Friday, July 31, 2009

Some people are stronger than you think...

Every day is a new set of amazing stories. I see so many different people in a day, and I'm amazed at what I get to learn, see and do.

Today was a really good day. In fact, this week has been a lot better.
I actually have the ability to chart on patients, I know where stuff is in the Pyxis (the medication machine), and my IV start scorecard has improved drastically. Like I'm at 80% now - I'm just working on stopping the bleeding after I insert the catheter.

Tentatively, I'm starting to feel like a *real* nurse. Sorta.
I took on two patients on my own today (the standard is 3 to 4), and I'm getting the rhythm of it. The most awesome thing about the ER is that for the most part, the nurses and the docs really help each other out. The teamwork is stellar. I've learned which nurses will leave you 4 straight caths and bloodwork to do at the end of their shift, which ones spend more time freaking out than working, and which ones see that you have a new patient and will help your other ones to the bathroom or draw the blood or help with a procedure when you're swamped. There are more of the helpful than the selfish ones in the ER, and that makes me happy.

This week has also been full of good lessons.
A 90+ year old man attempted to break my thumb today. He was confused, ripping out lines, his oxygen levels were low, and we had inserted a Foley catheter. Poor guy. I think I'd try to break someone's thumb if someone came at me with a Foley, too.
In any case, of course it came at the time that 1) we were supposed to take him upstairs to his med-surge floor on a heart monitor (and he didn't want the lines on him), 2) I had 3 other things to do for a patient going to CT scan who was worried she had cancer, and 3) I had to pee really bad (number 3 being the least important).
What do you do with someone who does that?
Me: "Hey that is NOT okay. You are hurting me. Let me go NOW." I grabbed his wrist, bent it enough to loosen his grip. I am acutely aware that I cannot hurt my patient.
Him: "I don't care if I hurt you. I don't like being here."
He releases his grip.
I sigh. I don't blame him. He's a DNI/DNR, and his blood pressure is sky high, his heart is working at 30%, and half the time he doesn't know where he is, and when he does, he's frustrated because he can't move very well.
We still got an order for Ativan to calm him down. When he tried to pull out his Foley (which sits in the bladder with an inflated balloon keeping it from slipping out) and his IVs, we had to. He was hurting himself.
And my thumb still hurts. But both of us are intact.

Yesterday I had my first violent patient as well. He called me every name in the book - and I told him to stop, that he had no right to be abusive towards me, or anyone else when we're trying to help him.
He fired me as his nurse.
It all started over a lost glove. Apparently the glove was more important than anything else, including the pain he had reported on admission.
The clincher was when he called the very large, formidable African-American security guard a "stupid, fat, n****r." You could have heard a pin drop. I think the patients all gasped and stopped vomiting. All of our jaws dropped. He continued to be belligerent, and demanded to leave. The patient was escorted out by numerous security guards. He obviously had some other major psych issues, but he was threatening the nurses, threatening security, and he swore at another patient. It was nuts. And a good lesson. I tried really hard to talk him down, and so did other nurses, and so did the Doctors and you know what?
It just didn't work. He signed out AMA, cursing all of us for losing his glove. It's the first time I really felt a sense of "good riddance." I feel sorry for him, and if he came back I'd try to help him, but there's a point where you have to cut off the kindness. I reached it.
The funny thing is that I don't think he even had gloves to begin with. It was a surreal experience.

And today, I had so many different people with different issues, it was amazing. From vehicle trauma (trauma!) to heart problems to a possible aneurysm, to Lupus flare-ups, to gallbladder attacks, to insect bites to Septic Shock with some very special circumstances... holy crap.

Kind of like nursing school, except - holy shit - it's real. I'm responsible. For people.

You can bet your sweet ass I'm checking every single medication. Is Vanco compatible with NS 0.9%? Is Toradol? How about Diphenhydramine? How much Fentanyl do you want to give IVP - his pulse is only 58? Hey Doc, you wrote the order for Morphine IM. Did you want it IM or IVP like you told me? Can you change that order?
These are the questions I'm asking constantly. I'm super anal about the meds. The seasoned nurses think it's cute, and they also respect it.
The other thing I'm stoked on is the critical thinking skills we got from UCSF. I can look at labs and have some sense of what's going on with a patient. I know where to look for info on Up-To-Date. It helps me anticipate what's coming, and it really helps in the ED.
I'm really grateful for our assessment skills.

Emergency. My dream. I still can't believe I'm here.
And you know what my feeling is at the end of the day?
I *really* love my job.

Saturday, July 25, 2009

All Thumbs

First of all, I am totally lovin' the Emergency Department (yes, it's a *department* not a *Room* - so when I say ED, you know what I mean).

I have seen so much cool stuff in the past two weeks, and I feel really fortunate to be where I'm at.
I also feel completely bass-ackwards. Somehow, between the end of nursing school and now, I lost all ability to start an IV. In fact, yesterday, I was the anti-IV starter. I blew the most perfect vein I've ever seen, and I have no idea why it was one of those days. It just was.
The nurses I work with have been super nice, "Oh, don't worry, it's ok, we miss too sometimes." Oh yeah? You guys miss on the 99 year old. I missed on the healthy person with an antecubital beauty the size of the Mississippi river.

And with precepting, I kinda feel like I'm in nursing school again, except I can actually sign off on insulin, heparin, and narcotics. I *just* got my ability to chart yesterday, and I still don't have access to the Pyxis. I am about 70% able to help patients as far as logistics go. That's frustrating. And I still don't know where things are.

And I miss my MEPN friends. I am finally making some new ones here, but it's tough, you know?

Growing, growing, growing.

Thursday, July 16, 2009

Bites, car accidents and emboli, Oh my!

Today was wild. All information has been changed to conform to HIPAA.

I walked in to a new place, with my nurse educator on vacation, which she had told me would be the case. Not a problem. I was paired with an AWESOME nurse, also named Nicole.

Holy crap today was busy.

Pulmonary Embolus, or more specifically, R/O pulmonary embolism, fit the description of one of our first patients of the day. A 30 year old young woman, into exercising, with chest pain had a D-Dimer level of 5500. HUGE. The cutoff for a negative is <500.
Her CT scan showed some interesting stuff, but no clot, so we did what we could to keep her comfortable.

15 year old girl kicks the dog dish and gets bitten. Sucks. Maybe we don't kick things at the dog anymore?

Pneumothorax took the cake though. The Chest X Ray (CXR in medical abbreviation speak)
was amazing! I asked, "um, what's wrong with the left lung?" and the doc looked at me and said, "Wow! Yep, that's a pneumothorax." And all of a sudden a bunch of surgeons were in our ER and the patient was on a gurney, and I was helping the surgeons with the insertion, and I was silently thanking Pam for all of her lectures on chest tubes since I immediately knew how to set up the Pleur-Evac device. A pneumothorax means something is in the chest wall between the lining of the lungs and the lungs themselves: in this case, air. Usually it's caused by a hole in the lung. By placing a tube in the chest wall that keeps negative pressure on the lung and allows it to expand, you allow your patient to breathe and heal. Docs place the tubes, nurses monitor the tube and make sure the suction device (Pleur-Evac) is working. Very cool.

And then there were the psych issues. Wow.
And the pediatric patients.
And the people with heart attacks.
And the irrigation of a skin issue the size of a tomato.

Oh yeah, and there was that Stage II pressure ulcer I saw this morning on a patient when admitted.
I asked if we had checked this patient's back, and everyone shook their head. "Ok, I'll do it." So, sure enough, it stared at me like an angry eyeball, red, painful, and begging for healing. One of the nurses documented it, and then I repositioned our patient so there was no weight on that spot.
I felt like I actually did something there. I have no computer access, medication access, or ability to chart, but I *do* have the ability to care.

So that's what I did today.

When I stop caring, I stop being a nurse. And a human.