Friday, September 26, 2008
Wednesday, September 24, 2008
My take...
... on the death of a man in a Winnipeg ED waiting room.
Although it is terrible shame that this man was not seen for his infection and that he died, he also did not alert anyone that he was requesting medical help.
Emergency department waiting rooms are filled with patients, their family members and friends. To ask a triage nurse or a volunteer to categorize EVERY SINGLE PERSON in the waiting room as a patient/non-patient would be insane. The focus of the triage nurse is to categorize patients that arrive and PRESENT THEMSELVES as patients. They do not have the time to go out and ask every single person there why they are there and if they could possibly need help.
If this is what the government will go to, then PROVIDE THE FUNDING to have some random person walk around and ask people if they need to be seen by a doctor.
And another thing, what about all the other people in the waiting room sitting near this man? Although perhaps not able to assess the patient properly, MOST people can tell if someone is not looking so well.
Again, it's terrible that this man died, but I don't think we can blame the staff in this case.
Although it is terrible shame that this man was not seen for his infection and that he died, he also did not alert anyone that he was requesting medical help.
Emergency department waiting rooms are filled with patients, their family members and friends. To ask a triage nurse or a volunteer to categorize EVERY SINGLE PERSON in the waiting room as a patient/non-patient would be insane. The focus of the triage nurse is to categorize patients that arrive and PRESENT THEMSELVES as patients. They do not have the time to go out and ask every single person there why they are there and if they could possibly need help.
If this is what the government will go to, then PROVIDE THE FUNDING to have some random person walk around and ask people if they need to be seen by a doctor.
And another thing, what about all the other people in the waiting room sitting near this man? Although perhaps not able to assess the patient properly, MOST people can tell if someone is not looking so well.
Again, it's terrible that this man died, but I don't think we can blame the staff in this case.
Friday, September 19, 2008
Wednesday, September 17, 2008
Are you supposed to know everything after nursing school?
The answer is no, yes, and maybe.
No: You have no experience yet, so you can't possibly know everything, and it's not expected that a newly graduated nurse is perfect 100% of the time. And, if you act as if you do know what to do all the time, the staff probably won't like you and would be wary of your nursing skills. Acknowledging you don't know something is a good way to learn and grow.
Yes: You do need to know when your patient is not doing well. They teach that in nursing school. Remember to start with the ABC's. Know your normals for vitals. Know the progression of the disease or ailment the person has. Know the common risks of the operation that the patient just had. You do need to know a lot, and you'll probably be spending a LOT of time learning it all both at work and on your own time. Try to look things up on your own before asking. If you don't have time and the patient is going sour quickly, ask your charge nurse or a more senior nurse NOW.
Maybe: You do have a license to defend. Work within your scope. Ask questions. Acknowledge you don't know something and LEARN IT. Don't settle for "that's the way its always been done". I catch myself sometimes with that. If it's an emergency and you don't have time to learn to do things or about the drug before you have to prepare it, and the MD and a more senior nurse is guiding you through the process, quickly scan the details so you prepare it properly, and then GO BACK AFTER AND LEARN WHAT YOU DID.
I'm no where perfect and I'm still learning ALL THE TIME. Something new comes into the ED everyday, and I find myself overwhelmed at times. I try to take it in stride, and read up on things afterward. Also, if you have a nursing friend you can trust, run it through them and your fears. They probably feel the same way.
Good luck!
MRSA/VRE
In the ED we look after patients with MRSA and VRE. MRSA, also known as methacillin-resistant Staphylcoccus aureus, is a bacteria which is resistant to a number of antibiotics. This means that the antibiotics we would normally use to fight infections by these bugs don't work properly, and thus increases the risk that patients will become sicker, and we have less antibiotics to treat them.
MRSA and VRE are quite common in hospitals, unfortunately due to the overuse and misuse of antibiotics both in the community and in hospitals. It's also (unfortunately) common for MRSA or VRE (vancomycin-resistant enterococcus) to be spread from patient to patient by hospital workers like nurses, doctors, patient support workers.
To combat the spread of this bacteria, it has been mandated in hospitals to screen for these antibiotic resistant bacteria, and to prevent transmission of these bugs by wearing protective gear such as gloves and gowns when entering an MRSA/VRE patient's environment. Also highly important is proper handwashing between patient interactions.
In the ED sometimes we do not even know the person's name, let alone whether they have the resistent bug. If the patient has been hospitalized recently, there is a flag that pops up on the computer. Sometimes, however, we don't find out that this flag has occurred until we have already touched the patient, and been working in their environment for a while. This means that MRSA or VRE could potentially be on our hands, and on our scrubs. With proper handwashing, the bug could be almost completely gone from our hands, but even I can attest that I dont always follow handwashing procedures 100% of the time even though my hands typically are raw from washing them so often.
There have been a few times when we have already recieved admission orders, and have completed them by the time I find out that a patient is MRSA or VRE positive. That usually constitutes HOURS of patient care before gowning and gloving as per our infectious disease policy. Some patients have even asked me why I am now wearing a gown when before I wasn't. I do explain to them about MRSA, and explain that prior interactions I was unaware that these precautions were needed, and that from now on nurses will wear this gear.
I'm not the only one that does not see the flag. I have been given patients from other areas for whom the reporting nurse did not know the MRSA/VRE status.
This is a huge problem, as not only do the patient workers (RNs, MDs, RTs, PTs, OTs) need to know for patient interaction, housekeeping and our other support workers need to know so they can properly decontaminate the area once the patient has been transported to another area, or upstairs to the floor. This means washing everything down,and changing the curtains. Also, if a patient worker did not know that the patient was MRSA/VRE and they took an IV basket into the patient environment, THAT BASKET is now contaminated and everything would need to be thrown out.
That's a HUGE waste.
I think I will see in my practice-lifetime the assumption that ALL patients have MRSA/VRE, that ALL interactions with patients will be with contact precautions until a negative screen occurs. This is a huge time-committment as every time you enter the patient area, you need to be gowned and gloved (EVEN TO FIX AN IV BEEP). I can see a mandate of IV baskets not being allowed in patient areas. Until we can get this silent epidemic of MRSA/VRE to stop spreading, the work of helping people is going to continue to increase.
MRSA and VRE are quite common in hospitals, unfortunately due to the overuse and misuse of antibiotics both in the community and in hospitals. It's also (unfortunately) common for MRSA or VRE (vancomycin-resistant enterococcus) to be spread from patient to patient by hospital workers like nurses, doctors, patient support workers.
To combat the spread of this bacteria, it has been mandated in hospitals to screen for these antibiotic resistant bacteria, and to prevent transmission of these bugs by wearing protective gear such as gloves and gowns when entering an MRSA/VRE patient's environment. Also highly important is proper handwashing between patient interactions.
In the ED sometimes we do not even know the person's name, let alone whether they have the resistent bug. If the patient has been hospitalized recently, there is a flag that pops up on the computer. Sometimes, however, we don't find out that this flag has occurred until we have already touched the patient, and been working in their environment for a while. This means that MRSA or VRE could potentially be on our hands, and on our scrubs. With proper handwashing, the bug could be almost completely gone from our hands, but even I can attest that I dont always follow handwashing procedures 100% of the time even though my hands typically are raw from washing them so often.
There have been a few times when we have already recieved admission orders, and have completed them by the time I find out that a patient is MRSA or VRE positive. That usually constitutes HOURS of patient care before gowning and gloving as per our infectious disease policy. Some patients have even asked me why I am now wearing a gown when before I wasn't. I do explain to them about MRSA, and explain that prior interactions I was unaware that these precautions were needed, and that from now on nurses will wear this gear.
I'm not the only one that does not see the flag. I have been given patients from other areas for whom the reporting nurse did not know the MRSA/VRE status.
This is a huge problem, as not only do the patient workers (RNs, MDs, RTs, PTs, OTs) need to know for patient interaction, housekeeping and our other support workers need to know so they can properly decontaminate the area once the patient has been transported to another area, or upstairs to the floor. This means washing everything down,and changing the curtains. Also, if a patient worker did not know that the patient was MRSA/VRE and they took an IV basket into the patient environment, THAT BASKET is now contaminated and everything would need to be thrown out.
That's a HUGE waste.
I think I will see in my practice-lifetime the assumption that ALL patients have MRSA/VRE, that ALL interactions with patients will be with contact precautions until a negative screen occurs. This is a huge time-committment as every time you enter the patient area, you need to be gowned and gloved (EVEN TO FIX AN IV BEEP). I can see a mandate of IV baskets not being allowed in patient areas. Until we can get this silent epidemic of MRSA/VRE to stop spreading, the work of helping people is going to continue to increase.
Monday, September 15, 2008
Tuesday, September 9, 2008
Miss-Elaine-ious's BIRTHDAY!
Happy Birthday Blog!
Today is my 1st anniversary of this blog. Honestly I didn't think I would stick it out this long, especially since I'm not a big fan of writing. However your support and my addiction to reading all your blogs makes me continue this.
To summarize the last year:
Some nurses have been saying to get some experience in the ED before doing courses. The way things are happening lately, when things DO start to pick up, I'll be done my mentorship. I learn better if I do the bookwork and THEN apply it, not the other way around. I like to understand things first.
Well, overall, a great year.
Looking forward to the next!
Today is my 1st anniversary of this blog. Honestly I didn't think I would stick it out this long, especially since I'm not a big fan of writing. However your support and my addiction to reading all your blogs makes me continue this.
To summarize the last year:
- Wasted a lot my life in classrooms
- Finished my MSc
- Finished classroom nursing
- Got into the rural ED nursing preceptorship
- Loved the ED preceptorship
- Found out that I may like being a nurse
- Got a job in the big city hospital in the New Grad program
- Went to Florida/vacation for the first time in over 10 years
- Moved in with the bf
- Broke my knee (ok my patella but still)
- Started big hospital orientation
- Went to two uni grads in one week
- Finished the precepted shifts
- Wrote the CRNE
- Did an ACLS course
- PASSED the CRNE
- Got my official RN registration in the mail
- Continue to do mentored shifts, until Oct 1
- Complete the TNCC course
- Complete either PALS or ENPC
- Start coursework for writing the exam to become an ENC(C) which I think I'll write in 2010
- Get a permanent job in the ED (December/January is the deadline!)
- Get engaged (ok that's Mr. E's department but still)
- Non nursing- GET MY BUTT IN GEAR for indoor soccer season (breaking my knee made me realize that I'm not a spring chicken and I need to take care of myself (aka lose 30+pounds) if I still want to play sports and keep my knees)
Some nurses have been saying to get some experience in the ED before doing courses. The way things are happening lately, when things DO start to pick up, I'll be done my mentorship. I learn better if I do the bookwork and THEN apply it, not the other way around. I like to understand things first.
Well, overall, a great year.
Looking forward to the next!
Monday, September 8, 2008
Learning curve continues
A patient had had an outpatient laproscopic surgery, and the next day didn't feel well so they came to us. He kept de-satting to 80% when not on a non-rebreather, although denied any chest pain or any other problems except feeling unwell. Sutures were intact, belly soft. A VQ scan showed a high probability of a PE. So we gave some anti-coagulants, and kept an eye on him. I was on the night shift, had "fluffed and puffed him" for a few hours sleep.
A few hours later I went in to do bloodwork and take vitals, and I knew in my gut something wasn't right. He woke up, but didn't talk to me, just kind of stared despite me asking simple questions. Now at first I thought, ok, he hasn't slept all night, was exhausted with trying to breathe. Earlier in the month I had a patient who was slow to rouse and answer questions (5-7 minutes) and I had summoned the other nurse and let the team know, all for probably nothing as she ended up being fine. I felt a bit stupid after that, because I probably just overwhelmed her and she was sleepy.
The monitor looked fine, saturation was fine, and BP was ok. I started to take his blood, he pulled back and said "ow". Ok, then he's fine, I told myself.
Anyway this patient had terrible veins so I asked another nurse to come in to draw the blood instead. The patient was still not responding well, and looked like he was having a hard time speaking. That's when I realized that he wasn't sleepy, that perhaps something else was going on. Total time was about 3 minutes which wouldnt' have mattered, but still I felt like an idiot, not going with my gut in the first place. Neurologically he was not really responding well, had expressive aphagia, and did not follow commands. However he did move all limbs.
Blood sugar was normal (something we always check with decreased LOC), and we called the team. They came and assessed him, and by the time they were done it was change of shift.
Apparently he had a stroke sometime in the night while sleeping.
I thought many times about my actions throughout the night, and I don't think there was anything I could have done differently that would have made a difference in the outcome. This patient was not a candidate for tPA which would be affected by time, and despite a small amount of hesitation and unsurity, I assessed the patient appropriately and notified the team.
Although I'm sad that this patient did not do well, it was a great learning experience.
I learned that I still need to pay attention to the subtle things. Another nurse thought she saw a slight difference in pupil size, which another nurse confirmed. After numerous attempts, I couldn't see it. I have been looking at pupil sizes for over 8 years, have I missed things? What else have I been missing?
Perhaps because its ingrained in me that I'm not supposed to stare, that I don't look hard enough at people. Perhaps I'm not actively looking for things in order that I miss things. I think I need to examine this, and really focus on it. Some days I'm thinking I might be ok at this stuff, but other times I feel like an idiot.
**note: "fluff and puff" is a term I learned just recently which means you get them settled into bed, provide and straighten out their blankets, pillows etc, so they can sleep.
**Ok so the picture is an obvious difference in pupils. I'd be able to see that 5 feet away.
A few hours later I went in to do bloodwork and take vitals, and I knew in my gut something wasn't right. He woke up, but didn't talk to me, just kind of stared despite me asking simple questions. Now at first I thought, ok, he hasn't slept all night, was exhausted with trying to breathe. Earlier in the month I had a patient who was slow to rouse and answer questions (5-7 minutes) and I had summoned the other nurse and let the team know, all for probably nothing as she ended up being fine. I felt a bit stupid after that, because I probably just overwhelmed her and she was sleepy.
The monitor looked fine, saturation was fine, and BP was ok. I started to take his blood, he pulled back and said "ow". Ok, then he's fine, I told myself.
Anyway this patient had terrible veins so I asked another nurse to come in to draw the blood instead. The patient was still not responding well, and looked like he was having a hard time speaking. That's when I realized that he wasn't sleepy, that perhaps something else was going on. Total time was about 3 minutes which wouldnt' have mattered, but still I felt like an idiot, not going with my gut in the first place. Neurologically he was not really responding well, had expressive aphagia, and did not follow commands. However he did move all limbs.
Blood sugar was normal (something we always check with decreased LOC), and we called the team. They came and assessed him, and by the time they were done it was change of shift.
Apparently he had a stroke sometime in the night while sleeping.
I thought many times about my actions throughout the night, and I don't think there was anything I could have done differently that would have made a difference in the outcome. This patient was not a candidate for tPA which would be affected by time, and despite a small amount of hesitation and unsurity, I assessed the patient appropriately and notified the team.
Although I'm sad that this patient did not do well, it was a great learning experience.
I learned that I still need to pay attention to the subtle things. Another nurse thought she saw a slight difference in pupil size, which another nurse confirmed. After numerous attempts, I couldn't see it. I have been looking at pupil sizes for over 8 years, have I missed things? What else have I been missing?
Perhaps because its ingrained in me that I'm not supposed to stare, that I don't look hard enough at people. Perhaps I'm not actively looking for things in order that I miss things. I think I need to examine this, and really focus on it. Some days I'm thinking I might be ok at this stuff, but other times I feel like an idiot.
**note: "fluff and puff" is a term I learned just recently which means you get them settled into bed, provide and straighten out their blankets, pillows etc, so they can sleep.
**Ok so the picture is an obvious difference in pupils. I'd be able to see that 5 feet away.
I love....
... how our clinical educator lets us know we are taking our own assignments soon by emailing the entire department in a newsletter. That's the first I've heard about this!
However, I think I will embrace this well. I'm torn between wanting the responsibility and being fearful of it. Onwards!
However, I think I will embrace this well. I'm torn between wanting the responsibility and being fearful of it. Onwards!
Wednesday, September 3, 2008
WTF?
Mondo writers block combined with a visit from the in-laws for a week makes Elaine not an interesting person. I guess I have ran out of things to say, as I have been almost writing on this blog for a year (gasp!).
Things are going well in the ED lately, for the patients. I still am not getting the crazy shit that seems to be happening every time I'm NOT in the ED.
Also, I think the paramedics are patching in things that are way exaggerated. Now don't get me wrong, I love the paramedics in the area, and I think I have a good relationship with them. But lately things haven't been what they seem...
For example, the SVT we were going to get was treated with adenosine in the field and converted before he arrived. He was hunky dory feeling lovely by the time he got to us.
The crazy psycho guy needing us to greet them at the door with a stretcher walked in without so much as a to-do.
The unconscious we were patched was alert and oriented.
I swear I have this cloud of happy happy sunshine that the patients see that immediately makes them better as soon as they get within 10 feet of the hospital. Ironically, instead of being happy that people are feeling ok and not that abusive, I'm feeling disapointed.
They ARE around, as patients tend to always be misbehaved in the ED, and I come in at change of shift and there's always a story or two about the guy that has been abusive all night. But that guy was calm by the time I see them. What the hell is going on?
Things are going well in the ED lately, for the patients. I still am not getting the crazy shit that seems to be happening every time I'm NOT in the ED.
Also, I think the paramedics are patching in things that are way exaggerated. Now don't get me wrong, I love the paramedics in the area, and I think I have a good relationship with them. But lately things haven't been what they seem...
For example, the SVT we were going to get was treated with adenosine in the field and converted before he arrived. He was hunky dory feeling lovely by the time he got to us.
The crazy psycho guy needing us to greet them at the door with a stretcher walked in without so much as a to-do.
The unconscious we were patched was alert and oriented.
I swear I have this cloud of happy happy sunshine that the patients see that immediately makes them better as soon as they get within 10 feet of the hospital. Ironically, instead of being happy that people are feeling ok and not that abusive, I'm feeling disapointed.
They ARE around, as patients tend to always be misbehaved in the ED, and I come in at change of shift and there's always a story or two about the guy that has been abusive all night. But that guy was calm by the time I see them. What the hell is going on?
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