An Education (In Nursing)

I decided on nursing after I realized that my first degree would not land me a job that I’d even remotely enjoy. However, I gained invaluable research and analytical skills that have served me well, and continue to do so, in my nursing career. I enrolled in an accelerated nursing program in which I could skip some electives and concentrate on core nursing courses. I bring this up because I recently finished preceptoring a nursing student and it was nothing short of a challenge. His lack of motivation was only matched by his creative excuses to justify his tardiness and absence from shifts. However, what really struck me was his absolute lack of research and math skills. I’m not talking about designing one’s own RCT in the midst of a code or solving a limit of a function as x approaches infinity but basic stuff like being able to look up the pathophysiology of DKA or calculating infusion rates by plugging values into an equation. When I brought up these concerns with him, he said that I was judging him unfairly because I was more educated when I started nursing. I was quite offended because even though I was aware of the economic factors that led to inflation, that knowledge did not really help me in figuring out how to manage someone in septic shock.

He did, however get me thinking about nursing education in general. I have worked with many students from the school that my student was enrolled at and they all mentioned that their school concentrated far too much on nursing theory and not enough on research and data interpretation skills. Based purely on anecdotal data collected during three night shifts, nurses who had another degree in the sciences were much more comfortable with gathering and interpreting data and understanding the biochemistry behind medications and disease processes. Sometimes I think that perhaps there should be a greater barrier to entry in the profession but I realize that the nursing shortage issue would be exacerbated. So nurses discuss – do you think that new grads are adequately prepared to face the job? What do you wish was taught more in school?

Old is Gold

I’ve noticed that my department’s staffing demographics are somewhat unusual because we have a lot of young staff. I’m defining ‘young’ as under 35 with 3-6 years of nursing experience. We also have a few ‘well preserved dinosaurs’ (their term, not mine) who work mostly part-time/casual hours. I have nothing but the best things to say about our dinosaurs because they took me under their considerable wings and set me on the right nursing path. However, when it comes to adopting new technology, some of them are downright useless! Every shift worked with them involves listening to how the order entry system is an abomination upon God’s Good Green Earth and could possibly be an additional horseman of the apocalypse that’s not mentioned in the Bible. Many of them are also viciously opposed to the new defib pads because they feel that the glue is inferior to the previously used brand.

So imagine my luck when I got partnered up with one of the dinosaurs in resus and we got a patient having a big ol’ stemi. We did the usual stuff to stabilize him for a transfer to the cath lab. On the way there the man went into v-fib. We tried to shock him but for some reason the shock wasn’t delivered. Absolutely panicking, I start throwing things out of the emergency transport bag looking for a new set of pads when my partner took the paddles attached to the defibrillator and used those to shock the patient. The baby docling accompanying us was speechless as was I because the monitor showed an organized rhythm and bought us just enough time to get the patient to the cath lab.

In summary – lesson learned. Dinosaurs may be old and roar a whole lot, but their bad-assery is NEVER to be underestimated. Ever.

Its been a long time - I shouldn't have left you...

I can't believe the last time I posted was in May! I've got so many half baked posts on the back burner but I haven't had any time to update. I started doing some agency work to kick start an aggressive project entitled, 'save a down payment or else work shifts with C. diff patients forever'. I was very close to landing a dream condo but got outbidded by a whole lot so it's back to trolling the real estate section of my local papers. In between psychotically obsessing over the real estate market, I've also been traveling which meant limited and/or prohibitively costly wifi access.

In any case, more posts are coming up - I'm here to stay blog world! I'll conclude this brief post by quoting a wise patient of mine who stated his reasons most eloquently for not taking his prescribed meds: 'I can't drink if I take those ma'am'

Let the good times roll!

Words of Wisdom

Yesterday I was taking care of an otherwise healthy 82 year old man with a nasty FOOSH injury when he said that I looked quite sad. I was actually quite happy except for the fact that I was starving and couldn't stop fantasizing about the ginger beef noodles in my lunch bag the entire time I was getting him prepped for the OR. I guess my hungry face is the same as my sad face which makes sense because when I'm hungry, I'm sad. Since this poor guy had been NPO longer than me, I decided it would be a wise idea to keep my yap shut. Before I had a chance to explain myself, he took my hand in his good hand, looked at me straight in the eye and said with the utmost sincerity, 'sweetheart, the world is large and you're insignificant so do whatever the hell ya want because no one will give two hootin' shits about it tomorrow!' Well said sir, well said!

Call me Nurse Muskels

In yet another night, my shoulders were aching from the crushing weight of self-loathing for having picked up an extra shift. I was assigned to the resus room but since my partner and I didn’t have any patients, we were helping out in the rest of the department. Just as I was frantically ripping off my sweat soaked gown from an isolation room, another patient looking worried told me that he saw the guy in the room next to him downing a large bottle of pills. “FML” I thought to myself as I walked away from the piping hot cup of green tea with just the right amount of honey in it and walked over to the room. Sure enough, the guy had downed at least three-quarters of a bottle of gravol. I asked him why he took all that gravol, he said that he was nauseated! “F F F FML” I thought once again as I called the doctor and charge nurse to have him moved into a monitored bed (ie: a resus bed because that’s all that was left). I had finished hooking him up to the cardiac monitor and was drawing up some valium for the seizures I knew he’d have (because such is my luck) when he got all twitchy and said that he had to pee. I gave him a urinal but he said that he also had to do a number 2 and climbed mighty fast out of the stretcher. I wasn’t about to fight with a 270 lb, 6”7’ man so I put on my sweetest voice and told him that me and another nurse would walk with him because his balance seemed to be getting worse. I could feel my heart sinking as I said that because I could feel that this wasn’t going to end well. And it didn’t. Just as he crossed the doorway from the resus room to the hall, he had a massive tonic-clonic seizure. I got to be the unlucky nurse close enough to catch him while avoiding being hit by his behemoth spastic arms. The doc came running and was all frantic when she asked me if he hit his head. I said no because I caught him just in time. “Are you kidding me? You CAUGHT him? He didn’t fall on you? Are you hurt?” Now I’m not exactly petit but I don’t look like I can catch a seizing man that size either. Patients came out of their rooms to see what the commotion was all about and my feat of superhuman strength was verified by them. Eventually six of us managed to lift him into a stretcher and start treating him for anticholinergic poisoning.

Moral of the story:
When nauseated, start by taking one PILL of gravol, not one BOTTLE.
Strength training has benefits beyond being a tool to be really really ridiculously good looking!

Really??

Dude gets dared by his friends to try ketamine for the first time and is brought by them sinking in the k-hole. I ask the friends what he took and they look at me most solemnly and seriously and tell me he must have had a bad cup of coffee several hours prior to his arrival. Really? F%$k you! At least save what little dignity you have and tell me the truth! I kicked them out after that because I was feeling annoyed and chocolate deprived.

Uptown Girl is Admitted to a Downtown World

There I was having just finished transferring some dude on some overdose to the ICU when the charge nurse tells me that she’s bringing in an exquisitely coiffed 71 year old lady with congestive heart failure. Soon enough I hear the crackles of wet lungs being wheeled towards me and I get ready to do my thang. The lady was quite pleasant, if not a bit snooty and started to change out of her very expensive street clothes into her own silk/cashmere robe by none other than Chanel (yes, I think I did quadruple takes at that). I did my assessment, got an ECG, established IV access, got the blood work done, put her on some oxygen, got a chest x-ray ordered for her and told the doc to come in and see her. The poor doc was getting into the stages of being heavily pregnant and was completely overwhelmed by an anxious family of a man with a shoulder dislocation. She gave me some orders to kick start my patient’s care and off I went to deliver some high quality nursing care. I told the patient that the doctor would be a little while but I got some advanced orders so she could be more comfortable. The lady thanked me as I pushed in some IV lasix. Sure enough she had to pee. I didn’t put in a catheter because she was completely ambulatory, the bathroom was beside her bed and she adamantly refused it. But she didn’t like the look of the newly cleaned bathroom so she asked for it to be cleaned again for her own reassurance while she insisted on staying in agony with a full bladder. I kept telling her that the bathroom has been thoroughly cleaned before she came in and if she has to pee that badly she should go for it! Watching her squirm made me want to pee even though I was thoroughly dehydrated. She kept refusing. Fine, whatevs. She kept squirming while the cleaner poured no name brand Lysol into the bucket. Then all of a sudden, she wailed. Then sobbed. Finally, she yelled at me to come to her bed. I dutifully unglued my tired arse from the comfy chair and went to answer her distressed cries which was when she took out $700 from her wallet and shoved it at me to go to her apartment, get her a new gown, underwear and toiletries!! A week later, I’m continuing to kick myself for not having ditched the smelly, snoring drunk in the room next door and grabbing a cab to get her stuff because I still need the money but don’t want to pick up another shift!

Too Much Charting?

A couple of weeks ago the department was absolutely swamped and really short staffed due to a particularly heinous strain of cold and gastro making its rounds with the staff. The staffing situation was dire enough that the manager changed her shirt into a scrub top and started helping out. It was quite a funny sight to see a woman in a pencil skirt, flats and a scrub top walking around the department carrying urinals full of hematuria. But I digress – that’s not the point. She eventually triaged a patient to fast track for back pain. Long story short, the woman was a drug seeker who’s very familiar to most of the staff. She didn’t let me examine her nor did she let the doctor do the same. Eventually, the doc told her to eff off (not quite like that, but her intention could not be mistaken) and that she could either get toradol or nothing before leaving. She then pretended to have a syncopal episode (seriously, how many times does a syncopal episode result in someone falling neatly onto the egg-crated mattress?). When she realized that the nurse was clearly ignoring her, she sat up and started to threaten her and swear at her using profanities that would offend a seasoned sailor’s sensibilities. Rightly so, my colleague didn’t put up with it for too long before she called security and had her ass dumped back out into the cold. Like any good nurse, she then documented. Then documented some more. She also included some direct quotes from her in her documentation because the patient was just that vile.

Lo and behold, this issue was brought up during our education day by the nurse clinician and our manager. Their position was that including some of her direct quotes was unprofessional and that now this charting would follow the patient around in her future encounters with the healthcare system.

I do see my manager’s point of view. Once something is written, there’s no taking it back. If she ever cleans up and has to access an ER again, this documentation is going to unfavourably affect how another nurse treats her. I can also see how in the midst of illness, one says things that they later regret and a person’s actions in one moment of time are not necessarily reflective of who they are. However, had I been in my colleague’s place, I probably would have documented in a similar style. Why? I’ve also dealt with this patient many times before and each encounter ends in almost the exact same way. A friend of mine who works in an ER across town also gets sworn at by her every time he invokes the fury of the triage gods. And yet, the only thing I’ve seen documented is that “patient is verbally abusive to staff”. I don’t think that this statement covers exactly how vile she is towards the staff. We regularly use quotes to capture what patients tell us so I don’t see why we can’t use direct quotes to document verbal abuse thrown our way. Moreover, in the unlikely scenario if she ever decided to sue my colleague, she would have documentation about the patient’s thoroughly reprehensible behaviour to back up her actions.

Obviously, I’m still not decided on where exactly I stand on the issue but I feel that I better pick a position soon because she’s not going to the only aggressive and abusive patient I’ll deal with.

My Triumphant Return

So I come back to Canada a little later than anticipated and all everyone is talking about is how Timmy Ho’s not only serves subpar (yet strangely addictive) coffee but is now also involved in emerg patient care. I figured that since I’m still in my post-vacation haze, I’ll contemplate those issues after I unpack, reacquaint myself with my soft bed, unpack, eat smuggled chocolates and upload my pictures. And get a couple of shifts done and over with.

But things rarely work out the way I want them to. I walk into a department that’s on the fast track to hell in a hand basket. Waiting room was packed leaving only standing room. An insane amount of eyes were trying to bore into the triage nurses’ skulls, probably hoping that if the gatekeepers to the department spontaneously combust, they would be quickly seen by the shining knight in a stethoscope and save their day. Inside the department, there were two codes (at the same futtha-muggin time!!!!) going on, one of which was a paediatric code and there were old, obtunded, septic patients circling the drain in every corner. It's as if every single nursing home had an outbreak of the plague and sent thier residents to our lovely department.

Not even fast track was showing any signs of patient movement. Everyone had a broken something with neurovascular symptoms and the simple lacs were gushing blood – almost as if arteries were involved. Which they were. Of course, the cherry on the crap sundae that was fast track were the FOUR patients that had bed bugs. FOUR of them. Getting them isolated and bathed made my skin crawl a thousand different ways. I’m still itching at the thought of it. Fast track spilled onto the outpatient surgery unit after a while, which isn’t too far away from one of my favourite Starbucks.

At least I still had my super-power of blood drawing. Got 4 vials from a knuckle vein! It's good to be back.

I'll be Back in 2 Weeks...

Because I'm on vaykay :)

Sleep Assessment

The past couple of shifts have been INSANE! Multiple codes every day, transfers to other facilities every other hour, police crawling all over the department all the time and everyone wearing the look of incomprehensible exhaustion. My ER saw a record number of patients this week. To say that it was absolute chaos and insanity would be the understatement of the year. When I finally got home after my last scheduled shift, I could barely walk in a straight line let alone speak coherently. I don’t know how I managed to change out of my clothes and wash up before heading to bed but it happened (I had witnesses).

Just as I settled into a really deep sleep, my sister woke me up in a panic and said that she just got a very sharp and sudden pain in her stomach and she feels like throwing up. Sister hasn’t been sick, hasn’t had any changes in her diet and wasn’t injured. She also never ever EVER gets abdominal pains, nor does she take any meds. I asked her some detailed questions and of course asked about her last normal doody (yes even family members aren’t safe from doody questions if they bring up abdo issues) and if she had any urinary symptoms. She said no to everything. Since I was too lazy to get out of bed, I asked her to gently palpate around her abdomen and tell me if any part hurts or is relieved by palpating. She told me that everything was normal. Not being able to think of anything else, I told her to take a gravol, go back to bed and if the pain worsens, wake me up. Naturally, she fell asleep.

The next morning, she told me that her stomach was still hurting and asked if she should go to our family doctor. I was at a complete loss. “When has your stomach been hurting since?”

“Since last night loser!”

Baffled by her annoyance, I shot back, “Well how the eff was I supposed to know that?”

“Dude wtf is wrong with you? We had this conversation at 3 this morning. You told me that if my stomach was still hurting, I should go to the doctor”.

At this point, I was completely baffled. “Alright imma hold you up a minute. What exactly did we talk about and what did I say?”

Now it was sister’s turn to be lost. “You don’t remember?” She then repeated everything I had told her up to and including the part about me telling her that if I didn’t sleep at that moment, my eyes would bleed out of my head.

I honestly don’t remember a single word of that conversation. In fact, the only thing I remember is getting into bed at around 0130 and waking up refreshed at 1230. As far as I’m concerned, I slept for eleven straight hours. This is troubling because up until now, I have never had a conversation that I haven’t remembered. My sleep assessment is the first incidence of amnesia I’ve experienced (or at least, the first incidence that I've been made aware of). However, once I managed to snap out of the ‘holy exhaustion related memory loss batman’ frame of mind, I was quite impressed that even while I was half asleep, I was able to go through an abdominal assessment. Maybe I should sleep through assessments more often at work (kidding – sort of).

Btw, the sister is not 100% fine but we did have a yummy lunch together. She is no acute distress at present :)

The Customers

It’s nice to have friends who are also nurses. A few days ago, one of my very good friends (I’m looking at you, J) met up with me after a harrowing night shift to vent (errr debrief) about a challenging family member who demanded medical care only to refuse every single treatment option offered. I’ve run into far too many similar situations and they’re a pain in the ass to deal with Every. Single. Time. I greatly respect the fact that a patient knows their body better than anyone else and that those who live with chronic diseases often know more about effective treatments than emergency RNs and MDs. I for one welcome the feedback because it not only enhanced my own learning but allows me to provide better care. However, when patients come in armed with a medical degree granted by Drs Wiki and Google and expect us to follow random internet advice to cure what ails them because they are ‘customers’ of the health care system, it’s not going to happen. Ever. Why? Because we use best practice guidelines to provide COMPETENT and SAFE care even if that care contradicts the generous stacks of printouts from magicunicornhealingpower.com. There are LEGAL ramifications to not providing care that is based on sound science.

One of my most irritating encounters happened with a middle aged man who came in complaining of shortness of breath. It was clear he had pneumonia (what with the raging fever, gunky sounding lungs and the dramatic expectoration of army fatigue coloured phlegm) but he absolutely refused the antibiotics citing concerns about antibiotic resistance and his consumer power. And yes, he had stacks of printouts, mostly with ads for weight loss remedies on the side, to ‘argue’ his case. Logic did not have a place in that exam room. I hate to get all flustered, but WTF??! Why bother coming into emerg at all?

This whole business about the customer always being right is total crap when it comes to providing safe, competent, evidence based care to a ‘customer’ who picked up their medical knowledge from internet pop-up ads and snippets of TV shows.

DISlike

It’s 0200, I can’t fall asleep (again) because of insane switch overs between days and nights so I decide to boot up my computer and watch some mindless movie to pass yet another insomniac night. While I’m randomly surfing, I check my facebook (of course) and this doctor with whom I had a major kerfluffle with regarding scope of practice and respect in general sent me a friend request! Not gonna happen. In fact, the privacy settings got bumped up even higher. Now I’m just too creeped out to sleep.

We (Still) Have No Cure for the Flu

The flu season is upon us and that means snotty noses, fevers, body aches, chills and generally feeling like crap for a while. You want to feel better quickly and that’s understandable. After all, having the flu sucks. But if you’re an otherwise healthy individual (ie: not old, no pre-existing respiratory diseases, etc), please don’t go to an emergency department demanding that the nurses and doctors give you Tamiflu. You’re depriving yourself of the comfort of your own home and bed and are spreading your germs around to people who are a lot sicker than you. There’s nothing we will do that you can’t do for yourself, like resting, taking Tylenol/advil for symptomatic relief and drinking a cup of hot tea. Also, if you’re a 20-something year old man-child, please don’t send your mother to the nursing station every 20 minutes to ask when the doctor will see you and if he can get something hot to drink. I’ve given your child Tylenol (which the doctor would have told you take anyways) and there’s a Starbucks in the lobby 10 feet away from you. They have all sorts of hot beverages for your precious baby. Following these tips won’t make the flu go away any faster but it will save you a huge wait time next to the drunk who keeps pissing himself that you could have spent sleeping at home.

Is it possible to eat so much that your stomach starts to displace your internal organs?

Normally, I consider myself a discerning glutton but this holiday season has been filled with eating on a scale unheard of until about 10 days ago (right when I wanted to pick up working out on a consistent basis again). Normally I don’t eat during night shifts but when I worked straight nights during Christmas, I was powerless to resist the goodies of our annual Christmas potluck. I was deliriously happy when I realized that the majority of my coworkers were amazing cooks on the side! Then I was stuffed silly by my elderly relatives as soon as I got home from work. Tonight is not going to be any different. In fact, as I write this post, I have 3 beef dishes on the stove and some baklava in the oven for a dinner party tonight. The point of this post? I’m far too stuffed to write anything relevant to nursing so I’ll just raise a glass to great food shared with great company, holiday shifts that were uneventful and let me have a chance to actually get to talk to my coworkers and wish you all a very happy and healthy new year!