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.