Friday, November 14, 2008

Insomnia Again

This time (and yesturday night too, unfortunately) my insomnia was directly related to work.

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.

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