Nurses don't eat their young...

But some definitely don't make it easy.

I have had some great preceptors and helpful mentors so far in my Emerg experience (only about 2 months worth so far) so I can't say that nurses typically eat their young. I think that people are starting to realize that they NEED new grads, and if they don't help newbies succeed, there will be no help in the future. I did, however have an experience with a nurse on another floor that bothered me. Perhaps this can start the Emerg/Floor debate, and the animosity between them (at least, in my hospital there is some animosity).

The other day, during one of my precepted shifts in Emerg, I had a patient who had a fairly active GI bleed, whose hemoglobin was about 68g/L (normal is 120-140g/L). We start transfusing patients below 80 typically. She was elderly, was cared for by friends at home for the most part, but was basically immobile and the caregivers knew something more was wrong then what they could deal with. She also had melanous, loose stools (eww).

Anyway, General Surg came to see her, and admitted her so that she could have surgery the next morning (they didn't feel she needed surgery ASAP, but definitely soon). They had a long list of admission orders, and not knowing when she would get to the floor, we got started.

She needed two packed RBC's (which require multiple vitals and constant monitoring), a 2nd IV line, more bloodwork, a foley, 2 fleet enemas, not to mention the pre-op meds and other medications. I spent 2 hours at the bedside getting almost everything done for her. The only thing I didn't get to was the 2nd packed RBCs and the 2nd enema.

The foley took longer than expected because the woman was fairly tall and large ( requiring a bunch of hands to help roll), and she had wet her bed and her gown. So I got the foley in, changed the attend, changed the sheets, and the gown. THEN she needed the fleet (I was not going to let her stew in her wet attend for the fleet to start working. She already had a level 1 pressure ulcer and I didn't want it to break the skin by sitting in wetness). Twenty minutes later I had to change her attend AGAIN. To save time, I was also infusing the medications as well as monitoring her vital signs for the packed RBC's. In addition, I was slower then a regular nurse because I'm new at this stuff. It all adds up.

So as mentioned, 2 hours later we find out that a bed is available for the patient. My preceptor (who was helping roll my patient when needed and working with 2 other patients) helped fill out the fax sheet, faxed it to the floor, and then called the nurse using the handy dandy phones they have. I guess you dial into the computer the phone you want, and the nurse who carries the phone acknowledges the call, and that comes up in the computer. Then we called a porter, and packaged the patient up to go to the floor.

The porter came and stated that because the blood was infusing, she couldn't take the patient up herself. So I went up with her. I was extra staff anyway so it was fine. There would still be someone to help with the other patients.

So we get to the floor, and the nurses look at us as if we are from another planet. "Who's this?" they ask. "This is Mrs. X, we sent the fax sheet up about 10 minutes ago. She's going to bed 205a" I said.

"We didn't get a fax", they reply, annoyance in their voice.

I clearly remember my preceptor sending the fax. Trying to be political (and in a bit of a shock), I state, "Well I'm pretty sure we sent it, perhaps it's at the machine."

She sighs and goes to the fax machine. No fax. So that happens once in a while, the fax machines break down. So I ask "We called the nurse phone as well, and it acknowledged the call. But its ok, I'll give verbal report once we take the patient to the room". So they call the primary nurse for the patient and we get her settled in the room.

I give a verbal report (which in hindsight was silly because everything was already written on the faxed sheet which was in my hand because we send it with the chart), and the first thing she asked me was "We need to do Packed RBC's TONIGHT?? and the fleet HAS to be done tonight?" as if to say that she was annoyed with me that I didn't get it done downstairs, and that it would be too much work for her to do this.

Look lady, I thought, I just spent 2 hours with her to get almost all of her admission orders done BEFORE she even got to the floor. Doing a few set of vitals and changing her once more won't be that hard.

Of course I didn't say that, and I was kind of shocked with the way she seemed to blame me for giving her some work to do. I kinda just stammered and said "that's what's in the orders for tonight, so yeah. Sorry."

She then did the angry sigh and said thanks in a sarcastic tone, and then left the nurses station in a huff. The others at the nurses station looked at me as if I was scum. I left the nurses station in a hurry, shocked at the reception I received from the floor.

I didn't get mad until I was in the elevator, I think I was too shocked to be angry before. Plus, I was new. I hadn't worked in the hospital for 10 shifts yet. And I"m a new nurse. What if I had done something wrong? What if there was this policy that I haven't heard of? So I just kept my mouth shut.

There was NO reason for them to talk to me in that tone, or that way. I'm a person, and I worked hard to limit the amount of work that they would have to do. What if the bed had been available right away, and they would have had to do ALL of the work? They should be THANKING me that I was able to spend that time with the patient and get those things done.

I know that the floors are busy. I used to come home exhausted as a student during 12 hour shifts on the floor. I had even worked ON THAT FLOOR as a student nurse, and I don't remember it being that hostile. I know the patient load is tough, and there are post-op patients that are heavy. But that does not mean that they get to be rude to the emerg nurse that is bringing them a patient. We're swamped downstairs too.

My mentor later stated that if I get run through the coals again, just think of yourself as a PERSON first and a NURSE second. No one should be treating me like that, despite my limited nursing and hospital knowledge. If I had done a nursing task wrong, it would have been my preceptor's task to mention it. I had done nothing wrong.

The only thing I did wrong was being at the right place at the right time for her to bitch. And the sad part is, she was a new(er) nurse herself. Probably younger than me.

And another thing...

I got offered a job today! WOO HOO! It's official... I , as of May, will be an Emergency Nurse! Not a student... A REAL WORKING PERSON! Scary, eh (the Americans in the crowd have officially snickered at the "eh", but you can't take the Canadian out of the girl). After all the work I have done the past 8 years, I am thisclose to being done.

I won't accept the job until I hear from the other hospital I applied to. In the meantime you can stew in your juices trying to guess which one I will choose!


Sigh, soon it will be time to start paying back those loans I've been ignoring....

I heart Emergency

I'm starting to get the feel of being an Emerg nurse. Call a patient's name, take them to the room, do an assessment depending on their complaint, inform the physician, and treat the patient until they are 1) admitted or 2) discharged. Fairly straight forward.

Today however, was different. In 1 shift:

- I was 2 for 3 for IV starts on patients.
- I was 0/2 for foley insertion (to give me credit, a total of 7 foleys were attempted on this patient, 2 by me, 5 by staff!)
- I saw first hand the confusion/disorientation associated with post-ictal states.
- I helped a man who had tried to commit suicide
- I helped out with a trauma; multiple stab wounds with a possible hemothorax.
- I was the one to do report to the charge nurse of the big-city hospital about this trauma.
- I set up and completed four 12-lead ECG's.
- I feel confident in the plan for cardiac patients
- I saw the devestating effects that a brain tumour can have
- I talked to a lady who has a severe degenerative disease who came in with exacerbation's of symptoms, and tried to develop a therapeutic relationship with her and her husband.
- I cut clothes off a patient
- I spent over 13 hours on my feet
- I am ridiculously exhausted

Overall, I had a FANTASTIC day.

20 something year olds shouldn't die

My first nightshift was fairly busy. I didnt' work nights as a student, so this was my opportunity to see if I could transition and stay up all night. At first it was fairly steady, if not slow. Around 0200 patients that were on hold were finally settling down for the night, and we didn't' have many in the waiting room.

Suddenly, the ambulance phone rings. My preceptor picks it up. It is dispatch, warning us that we were getting a 26 yo male VSA. As she is announcing this, my adrenaline pumps through my body. "This is what I have been waiting for", I think to myself. I have spent 8 years as an advanced first aid volunteer, I teach CPR, yet I have only done it once. This is my first experience with a code in the hospital. I try not to look too excited, as the story could change and as far as we know the patient is fine. However, there is a definite spike in energy in the staff, and it is decided that my preceptor and another nurse would be in the room, and the 3rd nurse will do triage and also take care of the rest of the patients. Being a small-town hospital, when we get a code in the ER at night, staff from the other floors are called down to help.

We wait in anticipation to get confirmation of the code. 5 minutes later, dispatch calls again. Confirmed, 26 yo male VSA, 2 minutes out. My preceptor gets on the phone and calls the code, and we prepare by getting on gowns and masks. Time inches by, it seems. It look longer then we expected... apparently the guy is not doing well at all, and the medics were going to try to get
him called on the scene. We waited, and we waited. 20 min later the ambulance calls, base hospital doesn't want to call it because of how young he is. He is on route.

Finally the ambulance arrives. The patient is pretty blue, and by that time the medics have been working on him for over 40 minutes. There was minimal chance we were going to get him back. I wasn't expecting to do much, but I got to do compressions, along with another nurse. My preceptor and an ICU did the medication pushes, and the Doc gave the breaths and watched the monitor. We didnt have much hope for him to return, and unfortunately, he did not make it.

This really made me think because apparently this gentleman played sports earlier, felt unwell and went to lie down. His fiance went to check on him and found him unresponsive. What caused his death? As of right now, no idea. There was no signs of trauma, and from the story it didn't sound like a drug overdose. He was the same age as me.

More and more 20-somethings are getting heart attacks, or other cardiac related symptoms. The nurses in emerg were saying how they are seeing more and more young people dying of cardiac related causes. This man had no history of heart problems, and yet he too passed.

Recently I have known that there have been some other 20-something related VSA's that some of my pre-hospital first response colleagues have responded to. It makes you really think about taking care of yourself, and cherishing the moment you have with loved ones.. you never know what can happen.

Synopsis... My first few shifts as an Emerg Nurse

I have just finished my first DDNN rotation in the small-town hospital Emergency Department.

WOW. I don't know anything about nursing! In nursing school, they try to give you a lot of theory and practical information so that you know how to help and work with people on the floors. They teach you how to do assessments, what general diseases are out there, and how to do various nursing skills. They also give you experience on the floors so that you feel comfortable giving injections, doing basic wound care, personal care, working with IV's, talking to patients, etc.

In the emergency department, there are SO MANY MORE THINGS TO LEARN. I need to learn the flow of a patient through the department. I need to know what is a standing order, and what I need to get an order to do (which the ED nurses know already, and just get started on things, but I feel clueless!). Overall, I feel stupid most of the time, and try to ask a lot of non-stupid questions. I used to be proud that I felt comfortable doing nursing, and that I was looking foward to increasing my learning and the acuity of my patients. Well I feel i'm on a sharp steep hill, struggling to stay upright. I hope it gets easier, and so far, every day has seemed a bit easier, because now I know where things are, and I sort of know how the flow goes.

There are also a lot of skills that ED nurses complete, yet as a student nurse I won't be able to do until after I pass and work as an RN and complete the competancies or testing within the hospital. Examples of things I won't be able to do as a student include: taking verbal orders, give meds below the drip chamber, and triage (i can observe but that's it until i have worked in the ED for over a year). I'm sure there are other things that as a student I should not be doing, but that is the list so far. I also do not know how to read ECG's, but I am proud to say that now I know how to use the machine to get one!

This emerg also has paediatrics, so I need to be on top of my paediatric assessment skills, something I am not good at, and I am still intimidated by those little people.

After reading ED nursing blogs for almost 8 months now, I have thrived in the stories and felt that I could really like working in Emerg. Now I can kind of relate to their stories about not having enough space, about people waiting for a room, seeing drug-seekers first hand, holding patients in the ER because they have no beds available in the hospital (our lack of beds right now is due to a norwalk-outbreak). I also, unfortunately, know what it's like to work 12 hours without a break, because the ED was so busy.

Overall, so far, I REALLY LIKE IT. I like the fast pace, and I like the learning. I can see myself working in Emerg after I graduate, and so far it looks like they need nurses badly so I could probably get a job there!

Hello, I am Elaine, and I AM AN EMERGENCY STUDENT NURSE!

Orientation Day

I think I will finally start having some interesting posts in my blog!

Wednesday was the orientation. I was correct in suggesting that my placement hospital is a tiny hospital, but I am so far happy to say it's busier then I thought it was going to be.

I am the ONLY student who is full time in the ER. THE ONLY ONE. There is only one RPN student who is doing the ER clinic (sort of like the ambulatory care area.. walky talky belly ache's, scraped knee etc), and that's it. Of the RN students.. there are only 3 of us. THREE. I'm used to seeing students everywhere, because my school is a fairly big teaching area. The rest of the students doing their final placement are RPN consolidating students, of which there are maybe 5. I dont' know a soul (RN's or RPN's) because I wasn't in their classes and none of my classmates are consolidating there, but meh, I'm ok with that.

The average age of the nurses on staff is 48. I didn't see a single young nurse there. (although I do happen to know there is one younger then me that works in OB/Labour&Delivery, but I digress...). In all my other clinical placements there were tons of younger RN's. Perhaps the older ones were in management, or have left practice. I have no idea, but having an RN to work with who has 20+ years experience gives me confidence in the profession, as well as their skill. That being said, I'll have to make sure that what they are teaching me is best practice- it has been a long time since they have been in school, and hopefully they have kept up to date!

I love how my clinical placement organizers did not tell us RN students that we were supposed to arrive at 0830h to get an ID badge, that I needed to bring paper proof of all my immunizations including 2-step TB, AND that orientation was until 1700. So I felt like an idiot showing up for 0900 and not having the paperwork. How am I supposed to impress these people enough to get a job if they are setting me up with a bad first impression?

My orientation book was approx 5 inches thick, for which I was supposed to know most of it by my next shift, which was, conveniently, Thursday at 0700. (I'll post more on that shift later!)

I will *almost* never have to do straight blood draws because the lab does it. I will, however, get to do IV starts once my preceptor feels I am capable with the general nursing stuff. I will also be able to draw blood from the IV when I start it. That I am ok with, and am looking forward to learning this new skill! It's interesting that they waited this long for us to start it. Yes, starting IV's and using IV's for meds etc is a more complicated skill, but honestly, in the end, it is a physical skill. Working on assessment is more important, and yet they didn't emphasize that nearly as much as they did IV's. (or perhaps in our minds it was a bigger deal then it actually is!)

I do a DDNN schedule starting Thursday. HOWEVER I also have a random Wednesday during the month. Conveniently it happens to be next week on Wednesday.. which means I will have worked for 5 days straight, have 1 day off, and then work a 8-8 in the middle of my 5 days off. Grr.

One final thing is that when I applied for this placement, I wanted to go into an area that I would like to work in later. I'm happy to say that they have essentially stated that they would like to hire us to work there post-graduation. They demonstrated that by giving us the same orientation as 5 new staff (4 RPN's and 1 RN) that started this week also.

It'll be weird working with RPN's, as except in Long term care, I have never worked with them. What can they do? Apparently everything but the patient has to be predictable. What does that mean? No clue.

Overall, I'm thinking this will probably be a good experience. First, I dont' have to share the cool stuff with other students. There aren't even any residents or med students or RT students etc, so nurses there get to make more of the decisions. That I find awesome, and forward thinking. Second, they are also going to be implementing a full version of the computer system for computer charting, not just the some-paper and some-computer method they use now.

I'll post more about my first few days later. For now, I need to get ready for another shift!

Gearing up for the new term

I'm just about done my winter vacation and about to start on my final term of nursing school.

School... alas, I have been in University for 8 years straight, and this is the cumulation of a lot of work (and a lot of debt!).

I'm proud to say that I finally finished all my thesis work needed to complete my MSc. As per previous posts, I defended my written work, and after that I submitted my final copy of my thesis just after I found out that my mentor had passed away. I figured Dr. T would have kicked my butt if I hadn't completed my MSc last term, especially if I was spending my time mourning him. He wasn't one for pomp-and-circumstance, and he would have encouraged us to go get a beer at the bar and enjoy ourselves rather then mourn him.

So now that my graduate degree has been completed, I can focus solely on finishing the BScN. I have been working on this degree for 5 terms straight since September 2006. Its the accelerated program just started in Canadian schools, so instead of a 4-year degree, the 50+ of us study our butts off (after some prerequisite courses, and minimum 2 years of another degree) and be RN's 20 months later.

The combination of the MSc and the BScN has been exhausting, so I'm looking forward to a term where I just can focus on working on nursing- specifically my clinical and assessment skills. As mentioned in a previous post as well, we have 1 final placement for which it is my ONLY course. I have been selected to work in the Emergency Department, for which I'm thrilled, yet it happens to be in a smaller town about a 40 minute commute from where I'm currently living.

I'm nervous and incredibly excited to be placed in the ED. I have about 8 years of pre-hospital volunteer advanced first aid experience, and have been involved in resuscitation and trauma, and I'm excited to see how the patients are treated in the hospital. I have read a lot of ED nursing blogs, just to find out what a day in the life of a nurse in the ED is like, and even though I have read some very brutal stories, I still feel that the ED will be the right fit for me.

I start next week with orientation, and then do the same shifts as my preceptor. Hopefully I'll start having some interesting stories to write about! I realize my posts have been really dry and fragmented recently. I guess that's what happens when you're over-extended and dont' even have enough time to sit down let alone write! Wish me luck! To the Emergency Department I go!

My day in the Emergency Department

So as you know I spent the day in the Adult Emergency Department.

First, to preface everything, I could not sleep last night. I don't know if it was because I was nervous, or because I was excited, or because I was anxious. All I know is that I woke up every half an hour pretty much all night. I reluctantly dragged myself out of bed at 5:30am so I could make it to the ED on time.

I was assigned to be with a nurse that was my age. She had graduated the same year I had for my first degree, yet she didn't lord over me, she treated me as an equal, for which I was grateful. It was weird that she has already had 3.5 years of nursing experience, and here I am a 2nd year accelerated nursing student, graduating this upcoming april at age ... well lets say 25+.

I have to say the very beginning of the shift was disappointing. Although the nurse was a great person to work with, we were assigned to work in the Ambulatory Care area. This is the area in the emergency department when the lowest acuity patients go. This is for the patient who is feeling unwell, who has abdominal pain, and who has a infected wound, etc. These patients are not going to die anytime soon, but can be also considered the "walking wounded". These patients generally didn't need much except to have blood drawn for labs, and not much treatment treatment besides IV fluids and a prescription for pain killers, antibiotics, etc. This was NOT what I had expected for my one and only day in the adult ED, as I really wanted to see a trauma or VSA, or something with higher acuity.

What started as a craptacular beginning quickly proceeded to change my mind once the nurses started working. I observed a lot of blood taking, and IV starting, for which all the nurses were more then willing to teach me the theory and what to look for once I am able to do those tasks*.

*IV starting and blood taking is an advanced skill not taught to nursing students in Ontario until during their practicum or even post-graduation. It is a designated act by a physician, although now it's mostly nurses initiating any peripheral IV.

Once the nurses felt comfortable with me, and I guess I showed them an adequate amount of knowledge, they then got me to do assessments on people, as well as start bringing in people from the waiting room! I felt like a pseudo-ED nurse.. I have only called people from a waiting room because I taught birth control, I have never done this in the ED! The patients thought I was an actual nurse (until corrected), which was cool, even though I introduced myself as a student nurse.

By the end of the day I was bringing in people, updating myself on the chart, asking a few questions to the RN's to make sure I was on the right track, and then assessing the patient by myself. I'm sure if they had an issue with what I had said, or if I hadn't answered any of their questions, they would have followed up with the patient. It felt nice that they were comfortable with me doing these assessments. Dont' get me wrong, I realize I am a student and I still have lots of learning to do, but it's nice to think that the RN's trusted me to do the right job.

Although I didn't end up observing any traumas or any high acuity patients, I enjoyed my day. I enjoyed the non-routine, and that the patients changed constantly. This is a great sign... perhaps now I can be more assured that ED nursing is for me.