old Paris and London. They harken back to a time when everyone used fireplaces to warm their homes. The buildings run continuously for blocks, sometimes. Lots of windows, little porches with iron work and hidden inner courtyards. Everywhere I look I am charmed. I don't feel like I am a typical tourist. Most go to places like Paris to see Le Louvre and Le Tour d'Eiffel. I want to see those as well, but I am also taking photos of the typical buildings of Paris, the ironwork, the streets. I find these just as interesting, and somewhat more enjoyable as the crowded famous attractions. We were attracted by a large and ornate building. We walked down alley ways toward it, through renovation work on Nouveau Jardin. The building was the church of St. Eustace.

As we were leaving this area, an older gentlemen stopped, looked me up and down and said "C'est bonne!" I just said "Pardon."

We walked the streets, being pulled in a direction that held something that looked interesting. We walked through an area of the Jardin Tuileries. I of course am trying to capture everything in pictures, while enjoying the sights. At one point I noticed some goats being used as lawn maintenance (keeping the grass and weeds short on the edge of the park. I took a picture, because I like animals and don't get the opportunity to see them up close very often.

At one point a women started scolding me for being a "Typical American woman taking pictures of the poor trapped animals." It was an interesting one-sided conversation. I again said "Pardon." and moved away. As I turned and observed her from a distance she was "baa-ing" at the goats and talking to them. I think I had just encountered someone who needed a few more meds. She eventually turned and jogged off, appearing for all the world to be a normal person out for a morning run, but I suspected this was not really the case.

We wandered through the area of the Musee d'Orsay. It was here we encountered another interesting character. I am busy taking pictures of everything, my eyes are not on the ground, but up looking at the buildings, the shop signs, the people. Suddenly I see a woman and child coming toward me and the woman is reaching down to pick up a large gold ring that she noted on the ground. She holds it out toward me, tries it on to show me it is too big, she insists I take it. I try to tell her to sell it or give it to the police. She insists I take it, she is allergic to metal. The ring has a decent weight to it, but I quickly realized that even though it looks like gold, it can't be. It's about now that the woman and child turn and come back. She asks me for some Euros so she can buy her son a coke and sandwich. I empty my pockets of change (about 2 euros), just because I enjoyed the entertainment of her little scheme. She seems disappointed, but I refuse to giver her any bills (I didn't have any small bills, anyway). As get closer to the Musee d'Orsay I am accosted by several more of these prestidigitators. After that first one, though, I am seeing the whole thing as they bend down and the ring appears from hiding in their palm to their fingertips. I of course just state "Ah, you already got me with that one!" Within the area outside the closed museum (just about everything is closed on Monday) I am accosted by another 4 tricksters. They are all targeting me...not sure why, maybe it's the huge camera around my neck, I am the only one with a backpack, maybe I look like an easy target. As we leave the area to return to the north side of the Seine, I am targeted by one more. I believe 6 times, including the first. We speculated on how we should handle more of these tricksters, SK wanted to buy a dozen and wear them, when the trickster brought the ring up to insist it was ours he would count out the rings on his hands and say, "No, I have all mine, it must be yours." We all laughed.

We then decided to go get a view of the city from on high. MontParnasse Tower is the highest skyscraper, really the only skyscraper, in Paris. Apparently it is not well liked by most Parisiennes. It does stick out from the surrounding charming older and much smaller buildings. It offers an excellent view of Paris from the air, and that includes the Eiffel Tower. I would've loved to time our visit to the 56th floor of this 59 floor building to be in the evening or at night, but almost everything closes up around 6 pm. The view was spectacular. I took many pictures, was able to identify many of the landmarks and we saw some interesting things.

We ended up going to one we saw from the tower next. A cemetery. I am sure there are some famous people buried there, we did see the tombstone of Sartre and his wife. There were some amazing family crypts and mini monuments. Many of the graves dated back to the 1800s, didn't see anything older than than. There were some disturbing things too. One tomb had the picture of a baby that had died at the age of 2. Another had an inscription of several people, the last not including the date of death. The tomb is waiting for her to join her husband who is buried there. We then found our way to the base of the Tour d'Eiffel. It is huge, it is amazing, and it is popular. They only had two of the pillars open for letting sightseers up, one of the elevators was down to the upper level, making the lines even longer than usual. I would love to go up the tower, especially after dark, but I hate standing in lines as it is, and with a city full of sites to see I feel like my time is better spent elsewhere. We took many pictures from close up and far away.

We then proceeded to look for a restaurant that was supposed to be close by that one of SK's coworkers recommended. We didn't find it, but we did find some good food anyway.

We then returned to the base of the Eiffel tower to watch it as it was lit up in preparation for the light show. In my opinion, the Eiffel tower is best viewed at dusk, from below. They light it up from inside, you can see the intricate iron work and beams that make up the structure. And the orange-ish lights contrast with the cerulean sky to an amazing effect. We then proceeded toward home. Coming home that night, after a long day of random exploration, we were tired and ready to collapse satisfied with our accomplishments.

Getting from the airport to the hotel

We then tackled the idea of getting from Charles de Gaul airport to our hotel in Goussainville. This also brought us face to face with the really of being in a foreign country.

It's like they speak, read and write in a foreign language here.

I can read enough to get a rough idea, I can understand a bit too, especially if given time to translate in my head, and if they use simple language and speak slowly. My speech, of course, is heavily accented, I really do try to properly pronounce things, but I know it must be atrocious. We decided to try the RER to the hotel rather than calling for pick up. I regret that decision now, but it was, now looking back, kind of humorous. We found our way to the RER station, taking a train from our terminal to the next. We found the ticket machines, though it took a couple of machines to get one that would accept our credit card, then we tried to fathom the directions on which gate to go through for the train we wanted. The real confusion started then. We had the tickets, but couldn't get it to work. I noted a sign that displayed a ticket saying ti wasn't accepted at the airport depot...but that's the one we had. We finally got the correct ticket to get us from the airport to Paris, then from Paris to Goussainville. There was no direct train. Up to this point I had been pronouncing Goussainville like Goose ane vill, but at the airport they couldn't understand that and it turned out that Guiss ane vill was the accepted pronunciation. More about this later. We figured out which stop to get off the train from the airport into Paris, Gare du Nord. This is a large junction where several RERs can be transferred to and you can transfer to the Metro (subway) or to a train. I believe on the surface you can also catch a surface bus. They have 5 public transportation systems in Paris. We knew which train we needed to Goussainville, but found it difficult to determine which bay we should be at to make sure we were going in the correct direction, north, away from Paris. The display information on the incoming train showing where they will be going next, so that is very helpful, but they never display the station you are at. The permanent schedules displayed can be more helpful there. After much milling about, a little arguing on interpretation we found the correct bay and train. We bought some of our first French food there too. Donuts are called beigne, I got some mini beigne de caramel (filled donut holes) and a friand fromage, a cheese filled square croissant-like bit of heaven. We got on our train, a bit of creative seating to accommodate our luggage. I packed light, but I still brought along a larger bag - room for treasures to bring home! AM suggested one set of seats, but I knew it would end up blocking the way with our luggage. We found a set of facing seats and crammed our luggage in, standing next to the filled seats. For a Sunday afternoon, the train seemed to have quite a few people. We carefully watched for the stations we stopped at, not quite catching what the soft-spoken announcer said. We then had our next surprise. As we approached our station, we prepared ourselves at the doors. The train stopped, the doors did not open. We tried pushing the button, turning the latch, but I guess we had waited too long and the train started off again. At this point we did think it was funny, we knew we could just get off at the next stop and take the next train south. I also was frustrated because I had this huge luggage that had to be lifted off the train and carried anytime we had to navigate steps. We got the door figured out and got off the train at the next stop and then proceeded to figure out how to get to the other side of the tracks to catch the next train south. This required going down stairs, under a tunnel and up more stairs. Oh joy. The next train came soon and we got on staying at the doorway since we were getting off at the next station.

At Goussainvile we managed to yet again figure out the door and got off. We weren't there yet, though. Once we figured out how to get out of the station, we needed to find our way to the hotel. AM kept saying that it was only 10 minutes walk, but in which direction we had to figure out. Lucky for us the station attendant spoke a little English and had a map to help us.

Her map, though, did not show some newer developed areas and her directions got us lost. We were supposed to walk all the way to the end of the street from the station then turn right. We actually needed to turn right before the end of the paved road. At this point we had been up for more than 26 hours with only plane naps, I was very tired and annoyed because I had stated that I did not want to be dragging my luggage through the streets. As long as we had paved sidewalks I had said it would be OK, but we didn't. We walked for more than 10 minutes, came to the end of the road and found we could turn right. We backtracked, discussed the situation. AM offered to scout, but I was not going to wait so we all started off across a dirt path. Not what I wanted to be doing with my luggage. AM was out front and shouted back as she approached the end of the trail that she saw our destination. Good! We still had a ways to go, because the parking lots to businesses are all fenced in you cant walk through them. We skirted the store's lot and found the hotel. crossing to it, though, was a dangerous proposition. We finally managed to get across the busy road with the blind corner and found the hotel completely fenced in. We finally hit an intercom button at the car gate and got someone to open the gate for us. Once inside the hotel we thought our adventures were coming to an end for the day. Wrong. At first the reception desk lady, with pretty good English, said our reservations were cancelled. We were about ready to panic. AM had made reservations through Expedia and they had booked the hotel rooms with her and I together and SK in a room by himself. AM had cancelled those reservations and had them do it the right way. So she kept trying to explain that to the reception lady and she took another look through her pile of papers. She found our reservations and we heaved a collective sigh of relief. Then we had to decide if we wanted the breakfast they served and WiFi. We said yes to both. Our key cards, codes for WiFi access were prepared and we were given instructions on what to do if we came back late, when breakfast was served, what breakfast entailed and how to get to our rooms. I immediately started up the stairs, thinking it's only one flight to the second floor, I wasn't going to trust the elevator, yet. I get to the second floor and it's not ours! They have designated the ground floor as single digit numbered rooms, then what we would call the second floor is the first floor here. I climbed another set of stairs, arriving at about the same time as the adventurous AM and SK in the elevator. We got to our rooms, and as far as I was concerned, I planned to stay until I had gotten at least a few hours of sleep. Mind you, we landed at CDG airport at about 1:30 pm local time (that's about 3:30 am back home). We left Kirkland at about 11:00 am (the second time). While AM and SK had managed to sleep a bit on the planes, I had only nodded off for a few minutes at a time. It was almost 6 pm local time and I was utterly exhausted and starting to get a bit cranky. We walked down a hallway of many doors, found chambre 220 and opened the door.

I smelled the stale odor of cigarette smoke, even though the room was supposed to be smoke-free. Besides that, our hallway sized room, with a small queen and day bed and postage stamp sized shower filled bathroom was home sweet home for the next 6 nights. I almost immediately unpacked my essentials (toothbrush, etc.) found the shirt I brought along to wear as a nightie and collapsed into bed. We had arrived in Paris!

Getting to Paris

The adventure started Saturday. I woke up early, with the excitement everyone gets when they are eager to get something, or start something new. I couldn't get back to sleep , even though I knew that sleeping in would be a good idea. Even though I had to work until Friday, I only had a few more things to add to my packing. SK, on the other hand, took all the way to 1030 to finish, even though he had had the last two days off. We left early, with the idea of getting an early lunch before going to AM's house to park the car and get the ride to SeaTac. Stopped for lunch and arrived just in time. I parked up top to unload, and regretted it immediately. My car is very hard to see out of when backing up, especially when you are trying to do so going down a hill. I backed up the 50 feet, hoping the whole time I wasn't going to damage someones car, fence or other valuable near the drive. Parked the car down below and removed all the important papers, leaving them inside AM's house. Got to the airport plenty early, checked in, and breezed through security. Woohoo. I'm going to Paris! Changed some money into Euros, rate is about 69 right now and searched for a bathroom so I could put on the underwire bra I chose to put in my carryon to avoid that awkward necessity of having a complete stranger grope me under my breasts. We got water for the flight, staying well-hydrated is supposed to help lessen jet lag and watched the runway as planes left Seattle. About an hour before boarding we got a light dinner at one of the restaurants. We didn't know if food would be available or not. We also made sure we had snacks for the flight.

 
Boarding call was chaotic, as usual, but we made it aboard and walked almost all the way to the back of the plane. Behind us were 8 young children and their parents. Does this flight seem to have a lot of kids? There were more scattered throughout the plane. I could tell when the kids had reached their limit of no play, constant noise and lack of sleep. It was especially a bad time for one parent whose child may have had a bit of congestion and the descent seemed to be painful to those of us with hearing. One other feature of this flight was a terribly uncomfortable seat which caused my tailbone to remind me that it was not happy sitting so long. And finally, it was HOT. The air in the cabin was too warm, the air vent could barely be felt. The sun was very bright on my side of the plane contributing to the heat. So I was too hot, on top of not being able to sit back in the seat for more than a few minutes because of the tailbone. I thought the food was tasty, though quite expensive. I stuck with water to drink and ice to try to cool down. The free inflight movies were nice - watched Sherlock Holmes again, a cute animated show about teen Thor, a documentary on Iceland and bits of over things. I tried sleeping, but the heat ad inability to sit up hindered my attempts. Leaning forward and supporting my head on the tray with blankets and a pillow was about as comfortable as I could get, but I couldn't breathe well. Iceland, at least in the area of the Keflavik airport, Reykjavik, is very flat, and a bit desolate brown. There were many beautiful lupines all over the taxi- and run-way borders. The people of Iceland seem to be very friendly. We breezed through customs, they checked my boarding pass, the passport picture against the real face and I am now allowed to travel to any European destination without going through customs again. We actually didn't put that together 'til later. We were supposed to have almost an hour between landing and the next flight, but our plane must of had a bit of a head wind and we had just enough time to relieve our bladders and go to the next gate for boarding. Boarding was handled differently than I have experienced before. They opened the doors and everyone started going through. They checked our boarding pass and passport for the custom's stamp and identity, but they didn't call for parents with children or those needing assistance first. It was first come, first gets on the plane. We were just about at the very back again, in fact same seats, different plane. This time, however, we did not have 8 children behind us. There were still children aboard, but not as many as from Seattle. I again got to experience the rush of takeoff. By this time it was about 2 am by our body clocks, though it was brightly lit and about 8 am. I was really tired. For the shorter flight I tried sleeping. The seat was better, but without additional pillows and blankets it was difficult to prop myself up. I also kept peeking out the window: I saw the Isle of Skye, south Britain - Brighton and the country of France. I was unable to see the cliffs of Dover - it's amazing how the clouds follow the coastlines of land masses. From the air, France is very green. The fields are well defined. The forests are tiny. From the air Kirkland still looks like a forest in my neighborhood. There are enough trees in France to make a neighborhood look like a forest. The forests are bounded by fields and roads. As we got close to Paris, I kept looking out the window to see if I could catch a glimpse of the city from the air. On final approach I did finally see the Eiffel tower, barely. We made a definite landing and all weariness went away. We claimed our baggage, after a delay, but faster than I had expected since we had checked in early and transferred flights in Keflavik.

I experienced a sense of deja vue when we started from the plane toward baggage claim when I realized that the people movers were the same we see in one of my favorite movies, French Kiss. They move fast and I was almost literally swept off my feet. After the first people mover we went up some escalators, then to more people moves through tubes. After getting our baggage we looked for customs, only to discover that going through Iceland is good enough for the entire European Union. No stamp of Paris in my passport?

A journey in reflection

The text to my slide show for my final presentation in my final class for my RN-BSN:

Reflectivity

Is seeing the details
Sometimes the details are endless
Sometimes the details are calm
Sometimes the details are chaotic
Sometimes the details follow a pattern
We are all looking for patterns
Details and patterns matter
Details often make the difference
So does our wellbeing
Look out for yourself
Enjoy the meal
Enjoy the activity
Drink in the details
Take time to notice the colors
See the reflections
Don't forget the bigger picture
Sometimes the path is easy to see
Difficult to get to
Obstacles may be high
Goals may be far away
Let your imagination fly
Find a way that works for you
Reflect on goals and accomplishments
Take time to enjoy the flowers
Take time to enjoy the details.

I'll post pictures later.

Welcome to my co-authors to this blog

During the last 3 months I have been writing a blog as an assignment for my reflective practice class. I have invited my co-authors from that blog to join me as they like to this one. Please welcome Sabina and Atefeh, who may or may not post here in the future. I hope they do, for I felt it was helpful to see their world of nursing.

SBAR #1

Situation - basically healthy 50-ish year old in for a total abdominal hysterectomy for a fast growing fibroid uterus. She is very thin, the fibroids are so large you can see her uterus pushing against her abdominal wall up above her umbilicus and to the left side.
Background - she has waited almost 5 years and suffered with heavy bleeding before coming to seek medical care.
Assessment - starts out as a relatively routine hysterectomy, turns into a life threatening event requiring 6 units of packed red cells, 2 units of fresh frozen plasma and leaving the OR intubated and directly admitted to the CCU.
Recommendation - calling for help early.

True story.

I was overwhelmed at times, but I got through with the support and help of my colleagues. Just as I was feeling the need to get help, help arrived.
BC, the nurse anesthetist (CRNA) asked me to call the blood bank to order blood. The surgeons asked what the blood loss was. There was only 300 cc in the suction canister, but I pointed out that the sponges were saturated, the surgical drapes were saturated and I could see that the linen under the patient was getting saturated. The surgeons agreed to order blood.
At one point there were 3 anesthesiologists and CRNAs, 2 anesthesia techs, 2 surgeons, 1 PA, 2 surgical techs, a helper RN and myself in the room dancing through our tasks. I couldn't keep track of all of the conversations.
Until Beth showed up, I was slowly losing ground in keeping up with all of the requests. I had been reaching for the phone to call for help when she showed up. At first I thought she coming to give me a break, I started shaking my head, meaning that this was not a good time. She then asked if I needed help. I wanted to hug her! We started working together to provide supplies, get equipment and chart all of the interventions being done. It truly was a dance.

The surgeons eventually finished their tasks. They slowed the bleeding, applied various hemostatic agents and closed the incision. BC and his attending tested the patient to see if she could be extubated, and determined that was not going to happen.
Getting the correct bed so the patient would go straight to CCU was a mix up since BC and his attending at first wanted to go to recovery then CCU.
I had Thursday off, to go to classes, and when I returned to work Friday I heard about my patient: she had returned to the OR twice to look for further bleeding. During the second time they didn't find much to concern them - the bleeding had slowed or stopped, finally.
I met up with BC at one time during the day and he thanked me for my assistance during the case and updated me further on her progress. She is doing better, may be extubated today or sometime during the weekend.


One frustration of my job is that we rarely hear about our patient's after they leave our care. HIPAA has made it so that looking at their records is not acceptable. Knowing that someone who is so critically ill is getting better is an amazing thing, especially if you took part in their care during such a critical time. I am grateful that my colleagues at work are so generous with their thanks and information. We aren't violating the patient's rights in a way that endangers their dignity or privacy. We cared for them, we care for them still, we are interested in their continued well being or outcomes.

First day of "independent" practice

Overall, a good day. Started out kind of rocky, but things smoothed out and went well.
My boyfriend lost his name badge and spent 20 minutes looking for it when we should've been on the road to work. So I did not get to work as early as I would've liked. I was not late, but I had no extra time to look things over.
The night staff set up the rooms so the first case of the day should be ready to go, except for opening supplies and instrumentation and setting up the sterile field. The cases got switched and there is not a mechanism in place to make sure the room is checked for the appropriate equipment and supplies. The OR table was set up wrong and our case cart was missing many items. I had to call for equipment, grab the positioning devices and my scrub called CS for supplies needed. Overall, we were only 9 minutes late into the room.

Last day of orientation

Friday was my last day of orientation. It was a whirlwind ending: my preceptor made herself available, but explained she had a project she needed to complete if I could work on my own. I had been doing the Litho room since the previous Friday and felt comfortable, so I said she was fine working on her project.
The first case went well, had to scramble to finish my charting before the case ended, but otherwise I felt really good about the flow of the case.
Then the patient went into laryngospasm after extubation. I knew it, I knew that wheezy sound. My scrub, who is really good at her job, jumps in to help the anesthesiologist, but doesn't know the drugs that are being asked for. I try to get in at the head of the table to help, but the scrub won't relinquish her spot. I also start calling in help: the anesthesia tech, and my preceptor. I pushed propofol in then I grab the succinycholine for the anesthesiologist, she asks me to push that in as well. She gets an LMA in, then tries to get an endotracheal tube in. The anesthesia tech is in the room and is helping as well now. No fogging on the ET tube, put the LMA back in. The oxygen saturations are coming back up and we are getting air movement into the lungs. Now I am asked to push some fentanyl. At this point my preceptor is back in the room and we are all just standing and breathing while the patient is breathing too. She looks at me and I explain the situation. She had been finishing her break, just about ready to come give me mine when I called. We watch to make sure the patient is stable for a few minutes, then she says she is going to go put her stuff away and come back to give me a break. Our patient is going to be intubated for at least another 15 minutes since the succinylcholine is a paralytic and needs to wear off before extubation. When I get back from my break the patient is still intubated, we are all just waiting. The anesthesiologist is being cautious now and waits until the patient is almost fully awake before she removes the tube. We get the patient to recovery just fine, the patient has a bit of a sore throat and admits now that he has been coughing a bit lately. The anesthesiologist is cautious for the rest of the day. She does acknowledge that I showed my experience in the situation - I knew the medications she wanted, knew she needed help and stayed calm.
Next time I may assert myself and ask the scrub to step away so I can handle the drugs. But really, the only thing I think I could've done better is to call for the anesthesia tech as soon as I heard the wheezing and knew we were going to have to re-intubate. As it was, the patient outcome was excellent and the entire team had a reminder of how important it is to work as a team.
Luckily the rest of the day went a little smoother than this. We had no more airway issues. On the last case we did have equipment and supply issues, which required me to call my preceptor back in to help. Overall, though, as my scrub left for the day, she said I had done a good job.
I had the pleasure of talking to one of the CRNAs as we finished up the last case. She asked me if I knew the criteria for extubation and then educated me. What a pleasure! She thinks I should think about CRNA school. I have, but I also have thought about the time: I have to work 2 years where I am now, then to get into CRNA school I have to have at least 1 year in ICU, CRNA school is 3 years, then I would have probably a year of residency - 7 years more of education and training. I am not that young! I do still consider this as a potential option, though. We'll see. Going to get the MN first.

Doc-zilla

Originally posted 4/7/2012 I'm going to steal a term for a particular physician I have to work with occasionally. I told "R" I was, so it's okay.
There is one surgeon at work, who has been described as being very nice and funny outside the OR, but in the OR he is Doc-Zilla. The first time I worked with him I was doing my scrub rotation, he seemed a bit intimidating, but not too scary. I left without fear of returning. My scrub preceptor always works with him on Tuesdays so I would be returning. I felt bad for his residents, though, he yells at them all case long.
The next time I worked with him was a disaster, for me, the patient did fine. My preceptor did most of the work, helped me get the case set up and stood back to watch. She had asked the surgeon prior to the start of the case what the chances were of converting to an open procedure. He stated that there is always a chance that we will open. Later when he got into bleeding and had to convert to an open case we had to wait a little for instruments, he spent hours ragging on her.
During another time I was scrubbed in for him, his pager went off and our circulator, a nurse who works with him all the time made the call. It was from a nurse taking care of one his post-op patients on the floor. The nurse described what sounded to me like a possible mild allergic reaction to a medication and wanted something for the patient. He told the nurse to put some lotion on the patient's skin. He then proceeded to complain about how nurses couldn't do anything for themselves any more. I should've kept my mouth shut, but I spoke up to say that hospital policy dictates what we can do without a physician order and maybe we should work to change that. He then turned his anger on me.
I was horrified at how he humiliated me and spent the rest of the day not speaking to anyone, even outside of the OR in fear that I would start crying.
On another occasion, after a long day of working with him he said something like: you're abandoning this case like rats from a sinking ship. Someone once asked me if maybe this is his way of trying to be funny. It may be, but when I am already in fear of his anger, it doesn't sound like anything except an insult.
Worked with him again more recently. The day went better: I didn't talk to him unless I absolutely needed to, did my job quietly in the corner but it wasn't perfect. He would ask for something, then immediately yell for it again. At one point during the case I was running over cords and around equipment from one side of the room to the other to do two things right after each other. I was afraid I was going to trip and land on my face, but I made it.As the case went the pager for one of his residents went off. I really hate answering the pagers, I really hate being the "middle-man" between the surgeons and their other patients. I would really rather be focused on caring for the patient I am in the room with. I answered the pager, relayed the information and made the call back to the nurse who paged. I explained to her that the doctor was scrubbed in surgery and she immediately said: oh, I just wanted to talk to him about my patient...when will surgery be done. I'll try back then. I gave her an estimate and hung up. I then relayed the message to the resident. Then I got yelled at by Doc-Zilla because this patient had surgery yesterday and might be having a complication and why would the nurse page us while we are in surgery unless it was an emergency... I explained, again, what the nurse had said and sat down to continue charting.
Later I overheard him, amongst his yelling at the residents, say: well, even a blind squirrel gets a nut once in a while. I was appalled. He immediately said: not that I think you're a squirrel, or anything. Again, when I later relayed this to someone, they asked if maybe this was his way of being funny. I don't think it's funny. Even taking back part of it, it was the wrong part to take back! He was basically saying that his resident was lucky, rather than admitting that they had done a good job.
I am done with the Gen-surgery rotation and am hoping I am not required to work with him EVER again. I know that is not realistic, but I do hope my "opportunities" to work with him are rare from now on. He scares me. He's Doc-Zilla.