Saturday, December 27, 2008
For those who celebrate this time of year, Happy Holidays. For those who don't, I hope you enjoyed the pre-Christmas and Boxing-week sales, and movies that opened up while everyone else was doing the family-thing.
I head to work again tomorrow for another stint before New Year's. Mr E is visiting his parent's in the even more Great White North... booneyville Northern Ontario. He'll be back by New Year's so we'll spend that time together.
Although I have to admit seeing one's family can sometimes be trying (and annoying!) and making small talk about the same thing over and over again can be boring, there are still some things I look forward to:
1) the food ('nuff said)
2) seeing my immediate family
3) the annual girl's movie night (we try to pick a really girly movie)
4) playing Phase 10 (a really great card game that I'm stuck on and typically play with my sister and bro-in-law)
5) being lazy while mom is creating her gastronomic miracles (anytime I don't have to cook is a great day for me!)
I hope you all had a great week.
Tuesday, December 16, 2008
Monday, December 15, 2008
To those who have subscribed to my blog, welcome! More than my best friend and Mr. E read my blog apparently. Although I didn’t create this blog to have people read it (ok ok I did want one comment that, again, wasn’t from Mr. E or my best friend), it has been cathartic and a fantastic way to reflect on myself as a nurse and the nursing experience.
There is a posting for an MSN-trained nurse to teach a university undergrad nursing research methods and stats course.
I have always thought I would teach if I didn’t go into healthcare, and I have experience teaching First Aid and Advanced First Aid.
Saturday, December 13, 2008
I'm sitting in my living room at 0810h and drinking a beer. I NEVER drink after work. I don't even drink post crappy day shift where people have died.
Nope, tonight I am sitting here going through everything in my head. This night shift, although incredibly busy, wasn't overly technically difficult except for one patient. Unfortunately for myself, it was also a patient who I can't talk about because the law was involved and I don't want to implicate or have this go against me in court.
My feet ache like an SOB. My right hand occasionally twinges because of all the bloodwork and IV's I started tonight. I bent over and my back twinged too from standing and lifting and working hard all night.
Soon- post beer- I will wash my face, brush my teeth and go and give a hug and kiss to darling Mr. E. Hopefully I can sleep decently.
Friday, December 12, 2008
Since I have graduated, I have completed 2 ECG courses, ACLS and ENPC. I consider that not much, but necessary for continuing work in the Emergency Department. I have also considered completing a certificate through a college to work on my ENC(C) status which I will qualify to take in about 2 years. In addition, when I am home I am constantly trying to learn more material about triage, and about things that I wasn't sure of when I was at work the previous day.
If I wanted to know why the doctor took the treatment in the way they did, or if I didn't know the clinical condition that well (or why they were testing certain things) I would look it up.
I worked with a newer nurse last night (has worked 1 year more than me) and although she was quite knowledgeable, I was surprised to hear that she had not done any ECG training. I can't say if she has taken any formalized ACLS/ENPC/TNCC course because I didn't ask, but the ECG thing surprised me. This nurse was going to be having a student in January, and is often trusted to work in the resuscitation room. She stated she didn't feel it was a priority for her, and her student had emailed her about things to study, she replied with "nothing".
I have done my own self study as well as taken 2 courses on it to make sure I was up to snuff on my ECGs well enough that most rhythms I can recognize and treat. Although there are some recognizable rhythms that you cannot mistake, there are so many nuances to reading ECGs that there is a medical specialty, electrophysiatry, to do a final read on them (these doctors do 3 years of internal, 2 years of cardiology and another 2 years of electrophysiatry to read ECGs and insert pacemakers etc).
As a new grad of course I feel I don't know enough about Emerg. I'm constantly thinking there is more that I don't know, so I take courses and do a lot of reading to learn. I do recognize that I will always be learning, but still, I want to be a knowledgable ED nurse that thinks ahead and takes in the global picture, not just a person who reacts afterwards. I've had a year's worth of Emerg experience, and still feel that I need more.
I'm not naive that I think that all people are like me, but come on, as a newer nurse there are tons of things you don't know. Doesn't it make sense to focus on continuing education to improve your knowledge? Not everything is completely learned at the bedside, and definately not everything is taught in nursing school.
Friday, December 5, 2008
At 1:30pm he had gone out to get the paper and when he came back in his wife noticed that he was speaking nonsense, and slurred-like. Being smart, she called 9-1-1 right away. As the stroke center for the area, a full workup was completed to prepare him for the clot-busting treatment.
Upon presentation to Emerg he was slightly aphasic, meaning he had a hard time speaking, and he had a slight left-sided deficit.
When a stroke patient comes in, neurology is paged right away. We also hook the patient up to the monitor, get basic vitals, do a finger-pick for glucose, start a line, draw bloods, get an ECG, and then prepare for transport to CT. Once this is all done neurology reads the CT, and pulls together the information to determine whether or not the patient is a candidate for TPA, a clot-busting drug that can effective in ischemic strokes and that is used within 3 hours of symptom onset. The problem with TPA is that the risk of causing a major bleed is so strong that after 3 hours post-symptoms, the benefits of giving the clot-buster don't outweigh the risks.
It was well in the timeframe for TPA: there had approximately 45 minutes left. In addition, the patient was clearly a stroke. His deficits were slightly worse on one side, and he continued to be aphagic. Unfortunately, however, we did not end up giving TPA.
Why? The patient was healthy, except for the fact that he had an irregular heart rhythm; a-fib. Atrial fibrillation is caused by many areas in the atria of your heart wanting to be the pacemaker, instead of the sinoatrial node. Due to the disorganized firing of the pacemaker, there is no effective pump to get the blood from the atria to the ventricles of the heart. This can cause blood to be stagnant and form clots within the heart. Generally, to reduce the chances of getting a clot, a doctor would prescribe a blood thinner.
Since this stroke patient was a diligent patient and took his blood thinner medication every day, he no longer became a candidate for TPA. His blood was already therapeutically thinned to help his heart. TPA would have caused his blood to further be thinned, essentially creating a huge risk for bleeds had the treatment been administered.
Not only did the blood thinner contraindicate TPA, in addition the neurologist could already start seeing the stroke's effect on the brain. Typically when a CT is completed for a stroke, the neurologist is looking to see if the stroke was caused by a bleed or a clot. However, changes to the brain of an ischemic stroke are not noticible on a CT until quite a few hours after the onset of symptoms. So, ultimately the CT is completed to rule out a brain bleed. Although not seeing any ischemic changes in the CT is common, in this patient, the CT showed some darkened areas consistent with brain death of an ischemic stroke.
The decision was made not to TPA the patient, and the neurology team had an incredibly hard thing to do- tell the family of the patient what was occurring, and that a decision needed to be made as to what our next steps were. Ultimately, the family would have to decide on whether the patient would be allowed to pass on (as the stroke was huge and the patient was rapidly deteriorating), or whether other treatment would be provided so that the patient could attempt some form of rehabilitation once stabilized.
Ultimately, the family decided that the patient would not have any aggressive therapy, and instead would be treated palliatively.
The patient continued to get worse: he now had complete loss of function on one side, and his vitals were changing. He went from GCS 14 upon arrival to GCS of 10 within about 4 hours. He knew he was having a stroke and tried to communicate with his family and with me, to no avail. The reason I could tell he knew what was going on was that up until a point, he obeyed all commands.
The man was stuck in a body that was failing him, and he knew it. I hate seeing people suffer, and I know that although his family was there for support, it would have been very hard on him. I wasn't the primary nurse for him, yet I know that all of us in emerg that day tried to lend a helping hand to him and his family.
By the time he went to the floor for palliative care, his GCS continued to decline, and from what I hear he passed sometime in the night.
Tuesday, December 2, 2008
In total, I have 40K of government loans, and approx 26k of private bank loans.
$64,000 of student loans for 4 years of school. That means I lived off $16,000 a year, and that included tuition of about $6,000 each year. I also worked part-time. Needless to say I was frantic about money and I limited my expenses.
Unfortunately now it's time to pay it back.
Although I don't have regrets as to how much debt I took on, I'm wondering what some people's limits are. As an RN I'll be making $50-80,000 a year depending on my seniority for full time work. If I decide to go to NP school I'll make $90-100,000 a year, but that will require another 2 years of school, and a loss of 2 years worth of wages.
I'm going to keep on trying to pay my loans off earlier by increasing my payments each month, but still, I want to be able to start saving for a down payment on a house, and into RRSP's. At what point does debt repayment not supersede savings and financial planning? If anyone in the universe could let me know, that would be great. In the meantime I'll keep working away at my debt, and maybe go to an actual financial person!