Saturday, December 27, 2008
For those who celebrate this time of year, Happy Holidays. For those who don't, I hope you enjoyed the pre-Christmas and Boxing-week sales, and movies that opened up while everyone else was doing the family-thing.
I head to work again tomorrow for another stint before New Year's. Mr E is visiting his parent's in the even more Great White North... booneyville Northern Ontario. He'll be back by New Year's so we'll spend that time together.
Although I have to admit seeing one's family can sometimes be trying (and annoying!) and making small talk about the same thing over and over again can be boring, there are still some things I look forward to:
1) the food ('nuff said)
2) seeing my immediate family
3) the annual girl's movie night (we try to pick a really girly movie)
4) playing Phase 10 (a really great card game that I'm stuck on and typically play with my sister and bro-in-law)
5) being lazy while mom is creating her gastronomic miracles (anytime I don't have to cook is a great day for me!)
I hope you all had a great week.
Tuesday, December 16, 2008
Monday, December 15, 2008
To those who have subscribed to my blog, welcome! More than my best friend and Mr. E read my blog apparently. Although I didn’t create this blog to have people read it (ok ok I did want one comment that, again, wasn’t from Mr. E or my best friend), it has been cathartic and a fantastic way to reflect on myself as a nurse and the nursing experience.
There is a posting for an MSN-trained nurse to teach a university undergrad nursing research methods and stats course.
I have always thought I would teach if I didn’t go into healthcare, and I have experience teaching First Aid and Advanced First Aid.
Saturday, December 13, 2008
I'm sitting in my living room at 0810h and drinking a beer. I NEVER drink after work. I don't even drink post crappy day shift where people have died.
Nope, tonight I am sitting here going through everything in my head. This night shift, although incredibly busy, wasn't overly technically difficult except for one patient. Unfortunately for myself, it was also a patient who I can't talk about because the law was involved and I don't want to implicate or have this go against me in court.
My feet ache like an SOB. My right hand occasionally twinges because of all the bloodwork and IV's I started tonight. I bent over and my back twinged too from standing and lifting and working hard all night.
Soon- post beer- I will wash my face, brush my teeth and go and give a hug and kiss to darling Mr. E. Hopefully I can sleep decently.
Friday, December 12, 2008
Since I have graduated, I have completed 2 ECG courses, ACLS and ENPC. I consider that not much, but necessary for continuing work in the Emergency Department. I have also considered completing a certificate through a college to work on my ENC(C) status which I will qualify to take in about 2 years. In addition, when I am home I am constantly trying to learn more material about triage, and about things that I wasn't sure of when I was at work the previous day.
If I wanted to know why the doctor took the treatment in the way they did, or if I didn't know the clinical condition that well (or why they were testing certain things) I would look it up.
I worked with a newer nurse last night (has worked 1 year more than me) and although she was quite knowledgeable, I was surprised to hear that she had not done any ECG training. I can't say if she has taken any formalized ACLS/ENPC/TNCC course because I didn't ask, but the ECG thing surprised me. This nurse was going to be having a student in January, and is often trusted to work in the resuscitation room. She stated she didn't feel it was a priority for her, and her student had emailed her about things to study, she replied with "nothing".
I have done my own self study as well as taken 2 courses on it to make sure I was up to snuff on my ECGs well enough that most rhythms I can recognize and treat. Although there are some recognizable rhythms that you cannot mistake, there are so many nuances to reading ECGs that there is a medical specialty, electrophysiatry, to do a final read on them (these doctors do 3 years of internal, 2 years of cardiology and another 2 years of electrophysiatry to read ECGs and insert pacemakers etc).
As a new grad of course I feel I don't know enough about Emerg. I'm constantly thinking there is more that I don't know, so I take courses and do a lot of reading to learn. I do recognize that I will always be learning, but still, I want to be a knowledgable ED nurse that thinks ahead and takes in the global picture, not just a person who reacts afterwards. I've had a year's worth of Emerg experience, and still feel that I need more.
I'm not naive that I think that all people are like me, but come on, as a newer nurse there are tons of things you don't know. Doesn't it make sense to focus on continuing education to improve your knowledge? Not everything is completely learned at the bedside, and definately not everything is taught in nursing school.
Friday, December 5, 2008
At 1:30pm he had gone out to get the paper and when he came back in his wife noticed that he was speaking nonsense, and slurred-like. Being smart, she called 9-1-1 right away. As the stroke center for the area, a full workup was completed to prepare him for the clot-busting treatment.
Upon presentation to Emerg he was slightly aphasic, meaning he had a hard time speaking, and he had a slight left-sided deficit.
When a stroke patient comes in, neurology is paged right away. We also hook the patient up to the monitor, get basic vitals, do a finger-pick for glucose, start a line, draw bloods, get an ECG, and then prepare for transport to CT. Once this is all done neurology reads the CT, and pulls together the information to determine whether or not the patient is a candidate for TPA, a clot-busting drug that can effective in ischemic strokes and that is used within 3 hours of symptom onset. The problem with TPA is that the risk of causing a major bleed is so strong that after 3 hours post-symptoms, the benefits of giving the clot-buster don't outweigh the risks.
It was well in the timeframe for TPA: there had approximately 45 minutes left. In addition, the patient was clearly a stroke. His deficits were slightly worse on one side, and he continued to be aphagic. Unfortunately, however, we did not end up giving TPA.
Why? The patient was healthy, except for the fact that he had an irregular heart rhythm; a-fib. Atrial fibrillation is caused by many areas in the atria of your heart wanting to be the pacemaker, instead of the sinoatrial node. Due to the disorganized firing of the pacemaker, there is no effective pump to get the blood from the atria to the ventricles of the heart. This can cause blood to be stagnant and form clots within the heart. Generally, to reduce the chances of getting a clot, a doctor would prescribe a blood thinner.
Since this stroke patient was a diligent patient and took his blood thinner medication every day, he no longer became a candidate for TPA. His blood was already therapeutically thinned to help his heart. TPA would have caused his blood to further be thinned, essentially creating a huge risk for bleeds had the treatment been administered.
Not only did the blood thinner contraindicate TPA, in addition the neurologist could already start seeing the stroke's effect on the brain. Typically when a CT is completed for a stroke, the neurologist is looking to see if the stroke was caused by a bleed or a clot. However, changes to the brain of an ischemic stroke are not noticible on a CT until quite a few hours after the onset of symptoms. So, ultimately the CT is completed to rule out a brain bleed. Although not seeing any ischemic changes in the CT is common, in this patient, the CT showed some darkened areas consistent with brain death of an ischemic stroke.
The decision was made not to TPA the patient, and the neurology team had an incredibly hard thing to do- tell the family of the patient what was occurring, and that a decision needed to be made as to what our next steps were. Ultimately, the family would have to decide on whether the patient would be allowed to pass on (as the stroke was huge and the patient was rapidly deteriorating), or whether other treatment would be provided so that the patient could attempt some form of rehabilitation once stabilized.
Ultimately, the family decided that the patient would not have any aggressive therapy, and instead would be treated palliatively.
The patient continued to get worse: he now had complete loss of function on one side, and his vitals were changing. He went from GCS 14 upon arrival to GCS of 10 within about 4 hours. He knew he was having a stroke and tried to communicate with his family and with me, to no avail. The reason I could tell he knew what was going on was that up until a point, he obeyed all commands.
The man was stuck in a body that was failing him, and he knew it. I hate seeing people suffer, and I know that although his family was there for support, it would have been very hard on him. I wasn't the primary nurse for him, yet I know that all of us in emerg that day tried to lend a helping hand to him and his family.
By the time he went to the floor for palliative care, his GCS continued to decline, and from what I hear he passed sometime in the night.
Tuesday, December 2, 2008
In total, I have 40K of government loans, and approx 26k of private bank loans.
$64,000 of student loans for 4 years of school. That means I lived off $16,000 a year, and that included tuition of about $6,000 each year. I also worked part-time. Needless to say I was frantic about money and I limited my expenses.
Unfortunately now it's time to pay it back.
Although I don't have regrets as to how much debt I took on, I'm wondering what some people's limits are. As an RN I'll be making $50-80,000 a year depending on my seniority for full time work. If I decide to go to NP school I'll make $90-100,000 a year, but that will require another 2 years of school, and a loss of 2 years worth of wages.
I'm going to keep on trying to pay my loans off earlier by increasing my payments each month, but still, I want to be able to start saving for a down payment on a house, and into RRSP's. At what point does debt repayment not supersede savings and financial planning? If anyone in the universe could let me know, that would be great. In the meantime I'll keep working away at my debt, and maybe go to an actual financial person!
Thursday, November 27, 2008
In the meantime, it's a regular old day for this Canadian, except some of the TV channels are doing reruns.
Tonight I get to use my newly honed paeds skills... for which I probably won't get a single paeds patient.
Has anyone finished a paeds course and then started to think that maybe you wanted one? That has been on my mind lately. I guess all females in their late 20s get like that!
Wednesday, November 26, 2008
I still think there comes a point where age becomes a factor in meaningful recovery, and one seriously needs to consider this before determining their own (or loved ones') resuscitation status.
This does NOT mean that I think all 80+'s should be DNR. This also does not mean that I hate old people and that I am unwilling to participate in a resuscitation attempt because they are over my 'age limit'. All I was implying in that particular post was that you cannot take age out of the equation.
I hope this appeases my friend the med student. And for the 2 people that read this blog, I hope that clarifies things.
The course wasn't too bad, just long. I must have said the right things to determine the triage of the children and run the stations.
F- Family/Full set of Vitals
G- Give Comfort measures
H- Head to toe/History
I- Inspect the Posterior Surfaces!
Now if only they can teach me how to get the kids to stop crying when I'm working with them....
Saturday, November 22, 2008
Tuesday, November 18, 2008
Rationing of health care is perpetuated in the U.S.A. as a reason not to incorporate universal health care. No one wants their granny to not get a kidney transplant when she needs it, and no one wants to hear "we won't fund this". The American mindset is that each individual should have options for their own life, and this unfortunately does not coincide with the idea of universal care.
Articles similar to this one, which Happy from Happy Hospitalist and Carpe Diem quote to bring attention to cost-cutting measures, often provide sappy stories of people dying without some very expensive drug that is the only treatment option.
As sad as these stories are, there is no 'other-side'. Privacy laws do not allow commentary by physicians to say whether this treatment option would work, or whether the state of the person's illness was so severe there would be no quality of life for the person afterwards, despite them living for a few more weeks. It seems as though the people who are requesting these drugs are in terminal stages of their disease. Although I commend them trying to fight for life, there comes a point when we need to say enough is enough and the person should be allowed to die with some dignity.
Oftentimes health bloggers rage about the 'fruitless end-of-life' attempts where people in terminal disease or the extreme elderly have full code status. It is not uncommon for these bloggers to also disagree with rationing. How is this possible? What they are suggesting is specifically to rationalize. Or is it only for the elderly? How is that fair?
So you know my personal position, after the age of 80, or if I have a terminal illness where treatment benefit is marginal, I will put myself as a DNR. As much as I may have 'good years' left post illness, I can honestly say I would not have advanced measures be taken to continue my life. My decision is based on my own observations and experience. I have seen people intubated, I have personally pounded on chests and broken bones. What quality of life are we offering these people? So they go to the ICU and instead of dying in emerg (or even at home when their family finds them unconscious), they spend another month lingering and then pass in the ICU.
For those who really don't like the idea of rationalized care and promote private insurance as the way to get around it, unfortunately rationing of health care dollars is not uncommon in the private care model. Private insurance places guidelines on repayment and reimbursement schedules, and primary care doctors have to fill out pre-approval forms for patients to get an MRI or CT. The movie John Q emphasizes how John's private employment-based insurance stated they would not cover the cost of his son's heart transplant.
Whereas rationing of health care isn't an ideal situation, I'd rather have that then not have universal coverage for everyone else. There is an impossible triad of health care, you can have two of the three options: Affordable, Quality, and Accessibility.
Monday, November 17, 2008
Sunday, November 16, 2008
We even got one of the traumas... I'm sure our ICU wasn't happy (they don't get trauma... ever.) But it was nice for a change to see something serious that wasn't a heart, stroke or medical related.
The rest of the night after that was so... incredibly... slow. I guess all the people needing admission in the city have already been admitted. Although I didn't mind; I was reading my ENPC book and learning how to put in an intraosseus line, still. I'm surprised they didn't send most of us home.
I guess the idea is that if they send us home, things will start going nuts.
Friday, November 14, 2008
I dreamt about nursing. And then I woke up, thought about my previous day, and then kept (what I call) 'spinning' - going over things again and again in my mind. Now on this particular shift I hadn't done anything wrong, I could have just done things better. I could have handled things better. I think I let my concern for a patient get to me. I had a patient arrive by ambulance who was pretty much bleeding out of every orifice (not haemhoraging so wasn't placed in the highest acuity- resuscitation room), who had a history of taking coumadin and whose last hospitalization had the patient's INR of over 10 (very bad, the person would not be able to clot!).
I tried multiple times to get a line in, and couldn't (this patient had palpable but fragile veins) so I had a very senior nurse try (who also had trouble) but the stress of getting a line in was palpable. At least, it was to me. My limited nursing radar was standing on end saying 'this patient is sick- you need to stick with them'. As mentioned above, the patient was not assigned to the resuscitation room which has 1:1 or 1:2 coverage- although the patient was sick and needed admission they were still alert and oriented, and only slightly tachy with no blood pressure changes. Thus they went to the next highest acuity room which I had been assigned.
Not only did I have this patient, I had 3 others. Luckily, one was waiting for bloodwork and was understanding about the wait (RARE!), another was an admitted patient not requiring anything at the moment, and finally the third was a patient who needed a blood transfusion whose blood was ready to go but I hadn't been able to hang it yet.
This is where I started spinning. The blood transfusion patient had a bed available on the floor, but I wasn't going to send the patient up with blood runing until at least 45 minutes into the transfusion. I wanted to make sure that the patient was stable with the blood (understandbly) before sending them up! It was also nearing change of shift, and I had a small window of opportunity to send them to the floor. It just wasn't going to happen in that time. PLUS, because I'm new to nursing I wanted to make ABSOLUTELY sure I was doing everything right for the transfusion. It's not something you can wing because it's VERY dangerous to the patient if things go wrong. This means I had to look everything up to clarify my unsurity about a few items.
In emerg when you have the opportunity for a patient to go to the floor, you get them there, because there of course is another really sick patient for you to look after. The pressure is there in the back of your mind, plus the patient had been in emerg for over 24 hours.
So I had these two patients that seemingly I was feeling useless about.
Here is an example of 'spinning'. *Note: if you haven't thought I was crayzee before this, I think you better start thinking it now*.
I think to myself: "What if I had quickly done vitals, looked the information up quicker, and hung the blood before assessing the bleeding patient?" "No-" I said to myself-"I needed to assess the bleeding patient. The blood for the other patient could wait. They are stable, even though the window to getting the patient to the floor is getting smaller and smaller. There was at least one bed available in the department if needed, so taking a patient to the floor is NOT a priority". "But-" my brain continued, "the blood is sitting there, getting warm, and is only good for 4 hours. 45 minutes have passed already. You have to perfuse the blood which takes 2 hours. That and change of shift is coming in 45 minutes. YOU DO NOT HAVE TIME TO WAIT." "WHy didn't you grab someone to help you?" I ask my brain. "Because you already have taken one nurse away from their patients to get the line in. You can't get another one, there IS NO OTHER ONE AVAILABLE". "But SOMEONE maybe could have done vitals for you if you had looked harder" "If I had looked harder or did some investigation, I could have HUNG THE BLOOD IN THAT TIME".
In the end the blood was hung correctly, the lines were in the bleeding patient and an MD called over to assess, the transfusion patient did make it to the floor (although not on my shift) and the other patients did get some attention before change of shift.
Get the idea? Overall, I didn't do anything wrong and I think I prioritized my actions well. BUT there is still the "Next time..." and the "What if..". This is the reason I was not able to get back to sleep when I woke up at 5am yesturday. This is also the reason I can't sleep tonight. Perhaps this cathartic writing will help settle my mind. I work nights so the pressure isn't on to get tons of sleep prior to a day shift- i have 14 hours more before my next shift.
Perhaps I care too much. Perhaps this is a normal "new grad" feeling- the classmates I have talkd to have mentioned this 'spinning' feeling, or at least dreaming about work. Or self doubt. WHo knows. I'm sure I'll look back at this later and see it clearer. Right now though... I think I might be able to get back to sleep. At least, I'm going to try.
Tuesday, November 11, 2008
Lately I have either slept WAY TOO LONG (see the 17 hour sleep post) or I can't either get to sleep or stay asleep.
Unfortunately, tonight is a "stay asleep" problem. I went to bed tired around 11pm, fell asleep rather easily (for me) which means within a half an hour. Unfortunately at 2:45am I woke up wide awake. I am still wide awake now at 3:30am.
I haven't had caffeine since about 2pm today, and didn't get enough sleep last night either (another round of insomnia, 4 hours worth actually!).
If I was an outsider looking in I would ask about depression or anxiety. Honestly, I have had mild depression (treated with weekly trips to a social worker) and anxiety along with it when I was completing my nursing degree and my masters degree. That is definitely not a feeling I want again and I don't have any of those symptoms now, except the insomnia.
I have been quite happy with my life lately. I have occasional bouts of stress (the whole not-knowing-if-I-will-have-an-ED-job situation) but with the 4.5 days off in between rounds of shifts I have plenty of time to relax and contemplate other options.
Counting out medically related items: I'm not pregnant, my iron has been stabilized, and I've already had mono (8 years ago).
Any thoughts as to why I can't sleep or seem to need extra sleep? I'm all ears.
Friday, November 7, 2008
This morning torward the end of my shift an Occ Health nurse stopped by and gave the department flu-shots. So now my arm is a bit sore but otherwise I'm feeling good.
I also find out whether I'm staying as an Emerg nurse today. If I don't get the job, I'll be headed to another floor in the organization. Any thoughts as to where I should go? Areas include:
Gen Medicine, Gen Surg, Ortho/Vascular, Neuro, Cardiac, Cardiac Surgery, OR, Paeds, Nursing Reserve/Flex, Respirology, Oncology
That's it, from what I remember.
Thursday, November 6, 2008
I'll know probably by the weekend, and I'll keep you in the loop!
Tuesday, November 4, 2008
I have an interview tomorrow for a permanent position in Emerg. Prior to this I have been mentored and doing my own assignment with a "mentor" available to guide as need be. Tomorrow determines whether I stay on in the department, or whether I go to other areas. I think I have done well in this program, and am eager to stay on. However this fate is not up to me alone...wish me luck!
P.S. The white cloud of mercy has melted away and now the black cloud of terror has arrived. Serious stuff happening a LOT lately. More later.
Thursday, October 30, 2008
I went to bed at midnight, slept until the alarm went off for Mr. E to go to work, than I fell back asleep and no joke, woke up at 1700.
It wasn't planned. In fact, I have a lot of stuff to do, but my body apparently needed the sleep. Now, i'm wide awake and probably will be till about 5.a.m.
Also, yesturday God decided that Ontario needed to be punished and sent about a foot of snow our way. Yes, that's right, snow right before Hallowe'en. It brings me back to when I was a kid and I had to wear snowpants underneath my Hallowe'en costume.
Here's a pic of an area near my apartment.
Have a snowy day!
Sunday, October 26, 2008
But by not only interfering with my work, but also undermining me in front of the patient was absolutely uncalled for. Thanks again, you bitch.
Also, thanks for cutting me off when the other nurse asked what had happend. You really know now to undermine and be a complete asshole.
Once again, thank you.
Thursday, October 23, 2008
in a 34 bed emerg. Some of those leftover "beds" are chairs, and a mental health room.
That means every possible actual bed in our department was taken up with an admitted patient.
This means ambulance holds over 4 hours, and over 6 hour waits in the waiting room for the 2 beds we have left.
How the heck are we supposed to run as an EMERGENCY department, when inpatients have taken over? We even had to hold someone in the resuscitation room because there were no ICU beds immediately available.
At least I'm getting "floor" experience, sigh. I hate when I arrive and the three to four patients at the start of the shift stay with me the whole time. I'd almost rather be at an Urgent care clinic or doctor's office.
The unfortunate part is that it's not getting any better. We need to increase 1) the number of inpatient units, 2) hire more staff to care for patients in areas that are closed, and 3) reduce the number of patients waiting nursing home placement.
Then MAYBE we can have an emergency department, and wait times will be more close to normal!
Tuesday, October 21, 2008
Lately my days off have been spent with a lot of family visits. Mr E and I drove 13 hours to Northern Ontario to visit his parents. Gosh I have forgotten how beautiful it is up there, as the last time I went it was in 2005.
Here are some photos of the landscape.
This picture is overlooking part of Lake Superior.
And here is a picture of the Canadian sheild jutting towards a small lake.
Even the drive is beautiful.
Overall, a wonderful trip. I hear they have snow now.
I'm just starting to get caught up with sleep!
Monday, October 13, 2008
Today I spent my day outside in the gorgious 25 degree celsius weather, and went to a local fair.
I even saw a cow-show... Like a dog show but for cows. They have a person walking them and everything. Secretly I was hoping one of the teenagers that were managing the cows would tip them over, but of course that didn't happen!
Now I'm stuffed with Turkey and gravy, taffy, pumpkin chiffon pie and candy-apples. Yum!
Wednesday, October 8, 2008
A patient came in and was VERY sick. We had no background story and no clear reason why the patient was the way they were.
Numerous interventions began: Intubation, blood glucose check, bloodwork was drawn, ECG completed. I was in the thick of things trying to help this patient... grabbing the glucometer, setting the patient up on the monitor, etc. However the patient's SpO2 was in the 40's, the BP was dropping; essentially the patient was dying.
Anyway, there was something I noticed along the process that I verbalized out loud to everyone. Everyone stopped and looked at the monitor. The doc agreed with my observation, and after a bit of further investigating it was deemed to be the reason for the patient being sick.
The thing I noticed was some slight ST depression on lead II that was being displayed on the monitor. It had not been there earlier upon the patient's arrival, and an earlier ECG hadn't shown anything.
Another ECG was called for. Sure enough, it indicated the patient was having a STEMI in multiple leads.
20 minutes later the patient was on a dopamine drip and on their way to the PCI lab. Afterwards I heard that the patient was doing much better.
This was the first time I have ever actively noticed something, or done something that saved a patient's life.
Don't get me wrong, someone not even 2 minutes later would have noticed the same thing as me and mentioned it.
But this time it was me. COOLEST... SHIT.... EVER.
I'm proud of myself.
Here was the actual letter.
Dear Sir or Madam -
As a blogger who writes about parenting and/or health topics, I wanted to let you know that the Centers for Disease Control and Prevention (CDC), together with Families Fighting Flu, Inc. (FFF) has launched a compelling video documentary via YouTube, featuring parents of children who have tragically died as a result of the flu. The documentary is available online at http://www.youtube.com/cdcflu.
We think your readers might be interested to know how bit a toll the flu takes on young children. Each year in the United States, an average of 20,000 children younger than 5 are hospitalized because of flu-related complications. Tragically, around 100 children die from this serious disease each year. Last year 86 children died of flu-related complications, half of whom were age 15-18. During the 2006-2007 flu season, of the patients for whom flu vaccination status is known, 94 percent of the children who died had not been vaccinated against the flu.
Directed by Emmy award-winning Mustapha Khan, creator of “House on Fire,” and Tommy Walker, award-winning co-director of “God Grew Tired of Us: The Story of Lost Boys of Sudan,” the video will be shown nationwide at events hosted by public health departments and CDC and FFF partners. It will also be posted on CDC’s and partners’ websites.
Let me know if you have any questions about the film or are interested in sharing it with your readers.