Imagine

.. you are a 60ish year old female who up until last week have been having a healthy life.

Last week, you start feeling flu-like symptoms, anorexia, and cannot go to the bathroom for a bowel movement.

You go to the Emergency Department because your ED-nurse son says you need to get some fluids. He's thinking you're dehydrated and constipated, and with a fleet or two you'll be fine.

Well you go, you get tests, and xrays, and a CT scan. Then the surgeons come see you. You have a bowel obstruction. NG tube took 4 tries but it got in (you have a sensitive gag reflex), and the foley was uncomfortable and a bit embarrassing. The ED nurse takes you up to the OR because you sent your husband home early, thinking you would be home in the morning.

The surgeon comes back into your room post-surgery. You are groggy, but you hear what he said:

Cancer. Large tumor, spread everywhere....... 6 months to live.

I can't imagine that, and yet this is what happened to my patient tonight. I sent a prayer for this family once I heard the news.

Do you find this weird?

A 30-something year old lady climbing into bed with her demented, ailing, father who has a dermatological condition, and the condition is serious but not life-threatening.

Saw that the other day when I was shadowing on a medical floor.

Chief complaint:

Watery diarrhea x10 years.

No Crohn's, no colitis, no diverticulitis.

What the hell do you want me to do for you besides give you fluids which you already received earlier today by a home care nurse?

Also: This person has a family physician AND a General Surgeon who she has been seeing for this problem.

WTF?

welcome

I'm a big geek but I looked at my Google Reader and noticed I have 4 more subscribers then the last time I checked about 2 months ago. For you who are new, WELCOME! For the oldies but goodies, I hope I'm keeping you entertained. (Yes I know I only have 12 subscribers, but to me that's a BIG DEAL!)

I realize I'm not one of the "famous" bloggers out there like Kevin MD or Kim at Emergiblog, or even Mother Jones at Nurse Ratched's Place (probably because I have yet to blog every day and honestly I don't have that much experience or sarcasm), however I do appreciate that you take the time to come to this blog.

I haven't updated my "who I read" section lately, and I will soon. If you're not on the list and would like to be, feel free to send me a message and I'll add you to my reader.

Rural vs Urban

After spending almost the equivalent time in the big city as I had in the smaller rural hospital, I can honestly say that I miss the rural hospital.

In the big city hospital, you have backup. Which is fabulous when you're a new nurse and still need mentoring, but since the backup is there you forget things like how to hook up an ecg, or where the syringes are (because you don't stock them), or what it's like to take a patient to xray.

There's something to be said about doing things ON YOUR OWN, and having the outcome be the same. Also, there's a smaller bunch of nurses, and since you are it, you get to do skills/procedures that there would be support staff (or more senior nurses) to do. For example, in the big hospital as a new nurse I probably wouldn't be a primary nurse in a trauma. However, in the small hospital, any nurse that is available is "a primary nurse" just because they need all the help they can get.

I also like having a mixture of cases throughout the day. In the big hospital, you're assigned to 3-5 beds and that's where you stay. In the little hospital, you take patients as they come in, usually getting about 3-4 each, depending on their acuity. Typically you get 1 high acuity and some lower acuity.

Most people assume that the periphery hospitals have lower quality care, and that the nurses may not be as good. I think the opposite: you have to know so much more to work rural, because you can't rely on anyone else.

One day, I'll feel ready to go back.

Change of Shift

Up at Emergiblog!

O what a night.

Background: Treatment room with 4 beds, no monitors. Ideally this room is used for fast track, MSK and lacerations. However lately it has been another room to hold admitted patients who are not sick enough to be directly by the nurses’ station in a monitored bed.

The night I was there was LOL night (lol=little old lady), where most had fallen and needed various pain workups. One had fallen a WEEK prior, but wanted pain control. This particular lady was elderly, from a nursing home, had fallen a week ago, and surprisingly instead of sending her to Emerg on that day, they properly assessed her, determined she was ok, and didn’t send her in. However the family a week later stated that she said she was in more pain than normal (she has chronic pain) and they wanted her assessed. Into Emerg she went. This lady was already on TWO 250mcg fentenyl patches, plus Dilauded for breakthrough pain. AND SHE WAS STILL COMPLAINING OF PAIN. Medically there was nothing wrong with her, she needed to have her pain meds changed, and to have attention so she would stop whining. I think the nursing home staff got so tired of her whining that she was in pain that they called the doc, and over time they would steadily increase her pain meds. The amount of narcotics she was on could tranquilize a horse. But her vitals were stable, and her pupils weren’t that pinpoint, and when she wasn’t whining, she rested in no apparent distress.

This lady was one of those patients that if you went to do vitals on her, or draw blood, she would keep you in that room for 30-45 minutes and suck you dry of all your nursing-type caring. “can you do this for me can you do that for me, and o my leg hurts, and I think I have to go to the washroom, and I need something to drink, and o I’m in such pain is there anything you can give me”. I’m thinking that her MD must be the sugardaddy of drug dispensers for the amount of narcotics this lady received. No wonder she was complaining of 9/10 stomach discomfort. She was completely FOS.

She drained me dry, and I had 3 other patients to look after.

I passed!

Not only did I pass ACLS with flying colours (whoo hoo!), I also received notification I passed the Canadian Registered Nurses Exam.

I'm an official RN (well once I send yet ANOTHER fee to the college). Notice the (temp) part is off the title of my blog.

Today is a good day. Now if I fall asleep quickly and stay asleep until 5:30pm that would be a GREAT day.

Not much to say.

Day one of ACLS completed. Not as bad as I thought it would be, as most of the things I have learned already through pre-hospital care (such as oralpharyngeal airways, Bag-valve-masks,etc) but the drugs are still new. Apparently this is ACLS for dummies now, because really, the drug list isn't as bad as it used to be.

Went to see the new Batman tonight. It was fantastic. I highly recommend.

That's it for me, no bitch sessions tonight.

I do have to say that Mr E and I have a very good strategy for our co-op play for shooting games. He goes rambo, I stay back and shoot from a distance. That way, when he dies, he can respawn and rambo again. Did I mention we play a lot of shooting type games? Lets see, we've gone through Bond 007 games (beat them but took some time), Army of Two (beat it in 3 days), Halo 3(beat it fairly quickly), Gears of War (beat it in a week), and now we're on this Rainbow Six Vegas. We've also conquered everything but the last set on Guitar Hero 3 on expert. Yeah we're video game burnouts. We also went a little nutty with Mario Kart for the Wii. The only goal we have now is a bigger TV so we can use our 360 better and be able to see the letters of the words!

Not much to blog about...

Spent the day on an off-service floor. Pooh. It was snoresville, but I'm glad there are nurses that like transplant nursing. I don't' think I could handle seeing the same patient for 2 weeks-months.

Tomorrow (or shall I say, today) I take ACLS. Did the prepwork so I'm feeling pretty good. Wish me luck!

Acetaminophen: good for headaches, bad for liver.

So a man who has had a rough past (he wouldn't go into detail) calls 9-1-1 after he has run out of percocets. We get him around 0200 and he states he has taken 6 percocets around 11pm, and has pain. Blood tests were drawn around 0300h. His acetamenophen level was 1105µmol/L. According to this chart, in the Merck Manual, he was at the top of the chart for probable hepatic toxicity.

Yikes.

I have never had an acetaminophen overdose ACTUALLY BE an overdose. It was too late for activated charcoal, so we gave him acetylcysteine (Mucomyst). He handled the first dose well (the dose has a bolus and then it is reduced and has a regular flow for about 16 more hours), but then developed facial swelling, nausea, and itchiness. This reaction is not uncommon. So diphenhydramine (Benedryl) and dimenhydrinate (Gravol) was administered, and we turned the rate down.

I had to do this (I never have done this before) and I also had 2 other patients. The other nurse who was mentoring me was on break, but she came back and helped once she was back. I felt that I was in panic mode, but I think I did ok, despite the fact that I think I was slower then most (I hadn't hung that drug before so I had to look it up, make sure I double checked the dosages, etc). I also had to start an IV because the person continued to insist they only took 6 percocets. Man that was an interesting 45 minutes. I was sweating buckets by the end... I sweat when I get anxious.

The manufacturers of acetaminophen state to not exceed the 4g a day limit on acetaminophen. It can wreck your liver. Please read the box carefully.

Another case of NETY (nurses eating their young)

I think I'm the unlucky one.

The other day I was asked to escort a monitored patient to a diagnostics lab. No problemo. However he needed a transfusion of Fresh Frozen Plasma after his initial blood transfusion had been completed. Well I wasn't sure what the procedures were 100%, so I quickly looked it up on the computer at the diagnostics lab before I went to prepare for the transfusion.

A nurse goes to me and says "hey, is Mr X your patient?"

"Yes," I reply. "Why?"

"His FFP (fresh frozen plasma) is there."

"Ok, thanks. I'm just reviewing how to hang it before I head in there."

"You're an emergency nurse and you don't' know how to hang blood products???" She asked in an incredulous voice, as if I was the worst ED nurse ever. That stung.

"I'm a new grad, and new to the ED" I fumbled, flabbergasted.

I then proceded to hang the transfusion appropriately, but that comment pissed me off.

She was totally and completely in appropriate for saying that to me. The other nurse at the lab clued in and tried to console me by saying that "we were all new at one point, how else are you supposed to learn?". I appreciated that, but still. Pisses me off that someone could belittle another person. I would NEVER do that to anyone. If I do, that's the time I need to get out.

Also, I really need to start thinking about what to say at the TIME of the incident, not afterwards. One day.

Change of Shift

This week's Change of Shift highlights the initial post of many different nurse-bloggers, including myself.

Thank you for stopping by, and enjoy!

Dreaming as a nurse

I have committed a crime of sorts.

I have taken work home with me.

Not in the usual way by bringing home paperwork or completing an online test for continuing education. Nope, I get it personal. I DREAM about nursing.

Considering I'm not 100% sold on nursing, it shocked me that I would start dreaming of it.

I was dreaming that I should be working with my patients and shouldn't be sleeping on shift. Then I startle and think WHY THE HECK AM I SLEEPING WITH SOMEONE BESIDE ME... WHO IS IT? ANOTHER NURSE? A PATIENT?

Then I wake up and realize I'm at home, in bed, with my boyfriend sleeping, blissfully unaware of my dorky-ness. I will attempt to have non-nurse dreams in the future.

God I can't imagine what I will dream about after 5, 10 and 15 years of this. Thoughts?

Punished

So here's an interesting topic

I got sent home from work today because I was too eager to work.

We have an inservice day today, from 0830-1630. As you can see by the time that I'm sending this message (0850), I am not at the inservice. WHy am I not there? Because I had to work last night, or so I thought.

See, apparently I was supposed to know that I was only supposed to work 4 hours last night. No
one had told me this, and it was not on the schedule. I had even mentioned that there was a inservice tomorrow all day and that I was working... people didn't blink an eye or suggest I shouldn't work all night

So I jokingly say to the Educator today that I'll make sure I stay awake today.... and she asked why. I stated because I worked last night.

She looked at me in shock and said, well I can't keep you. Go home.

I ask, "what do you mean?"

She says " you were only supposed to work until 2330. " I say "o really? I didn't see anything on the schedule and no one had told me this, so I assumed that I had to work all night. I would be more than willing to stay the day and I am wide awake now, so it's no biggie."

Yes I still use the phrase "no biggie".

Continuing on....

The Clinical Educator said to me that she thought she had made comments earlier on about going home early if you had a night shift before things during the day, and that she had made this clear. I was not aware of this, nor was I not paying attention. It is a new job after all, and I'm the new kid on the block.

How was I supposed to know that I was supposed to ask to leave early (aka 2330)? Am I being punished for being too eager? (the Educator was ticked off that I worked last night and that I'm going to be missing the inservice cuz she wont' let me stay)

I guess I have a different work ethic than others. I didn't even blink an eye when I thought I had to be at work for 21 hours

I'm just hoping no bad repercussions come of this, and I'm pissed off that people assume that I know the policies of the department.

I'm still learning them. How was I to know this is the way things are done in Emerg at cityhospital?

Because in Small town hospital, if you had a meeting to go to all day, and you were scheduled the night before, you worked the night shift and then went to your meeting, unless you had traded or booked with someone else.

I'm ticked off because the situation makes me look bad (despite my good intentions), and since I dont' have a full time job secured, it makes me angry that something has happend that could put me in a bad light with the Educators and bosses.

Anyway, I'm done ranting now, thanks for listening.