Archive for October 2009
The first awkward moment was in the med room, with my preceptor needing her H1N1 shot and not wanting me to give it to her. ouch. Nothing personal, ya sure.
My goal for the first week in ER was to take care of one patient from start to finish. Today I managed four! No, not at once, one after the other, never more than one at a time. I was working the blue side, less critical patients, mostly things like abdominal pain, fever/ flu, alcohol intoxication, UTI and the like. I managed to get an IV in an intoxicated patient on the first try, even thought the guy had some pretty tough leathery skin from spending many a night sleeping under bridges. I learned how to mix a banana bag, saline with vitamins and minerals added that rehydrates and replenishes the nutrients a chronic alcoholic desperately needs. All the while our fabulous social worker was trying to find a place for him to go to detox, I was trying to convince him to stay long enough to get rehydrated and stable.
I greeted my 15 month old patient in the lobby and she was all smiles in her mom’s arms until we walked into the exam room then she grabbed her mama’s neck and screamed. No way was she going to let me listen to her lungs and take her temperature. I was actually glad to see her respond appropriately to a stranger, and thankful I didn’t have to give her an injection.
I stood by observing a patient brought in by ambulance having a seizure. The patient was having trouble breathing, swelling in her eyes and face, and her skin was quite red. The MD looked at me and started firing questions as if I were her med student
MD: what do these symptoms indicate?
Me: anaphylactic shock?
MD: good, how do we treat it?
Me: uh, give epinepherine
MD: perfect, how much and how do we give it?
Me: (in my head, aaaah I have NO idea how much, why is my mind blank?) um, 1mg I think? IV?
MD: no! that is for ACLS, the dose for anaphylaxis is 0.3 mg and we give it IM, where?
Me: in the thigh ( suddenly remembering EPIpens that you stab into the thigh)
MD: yes! go get it, you are an RN aren’t you?!
Me: I am! (rushing off to the med room feeling like, wow, I AM an RN, I CAN go get this med and help this patient ) I felt like I was really on the spot and really I was just observing why did the MD turn to me? I guess, I did okay. And the patient came out of the situation and in a couple of hours was sitting up and ready to be discharged with her very own EPIpen in case this ever happened again.
I was starting to gain some confidence, learning the routine, knowing where to find supplies I need, even helping another nurse put a foley in. Then came another awkward moment one of the MD’s made a comment that she could tell I was new to the unit because I had the chart ready in the slot for her to take in to see the patient to write her orders. And another nurse quipped “yea, and she doesn’t have a bad attitude yet.”
And I hope I don’t, it is not in my nature.
After what seemed like an eternity of preparatory training I am finally in the ER. This has been my dream since I started nursing school and here I am on the job in a busy county ER. I am working with a preceptor that is very experienced but not that happy about having someone to train. Luckily I don’t need much hand holding and I don’t take her reluctance personally, she is just overworked. We worked on the “blue” side which is the less acute side, seeing patients that are triaged as level 3 or 4. Two patients stood out for me because we weren’t really able to help them. One was a woman with chronic back pain who had suffered a fall, she had used up all her pain meds and was not able to refill her scripts before the first of the month. She got some new RX’s but could not fill them due to lack of money. She came in looking for some pain relief. We were able to give her some pain relief, and take an x-ray, but could not give her medication samples to carry her over till the first of November when her scripts would be available through her basic medical insurance. We provided her with a new cane and a cab ride home, she was not happy. The other patient broke my heart. A young woman doubled over in pain came in with her husband. The history looked like this could be a chronic bowel issue, or a kidney stone. She was nearly hysterical in fear of what was wrong with her and not being find relief from this pain. The MD immediately pegged her for a meth user and ordered a urine tox screen and pregnancy test which came back negative for everything. We gave her Ativan to calm her and some dilaudid to ease the pain and 3 liters of fluids. She went for an abdominal CT which was negative and she was discharged with a script for go-lytely and donnatal and instructions to come back if she did not get relief. She was not a happy camper, she felt we were ignoring her needs and not listening. She wanted to get to the bottom of what was causing her pain and I have to say I agree with her. In the end she left without signing the discharge papers, without taking her prescriptions or instructions, and telling us she was going to go to another hospital for help. I felt like we didn’t listen well, I don’t know if the MDs and other nurses misjudged her, I am too wet behind the ears to see what they see. but my gut feeling is that we missed something, and it broke my heart that she left feeling frustrated with her care. Both the charge nurse and my preceptor talked about how you have to be firm with these kinds of patients and not be caught up in their drama, I just don’t see the category of “these kinds of patients” yet and I am not sure I want to.
I take report from the day shift on patients and they are immediately mine, they are here in this moment needing my care regardless of what came before or what might come in the future. It is not my place to question if they are deserving of my care and the expense of the procedures that we provide in ICU, those decisions were made in the admission or transfer to the floor, once here, I do everything within the scope of my practice to ensure the safety of the patient and improve their condition or make them comfortable. Those issues don’t cross my mind until in relating a story to Hero (aka hubby) brings to my attention that many might question whether we should be providing this level of care to undocumented immigrants or incarcerated individuals. This boggles my mind, I try to clear the faces of these human beings from my mind and erase the direness of their condition to get a glimpse of the perspective that might deny these people care. I can’t.
The septic patient we saved the other day who I took care of again just before he was transferred to the med/surg unit, looked at me with grateful eyes and said (through his son, interpreting) “you are pretty.” Okay, flattery will get you everywhere with me, and at my age I don’t hear this particular one very often, but those words told me lots more than their face value. They told me of a 73 year old man that has come through the worst of his illness with enough alertness and humor to even make that comment, they told me he was feeling better and on the way to being mended. His sons; one or another of them were at his side every moment through his days in our unit, holding his hand and searching for reassurance from us, his nurses that their father was going to be okay. He and they needed my care.
Another patient, came to us after collapsing in his jail cell, coding in ER, being resuscitated and placed on a ventilator. He had taken a months worth of his blood pressure medication at once, and was in septic shock as well. In spite of the ventilator, being sustained with fluids, levophed, versed, insulin, bicarb, and fentanyl the sheriffs had him chained to the bed at the ankles with heavy chains and two of them stood guard at the door. This guy was not responsive let alone an AWOL risk. His pupils were fixed and pinpoint and he did not respond to painful stimulus. The day I took care of him he was on a two nurse to one patient ration because he was getting CRRT. We monitored and titrated all his drips to keep him hemodynamically stable, took care of the ins and outs, and basically tried to keep his vitals as stable as possible. His perfusion was so bad that we were unable to get pulse-ox readings so we were constantly drawing blood gases. They were reassuring, 94-96 PaO2. For some reason the lab was never able to get a good PTT reading on his coag panel that we were concerned about giving his heparin. We would draw blood from his art line, pulling off the first 10-12 mls before taking our sample, and still no reading. Finally the lab came and tried to draw a venous sample but they couldn’t get anything out of any veins they punctured. The central line was full of all of his drips so not useful for drawing blood. We never did get a good PTT on him. His platelets were steadily dropping from 250 to 91 to 37 over the last 48 hours and that had us worried. During this shift this patient’s brother came to see him and was not allowed in, his mother called the nurse’s station and we were not allowed to give her any information. At one point the brother was allowed in for a few minutes, and was clearly distraught about seeing his brother this ill. I spent some time in the hall with the brother just listening to him and being a caring presence. I’m pretty sure that when I am no longer orienting I will not have the luxury of time to spend with family members. This patient needed our care and so did the family. I don’t know what he did that put him in jail, I can only imaging why he might want to end his life, but he deserves to be cared for as a human being and his family deserves to a compassionate ear.
The last patient I want to mention was the organ donor we took care of while the transplant teams got ready to recover her liver, kidney and lung. By the time she was under my care, the family had made their decisions, said their goodbyes and left the hospital. Although her body was being sustained medically, she was clearly gone. I kept focused on the people her organs were going to help and how important it was to maintain perfusion and keep these organs healthy. Even in death the patient and future patients need our care. And I do my best to provide it.
I am beginning to see that in nursing, schedules and plans are never firm. It turns out my preceptor in the ER isn’t ready for me yet so I have spent this week in the ICU. As anxious as I am to get to my ER training, this week has been incredibly enlightening for me. I see the value of being oriented to the different units and getting a feel for how they work and what their challenges are. It will help me be more understanding and better prepared to transfer patients there from the ER.
On my first day I hit the ground running. I met the nurse I would be working with as we were receiving a patient from one of the medical floors who had come in through the ER the night before. This patient had come here from Mexico a few days earlier to celebrate his birthday with his nine children now living in CA. He came into ER with pneumonia and abdominal pain and was admitted. Then his labs came back showing he had a raging infection and his lactate was 6.0 and PPT of 107! Yikes he was going into septic shock. CT scan of his abdomen showed stones in his common bile duct and the MD’s suspected ascending cholangitis. When he arrived on our unit his blood pressure was in the 60’s and his extremities were cold and cyanotic. Our first task was to get fluids into him fast. He had one IV running Lactated Ringers which we turned up to 1200cc/hr, and quickly got another large bore line started, more lactated ringers 1200cc/hr. At this point the room was swarming with residents and an attending, all trying to get an arterial line started so we could measure his blood pressure internally which is much more accurate. The main goal being to keep his organs perfused to prevent organ failure. The poor patient was stuck numerous times since the blood pressure was so low it was hard to get the art-line in. They all kept asking for supplies which I would run to find, BUT it was my first hours on the floor I didn’t know where stuff was kept, OR the code to get in the room! I caught on quickly though and soon was grabbing supplies, opening sterile packs, handing out 4×4’s and tape, and most of all trying to comfort the patient as he was being poked and prodded. They finally got the arterial line in, and we got some blood gases drawn and set up the pressure monitoring. We hung two units of FFP to help his clotting, and more fluids. They also started a levophed drip which can raise blood pressure after fluid replacement in hypotensive shock and a versed drip, and IVP fentanyl to sedate him for the procedures, He started to have some fluid in his lungs as they were about to take him to radiology for an ERCP, so they intubated him and put him on a ventilator. I was able to go to the ERCP and observe. The MD found the stones blocking the bile duct and flushed them out, releasing a slew of pus and debris. Then it was back to the ICU, next a central line and a foley catheter. The central line used was a special one called a presep catheter, it has a fiberoptic tip to allow measurement of SvO2, or oxygen saturation which is important to measure in sepsis. By this time it was 10pm and we were starting to see some improvement in his blood pressure and hoping he was out of the woods. He hadn’t produced any urine yet, due to some kidney failure and we were quite worried about that. As we gave report to the night shift and reflected on the evening I really saw how the nurses and MD’s work well together, everyone stayed focused and helped each other as we worked. The residents and attending MD discussed the plans and procedures in detail so I learned a lot just listening in and observing. It felt great and exhausting to be part of the process. I hope this patient improves through the night and that tomorrow is calmer.
I have one more shift to go on my med/surg portion of training before I FINALLY get to the ER. The floor I have been on has a wide variety of patients, mostly medical with diagnoses of alzheimers with extreme dehydration, to CVA, cancer, wound abcess, brain mass, cellulitis and more. My goal working in this unit was to understand the criteria for admission, learn the equipment in less chaos than the ER, and get a perspective of what it is like for the RNs receiving the patients we will be sending from the ER for admission. This is a new approach for our ER training, I am gathering based on the questions I have been getting from the nurses. They all want to know why we are being oriented in their unit if we are going to work in the ER, then they chuckle that we will soon forget their perspective once we have been in ER for a little while. I have to say the main question I get is, “how did you get hired as a new grad?” It seems that this new grad program I managed to get into was not only a well kept secret on the job boards, it was not on the radar within the hospital either. I really am fortunate to have found out about it and gotten hired.
I have been working mainly with one nurse but tagging along with any nurse that is doing an admission from the ER so I see the process once the patient comes to the floor.
It took me a day to figure out where things are, and get a feel for the routine of the shift, most of the nurses have been very friendly and eager to welcome me to the hospital. It is the patients however that confirm for me that I am on the right path. I love working with them, even the cantankerous ones. This is one place where my age is to my advantage, they assume I have been a nurse for years and don’t seem to notice my clumsiness with equipment or nervousness inserting an IV. I have had several successes now so that nervousness is lessening.
On my second day we had a patient die at shift change. She had just come to the floor from ER a few hours earlier and her friends had just left to arrange hospice care for her. We were getting report when the nurse taking over this patient’s care went to meet her and discovered that she had died. I helped carry out the death protocol which involved notifying the appropriate people, getting the MD to fill out the forms, calling the organ donation network, and preparing the body. The thing that always catches me by surprise is the change in skin color that happens, the skin takes on a definite yellow tone. We washed her, changed her gown and linens, and tucked her in the bed for when her friends returned. It turned out that she was not approved for organ donation due to her liver disease. We moved her roommate to another room without revealing the death had occurred so as not to freak her out, and talked with and comforted the two friends as they said their goodbyes. Then we wheeled her body down to the morgue. Wow, I felt a mixture of emotions through the evening from sadness that she died alone to the profoundness of the end of life, to the the confidence that came from the self discovery that I can handle the process in a professional way and be there for the patient and family. I know I will be dealing with patients dying while working in the ER and I was glad to have gone through this experience.
Another patient that moved me was a gentleman with end stage colon cancer who has not been able to control his pain. He was extremely dehydrated and constipated, had gotten a few doses of morphine in ER but came to the floor with an infiltrated IV, pain level of 10/10 and respirations of 36. I tried unsuccessfully to place a new IV, but another nurse was able to get one in and we gave him some more pain medication. In spite of the excrutiating pain he was in, this patient was pleasant and patient as we tried to make him more comfortable. In contrast another patient I had that same day, a demanding former meth user with neuropathy in her feet and legs and suffering from panic attacks, yelled for her pain meds constantly, became combative on several occasions, and left the floor against advice to smoke. If one nurse didn’t give her what she wanted she yelled for another nurse or MD.
I could go on about each patient, they each presented situations that I learned a great deal from. (I know, my learning curve is steep at this point in my career, I have so much to learn) I am grateful for the chance to work in this unit for a couple of weeks, it has confirmed that I have made the right career choice and makes me even more excited to get into the ER. Next week!
This afternoon I start on a med/surg floor with a preceptor. For two weeks I will work with her to learn the basics before I go to the ER. The plan is to learn in a less chaotic environment so we have time to absorb what we are learning. Seems like a good idea, I hope it goes smoothly. The last three weeks have been spent in classrooms and in the ancillary departments. It has been useful, but I am anxious to start working with patients. Stay tuned.