Thursday, January 31, 2008

Accidental death....

I heard about this one case from one of my classmates, who also works in an ED. This is an incredibly sad story. For privacy purposes some of these elements have changed.

A family of a 2 year old were in the living room. Mom was on an elliptical machine, Dad was nearby on the computer, and their 2 year old was on the couch. Child manages to get off the couch, but in the process falls into the elliptical, which was still being used by Mom, and gets crushed. Mom immediately stops, gets off, and then calls 9-1-1.

Child ends up dying.

I cannot imagine what it must be like to lose a child. I can't even fathom how someone must feel who had unintentionally caused their child's death. My sincerest condolences to this family.

This is a fear I have, working in the ED. I have fully admitted I"m not a fan of paediatric nursing, however I am coming around and learning to step up to the challenge. The idea of having to work on a child who was severely injured makes me sick to my stomach. I can't imagine how the staff felt that day, and how they could go back to working on the sore throats, injured hands, etc that we generally get in Emerg.

Blows my mind.

Tuesday, January 29, 2008

Getting a job

So now is the time to start applying for jobs as a full time nurse. Currently, I have applied to my small town hospital, as well as the big-city hospital that I happen to live nearby.

Both offer positions, both offer the graduate guarantee in the emergency department. (The graduate guarantee is a government initiative to help new grads get full time work immediately after graduation. Ideally after the trial period they are offered full time at the hospital, in the specialty for which they have been mentored.)

Unfortunately, the 1 job is in town, and the other is 40 minutes away. So far I haven't' minded the commute that much, but when they are equally offering the same salary, it would be hard to turn down a job that is so close to home. Especially when gas prices are fairly high, and kilometers get racked up on my car.

However I'm torn because I have felt very welcome in the small emergency department. I see what staffing issues they have and I really want to help, especially since they have been so great to me. However, can I afford the commute, time and money wise? Am I getting the experience I need from a small town hospital, so that later I could work in the bigger center?

On the other hand, if I do get the job in the big city, will I be able to get a full time job once the Graduate Guarantee is over? Some of the people who went through that program didn't get offered full time and now are applying to the smaller hospital.

I really don't know what I will do if I'm offered a position at both places. I know I am ahead of myself, because I JUST applied yesterday, yet from what I hear they want to have things settled by mid-late February.

I'll keep posting updates. In the meantime, any thoughts?

I heart Emergency

I'm starting to get the feel of being an Emerg nurse. Call a patient's name, take them to the room, do an assessment depending on their complaint, inform the physician, and treat the patient until they are 1) admitted or 2) discharged. Fairly straight forward.

Today however, was different. In 1 shift:

- I was 2 for 3 for IV starts on patients.
- I was 0/2 for foley insertion (to give me credit, a total of 7 foleys were attempted on this patient, 2 by me, 5 by staff!)
- I saw first hand the confusion/disorientation associated with post-ictal states.
- I helped a man who had tried to commit suicide
- I helped out with a trauma; multiple stab wounds with a possible hemothorax.
- I was the one to do report to the charge nurse of the big-city hospital about this trauma.
- I set up and completed four 12-lead ECG's.
- I feel confident in the plan for cardiac patients
- I saw the devestating effects that a brain tumour can have
- I talked to a lady who has a severe degenerative disease who came in with exacerbation's of symptoms, and tried to develop a therapeutic relationship with her and her husband.
- I cut clothes off a patient
- I spent over 13 hours on my feet
- I am ridiculously exhausted

Overall, I had a FANTASTIC day.

Friday, January 25, 2008

I'm a geek

AAAAhhhhh... after many hours of working in the ED, I finally get my first 5 days off. At my hospital the nurses that are full time do a Day-Day-Night-Night rotation, with 5 off in between. Mind you, the first day is a sleeping day, but essentially for 4.5 days you are not hospital property.

So here I am in the middle of my five days off, and what do I do? Well, I do homework (learning goals due today), I go to school (I need references for a job), I go grocery shopping, and then I relax with a tea and.... a book on how to read EKG's.

I am the biggest nerd in the world.

Thursday, January 24, 2008

Monday, January 21, 2008

Life of a student in a small town ED

I've started to feel more comfortable in the small-town ED. Now that the nurses are getting used to me, they have been making sure I get "learning opportunities" all the time....

"Student!... want to do another glucose?"

"Student!... want to take out some stitches?"

"Student!... how about you do the interview for room 3, both kids have a rash."

"Student! ... go and pack that abscess wound"

I know that I'm the runt of the pack right now, and I take it in stride. Honestly, this department has been really welcoming, a change from other floors I have worked on as a student.

Although I still feel I don't know very much, I'm starting to feel more comfortable doing assessments, and doing basic treatments without the aid of my preceptor. I still check in with her and we do a lot of stuff together (I'm surprised she's not sick of me yet!), but I'm feeling more independent.

Friday, January 18, 2008

My first I&D.....

I have been reading in a few emerg nursing blogs about abscesses, and having to drain them. Some people apparently hate it, some love it. I am officially in the 2nd category. If you have a weak stomach please don't read!

Tonight we had a 20 yo female in with an abscess from her arm pit for which redness had travelled to midshaft of her humerus. After some IV antibiotics, the doc needed to drain it so that it could heal properly. Being the only nursing student in the Emergency Department makes it easy for me to be remembered when they get to do interesting things. "Hey student" (not Elaine.. they probably dont' remember my name yet) "you want to come and see an I & D?" I say "Of course!!" and then stupidly ask"what's an I&D???"

"Incision and drainage." They snicker, thinking that I'm going to be grossed out. They don't know me just yet. "WOW COOL" I say in the nursing student way.. and off I go to the room.

The doc was just getting set up, and I helped grab some additional supplies. Finally, she dons the surgical gloves and starts incising. Pools of serosanguinous (pus and blood and goopy stuff) fluid poured out of this girl's arm... most people by this time would be fainting.. I'm thinking this is AWESOME. After a bunch of incisions, even a bit of internal cutting to get all the exudate out, it was over. We cleaned her up, packed the wound (ok ok i didn't but I got to watch) and then sent her home with some pain killers and told her to return tomorrow.

I can't wait to see the next one!

Tuesday, January 15, 2008

20 something year olds shouldn't die

My first nightshift was fairly busy. I didnt' work nights as a student, so this was my opportunity to see if I could transition and stay up all night. At first it was fairly steady, if not slow. Around 0200 patients that were on hold were finally settling down for the night, and we didn't' have many in the waiting room.

Suddenly, the ambulance phone rings. My preceptor picks it up. It is dispatch, warning us that we were getting a 26 yo male VSA. As she is announcing this, my adrenaline pumps through my body. "This is what I have been waiting for", I think to myself. I have spent 8 years as an advanced first aid volunteer, I teach CPR, yet I have only done it once. This is my first experience with a code in the hospital. I try not to look too excited, as the story could change and as far as we know the patient is fine. However, there is a definite spike in energy in the staff, and it is decided that my preceptor and another nurse would be in the room, and the 3rd nurse will do triage and also take care of the rest of the patients. Being a small-town hospital, when we get a code in the ER at night, staff from the other floors are called down to help.

We wait in anticipation to get confirmation of the code. 5 minutes later, dispatch calls again. Confirmed, 26 yo male VSA, 2 minutes out. My preceptor gets on the phone and calls the code, and we prepare by getting on gowns and masks. Time inches by, it seems. It look longer then we expected... apparently the guy is not doing well at all, and the medics were going to try to get
him called on the scene. We waited, and we waited. 20 min later the ambulance calls, base hospital doesn't want to call it because of how young he is. He is on route.

Finally the ambulance arrives. The patient is pretty blue, and by that time the medics have been working on him for over 40 minutes. There was minimal chance we were going to get him back. I wasn't expecting to do much, but I got to do compressions, along with another nurse. My preceptor and an ICU did the medication pushes, and the Doc gave the breaths and watched the monitor. We didnt have much hope for him to return, and unfortunately, he did not make it.

This really made me think because apparently this gentleman played sports earlier, felt unwell and went to lie down. His fiance went to check on him and found him unresponsive. What caused his death? As of right now, no idea. There was no signs of trauma, and from the story it didn't sound like a drug overdose. He was the same age as me.

More and more 20-somethings are getting heart attacks, or other cardiac related symptoms. The nurses in emerg were saying how they are seeing more and more young people dying of cardiac related causes. This man had no history of heart problems, and yet he too passed.

Recently I have known that there have been some other 20-something related VSA's that some of my pre-hospital first response colleagues have responded to. It makes you really think about taking care of yourself, and cherishing the moment you have with loved ones.. you never know what can happen.

Synopsis... My first few shifts as an Emerg Nurse

I have just finished my first DDNN rotation in the small-town hospital Emergency Department.

WOW. I don't know anything about nursing! In nursing school, they try to give you a lot of theory and practical information so that you know how to help and work with people on the floors. They teach you how to do assessments, what general diseases are out there, and how to do various nursing skills. They also give you experience on the floors so that you feel comfortable giving injections, doing basic wound care, personal care, working with IV's, talking to patients, etc.

In the emergency department, there are SO MANY MORE THINGS TO LEARN. I need to learn the flow of a patient through the department. I need to know what is a standing order, and what I need to get an order to do (which the ED nurses know already, and just get started on things, but I feel clueless!). Overall, I feel stupid most of the time, and try to ask a lot of non-stupid questions. I used to be proud that I felt comfortable doing nursing, and that I was looking foward to increasing my learning and the acuity of my patients. Well I feel i'm on a sharp steep hill, struggling to stay upright. I hope it gets easier, and so far, every day has seemed a bit easier, because now I know where things are, and I sort of know how the flow goes.

There are also a lot of skills that ED nurses complete, yet as a student nurse I won't be able to do until after I pass and work as an RN and complete the competancies or testing within the hospital. Examples of things I won't be able to do as a student include: taking verbal orders, give meds below the drip chamber, and triage (i can observe but that's it until i have worked in the ED for over a year). I'm sure there are other things that as a student I should not be doing, but that is the list so far. I also do not know how to read ECG's, but I am proud to say that now I know how to use the machine to get one!

This emerg also has paediatrics, so I need to be on top of my paediatric assessment skills, something I am not good at, and I am still intimidated by those little people.

After reading ED nursing blogs for almost 8 months now, I have thrived in the stories and felt that I could really like working in Emerg. Now I can kind of relate to their stories about not having enough space, about people waiting for a room, seeing drug-seekers first hand, holding patients in the ER because they have no beds available in the hospital (our lack of beds right now is due to a norwalk-outbreak). I also, unfortunately, know what it's like to work 12 hours without a break, because the ED was so busy.

Overall, so far, I REALLY LIKE IT. I like the fast pace, and I like the learning. I can see myself working in Emerg after I graduate, and so far it looks like they need nurses badly so I could probably get a job there!


Sunday, January 13, 2008

Orientation Day

I think I will finally start having some interesting posts in my blog!

Wednesday was the orientation. I was correct in suggesting that my placement hospital is a tiny hospital, but I am so far happy to say it's busier then I thought it was going to be.

I am the ONLY student who is full time in the ER. THE ONLY ONE. There is only one RPN student who is doing the ER clinic (sort of like the ambulatory care area.. walky talky belly ache's, scraped knee etc), and that's it. Of the RN students.. there are only 3 of us. THREE. I'm used to seeing students everywhere, because my school is a fairly big teaching area. The rest of the students doing their final placement are RPN consolidating students, of which there are maybe 5. I dont' know a soul (RN's or RPN's) because I wasn't in their classes and none of my classmates are consolidating there, but meh, I'm ok with that.

The average age of the nurses on staff is 48. I didn't see a single young nurse there. (although I do happen to know there is one younger then me that works in OB/Labour&Delivery, but I digress...). In all my other clinical placements there were tons of younger RN's. Perhaps the older ones were in management, or have left practice. I have no idea, but having an RN to work with who has 20+ years experience gives me confidence in the profession, as well as their skill. That being said, I'll have to make sure that what they are teaching me is best practice- it has been a long time since they have been in school, and hopefully they have kept up to date!

I love how my clinical placement organizers did not tell us RN students that we were supposed to arrive at 0830h to get an ID badge, that I needed to bring paper proof of all my immunizations including 2-step TB, AND that orientation was until 1700. So I felt like an idiot showing up for 0900 and not having the paperwork. How am I supposed to impress these people enough to get a job if they are setting me up with a bad first impression?

My orientation book was approx 5 inches thick, for which I was supposed to know most of it by my next shift, which was, conveniently, Thursday at 0700. (I'll post more on that shift later!)

I will *almost* never have to do straight blood draws because the lab does it. I will, however, get to do IV starts once my preceptor feels I am capable with the general nursing stuff. I will also be able to draw blood from the IV when I start it. That I am ok with, and am looking forward to learning this new skill! It's interesting that they waited this long for us to start it. Yes, starting IV's and using IV's for meds etc is a more complicated skill, but honestly, in the end, it is a physical skill. Working on assessment is more important, and yet they didn't emphasize that nearly as much as they did IV's. (or perhaps in our minds it was a bigger deal then it actually is!)

I do a DDNN schedule starting Thursday. HOWEVER I also have a random Wednesday during the month. Conveniently it happens to be next week on Wednesday.. which means I will have worked for 5 days straight, have 1 day off, and then work a 8-8 in the middle of my 5 days off. Grr.

One final thing is that when I applied for this placement, I wanted to go into an area that I would like to work in later. I'm happy to say that they have essentially stated that they would like to hire us to work there post-graduation. They demonstrated that by giving us the same orientation as 5 new staff (4 RPN's and 1 RN) that started this week also.

It'll be weird working with RPN's, as except in Long term care, I have never worked with them. What can they do? Apparently everything but the patient has to be predictable. What does that mean? No clue.

Overall, I'm thinking this will probably be a good experience. First, I dont' have to share the cool stuff with other students. There aren't even any residents or med students or RT students etc, so nurses there get to make more of the decisions. That I find awesome, and forward thinking. Second, they are also going to be implementing a full version of the computer system for computer charting, not just the some-paper and some-computer method they use now.

I'll post more about my first few days later. For now, I need to get ready for another shift!

Wednesday, January 9, 2008

...and one more thing...

I just bought 3 new pairs of scrubs so that I can be that stereotypical squeeky clean nursing student (instead of my faded ones from past rotations). Then finally my preceptor emails me (midnight right before orientation!) that on my first shift on Thursday I would be issued greens. Fantastic that I dont' have to do laundry to wash the them and bring home random infectious diseases, but I was looking forward to wearing my new scrubs! Sigh. It looks like I will return them.

However, with the money I have saved by not wearing scrubs, perhaps I can splurge on new shoes.. my current ones are so bad my orthotics aren't even helping. I just wish I had known earlier, so I could have avoided spending 2 hours looking at 3 different stores.

I should be tired

In my winter-break month-long hiatus (well deserved, but yes I realize I was spoiled this year!) I have been getting into the habit of all night-people.. staying up till 3am and waking up around noon. However tonight is a night I have to convert back to a "normal person" schedule.

My attempt at rationing my sleep last night was an utter failure. Not only did I feel tired all day, but I am STILL UP AT 3am. Unfortunately for me, however, my alarm will be going off at 6:45, so I can be at orientation for 9am.

Tomorrow is going to be painful. I just hope I can keep caffeinated enough to make it home safely.. if I get tired I can fall asleep anywhere, including while driving (yikes!) . Typically I manage with downing copious amounts of coffee, antacids and opening up the windows to the Canadian winter.

Perhaps its the orientation, and the placement that has me edgy. I have been thinking about it a lot, and I have come to the realization that I do not feel at all confident in my nursing skills. I have pre-hospital experience and training, and feel really confident with that.. but throwing in a detailed respiratory assessment, anticipating an intubation, IV starts (which in my nursing school they don't teach us until the final placement!), blood testing (again same with the IV, no-can-do until the final placement), circulation medications... That's a lot different then checking ABC's as an advanced First Aider! I know 3-5 drugs as a First Responder... aspirin, epinephrine (through an EpiPen), nitroglycerin, ventolin (only to be used as prescribed), and various illicit and recreational drugs. That is very different than needing to know the 100's that nurses know and use on a regular basis! I think my first year (or more) will be spent with my nose partially in a drug book.

I should have more stories as more experiences occur.

Thursday, January 3, 2008

Gearing up for the new term

I'm just about done my winter vacation and about to start on my final term of nursing school.

School... alas, I have been in University for 8 years straight, and this is the cumulation of a lot of work (and a lot of debt!).

I'm proud to say that I finally finished all my thesis work needed to complete my MSc. As per previous posts, I defended my written work, and after that I submitted my final copy of my thesis just after I found out that my mentor had passed away. I figured Dr. T would have kicked my butt if I hadn't completed my MSc last term, especially if I was spending my time mourning him. He wasn't one for pomp-and-circumstance, and he would have encouraged us to go get a beer at the bar and enjoy ourselves rather then mourn him.

So now that my graduate degree has been completed, I can focus solely on finishing the BScN. I have been working on this degree for 5 terms straight since September 2006. Its the accelerated program just started in Canadian schools, so instead of a 4-year degree, the 50+ of us study our butts off (after some prerequisite courses, and minimum 2 years of another degree) and be RN's 20 months later.

The combination of the MSc and the BScN has been exhausting, so I'm looking forward to a term where I just can focus on working on nursing- specifically my clinical and assessment skills. As mentioned in a previous post as well, we have 1 final placement for which it is my ONLY course. I have been selected to work in the Emergency Department, for which I'm thrilled, yet it happens to be in a smaller town about a 40 minute commute from where I'm currently living.

I'm nervous and incredibly excited to be placed in the ED. I have about 8 years of pre-hospital volunteer advanced first aid experience, and have been involved in resuscitation and trauma, and I'm excited to see how the patients are treated in the hospital. I have read a lot of ED nursing blogs, just to find out what a day in the life of a nurse in the ED is like, and even though I have read some very brutal stories, I still feel that the ED will be the right fit for me.

I start next week with orientation, and then do the same shifts as my preceptor. Hopefully I'll start having some interesting stories to write about! I realize my posts have been really dry and fragmented recently. I guess that's what happens when you're over-extended and dont' even have enough time to sit down let alone write! Wish me luck! To the Emergency Department I go!