Thursday, December 27, 2012
That turned out to be a fine decision. Nobody wants to be in the hospital on Christmas, so actual sick people avoid us from the start of the weekend. Even the drug seekers were apparently discouraged by the freezing wind and icy sidewalks. On those two shifts combined, I think I cared for about nine patients. I earned most of my time-and-a-half holiday pay just by weighing down my chair while I munched Christmas cookies.
Those were an easy couple of shifts and I may do the same again next year.
But then! Being a relatively new emergency nurse, I made the mistake of agreeing to work the day after Christmas, too.
That's when all those patients, the ones who didn't come in over the last several days, suddenly show up all at once. And because they delayed their visit so they could stay home with the family, they're sicker, and everything contagious has infected the entire house. Plus they're joined by all the newly ill patients who drank too many quarts of eggnog, or had an allergic reaction to fruitcake, or felt heart palpitations after arguing with their kids' new boyfriends. Doubleplus, there's the usual crop of drug seekers and STI screens and requests for pregnancy tests. All of those people, all to the ER, all together, all day long.
We broke traffic records again. I lost count of how many patients I cared for personally. I'm not sure I can even remember them all. I remember the clammy toddler with a fever of 105º F, because that was my first IV start on somebody his size. And I remember the asthmatic teenager with blue lips, because she was the most cyanotic living person I've ever seen. Several of those "firsts" and "mosts" stick out in my head.
But I can't say anything about the other thirty-odd patients I laid hands on. I devoted close attention to each one while they were with me, and asked lots of questions and gave careful care, but after they left, they all kind of blurred together. Patients, triage, vital signs, lab tests and EKGs and blood and urine and x-rays, flat out all day long. We didn't keep an open room for more than 10 minutes my entire shift. Half the time, we had more patients in the department than we actually have beds. The waiting room didn't empty out until nearly midnight. I did 6 miles of walking and wore a hole in my socks. It's a good thing I ate breakfast because I did thirteen hours without a lunch break.
Nobody coded. Nobody died. Several were admitted to the hospital, but in stable condition. Remarkably few got impatient and left before seeing the doctor. In terms of results it was a great day. I'm just tired and dehydrated and I ache like I've been beaten up.
That must be why they call it Boxing Day.
Thursday, November 15, 2012
The next day was even busier.
Then the third day beat them both.
It was absolutely crazy nuts bonkers.
I don't know what made everybody decide to run out to the hospital all at once, but it was the same all over the city. In fact we had quite a few patients who had been to other EDs first. Some of the bigger hospitals had multi-hour wait times, and when people didn't want to wait anymore, they decided to come to us. Most days this would be a good decision as we move people through very quickly, but when overflow from four different hospitals tried to show up all at once, we could only handle so many at a time.
It's not even as if they were all easy cases. For instance I admitted a patient with pneumonia, one in acute stroke, and a couple of assault victims, including one who went directly to the OR. The admissions got the majority of my time and attention, but of course there were also many more patients who were treated and discharged-- like the abdominal pains, lacerations, assorted genitourinary issues, and whatnot.
All told, I saw 29 patients in my twelve hours.
The next time one of my friends working med/surg complains about having 5 patients at a time, I'm not sure if I will be able to muster very much sympathy.
Wednesday, October 31, 2012
Only one patient so far in my nursing career has managed to make me angry. That's the guy I saw today who said, "I don't know what they're bitching about in New York. It's only a little rain."
A little rain.
At least 50 deaths in the US alone, so far. Thousands injured. Over eight million people without power. Twenty billion dollars in property damage.
That's what a little rain did.
I had to leave the patient's room, because the only response I could think of would have been... unprofessional.
Tuesday, July 31, 2012
Me: "How far from home were you when that happened?"
Mr. Gasp: "Well we're on the way to visit my in-laws, and we live in Distantville, so I guess about five hours. And we got another two hours to drive before dinner, so I hope you guys can get me out of here soon."
Me: "Okay, and how long does your portable tank normally last?"
Mr. Gasp: "About four hours."
Me: "...Right. So how many tanks did you take with you?"
Mr. Gasp: "Just one, why?"
People, if your life and health depend on medical supplies, remember to bring them along when you travel, and please make sure you've packed enough. Perhaps consult a local third-grader to help you with the arithmetic.
Sunday, July 29, 2012
Tuesday, July 10, 2012
You know you're a nurse when you knock on the stall door and inform a surprised stranger that he needs to see his doctor. Nurses learn to have very little shame.
Tuesday, July 3, 2012
What's weird is that we aren't seeing many heat-related injuries in the ER. We have had a few, but not nearly as many as were expected from such a big heat wave. And all of the ones I've seen have been guys who work outdoors, who don't have the option of getting out of the heat.
I think might be hot enough that people are realizing the danger.
When it's 95 degrees out, you know it's hot, but it doesn't seem threatening. That's when people go and do yard work, thinking they'll be fine as long as they hurry. Or they decide to go up and clean the gutters, because it's sunny out and he won't get rained on. Next thing you know, Dad got dizzy and fell off the ladder, and Grandma is passed out in the peonies. Those days, the ER is busy.
But when the official temperature is one-hundred-and-ass degrees, and peeking out into the sunlight makes your hair burst into flame, I guess even the most lawn-obsessed suburbanite is going to retreat into the a/c and leave his mower in the garage. They stay home, I have an easy day at work, and everybody wins.
People might really be acting intelligently. Maybe there's hope for the species yet.
Wednesday, June 20, 2012
For instance, let's say you're somebody who hurt yourself fixing your car. You went to the ER with a big laceration, and got 19 stitches up the side of your forearm. The doctor told you to keep it clean, wash twice a day with soap and water, and come back in 7 to 10 days to have the stitches removed. The nurse repeated the same instructions. They're printed on your discharge paperwork, in bold face, underlined. Don't ignore them.
Don't let the wound get covered in dirt and engine grime because a bandage sounds like too much trouble.
Don't leave it unwashed for a few days because you think dirt is macho.
Don't goof around for two weeks because you're afraid the suture removal will hurt. It'll take ten minutes and I promise I'll be gentle.
After the third week, when the wound starts to get swollen, red, and scabby, don't procrastinate while you show it off to gross out your buddies.
In week four, when it swells more and starts to get really painful, that would still be a good time to see the doctor. Don't put a bandage on and avoid us because you're afraid we would criticize your choices. We might, but we'll do our best to be polite about it.
At the beginning of week five, when your girlfriend catches a glimpse of the wound and flips out, don't tell her she's overreacting. Don't make her have to threaten and manipulate you for days on end just to get your silly ass back to the ER.
Don't do these things, because your 19 old dirty stitches may lead to 38 individual abscesses, and they will swell up and glom together into a painful, oozy, disgusting mass of skin and pus. You'll need a good scrubbing and some powerful antibiotics in order to head off the infection and save your arm. And those sutures still need to come out, which means I need to take tweezers, scissors, and face shield, and go spelunking to find each individual knot somewhere inside the mass. This will take ten times as long and hurt a hundred times worse than if you had followed instructions in the first place.
Tuesday, June 19, 2012
For instance, don't pick a fight with your reflection.
Some dude was practicing his ninja moves in the street, walked past a plate glass window, and freaked out when he suddenly saw another guy doing ninja moves. So he started throwing punches. (There's a suspicion that drugs may have been a factor.)
I don't know who won the fight, but the window got a few hits in. Dude strolled over to my ER and wound up with stitches all up and down his forearms.
Friday, June 15, 2012
...tempered by two boring facts.
First and boringest, I don't yet have any of my login passwords. This means I can't chart and I can't check out medications from the drug cabinet. I was stuck doing physical jobs and watching over my preceptor's shoulder.
Second, this was the slowest day shift this ED has had in recent memory. They got less than one-quarter as many patients as they expect on an average Friday.
I was assigned a few patients, widely spread over the course of the day, but in between them I didn't know what to do with myself. For starters I practiced on new equipment, assisted with radiology, toured the building, memorized the stock room, and made myself a nuisance in triage. This still left me enough slack time to download and read an entire novel on my smartphone.
But hey, who cares about that stuff? I'm officially in my new job! The people are great, the environment seems fun, and I'm absolutely sure I'll soon have as many patients as I can handle. I'll enjoy the quiet while it lasts.
Monday, June 11, 2012
This was new employee orientation, which seems to be much the same in every industry. It was a long run of mission statements, benefits information, parking passes, and other administrivia. I lost track of how many different HR people came to speak with us. We also got short presentations from people in pastoral care, the security department, ethics & compliance, and a couple of other departments along the way, but mostly, it was HR people with PowerPoint and paperwork.
Today's stuff was for new hires in general, from all departments, from nurses and techs to pastors and environmental services. Nursing orientation begins tomorrow. That's where they teach and test our clinical skills, like how to correctly operate their blood glucose meter, or how to place an IV with their chosen brand of catheters and supplies. Somewhere in there will also be a test on drug information and calculation.
The testing does not worry me in the slightest. After working nine months in the state's best critical care unit, I've got all my basic skills nailed down hard. I'm more worried about avoiding hypothermia in their too-aggressively air-conditioned conference room.
More posts will follow, assuming I don't get frostbite in my typing fingers.
Tuesday, May 22, 2012
This is kind of a bummer because I loved working in the critical care unit. The work there is interesting and challenging, the place is staffed by a well-knit team of some of the best nurses in the world, and I was at last feeling very comfortable about my clinical skills. Quitting wasn't because of any problem there.
It is for a good reason, though. I'm moving!
My other half has landed a fantastic new job, more than attractive enough to lure her out of town, and of course I followed. We've now moved from Large Midwestern City, and have settled in Other Midwestern City. It's much too far to commute, which meant I had to leave that hospital. My coworkers signed a nice card and threw a small party on my last weekend.
Fortunately, the nursing shortage seems to be alive and well in some places, because I've already found my job in the new city: I'm going to be an ER nurse.
This ER isn't the same as the trauma center where I did clinicals during school. It's very busy (most of the time) and is equipped to deal with any kind of emergency, but the sickest folks wind up at bigger hospitals, so I'll generally be seeing much lower acuity patients. I'm hoping this situation will work out well for me. Having "lighter", more stable patients should give me time to re-gear my brain for the ER pace and the ER job, without having to learn lots of new pathophysiology or case care principles at the same time. And when, once in a blue moon, a patient comes in with septic shock or an acute heart attack or something, I'll be able to handle that too, because I've had experience with those situations up in critical care.
I'm really very excited about the whole deal.
The new job starts sometime next month. Once it does, I expect I'll have a lot of interesting stuff to write about. Until then I plan to take full advantage of my time off.
Friday, May 18, 2012
DT-ing drunks seeing pink armadillos
C-Pap and Bi-Pap for pressurized air
That's what I see here in critical care
Violent nausea, emesis, dry heaves
Cannulas caught in a funky blue hair weave
Comatose dude with the thousand-yard stare
That's what my night's like in critical care
External pacers and new intubation
Dads who collapsed on the plane on vacation
Hospital gowns leaving bottoms all bare
That's what we get up in critical care
When there's blood loss
When their sats drop
When they're fading fast
They simply come here to the MICU
Because they know we're the best
Lung silicosis in workers from coal mines
Scrub-clad intensivists placing IJ lines
Pastoral Services leading a prayer
That's how the shift goes in critical care
TB and C. diff and nasty infections
Searching supply rooms for bandage selections
Spouses and visitors sleeping in chairs
That's what my job is in critical care
Tachy and brady and Wenckebach rhythms
IVC filters to stop embolisms
Cranial post-ops with shaven-off hair
All these and more come to critical care
When there's blood loss
When their sats drop
When they're fading fast
They simply come here to the MICU
Because they know weeeeeeee're
Thursday, May 3, 2012
When I came back to work, I dropped back into the groove like nothing had happened. I didn't think about my patient who had died, until halfway through the shift, when I noticed I hadn't thought about him. I suppose this is normal.
Some small, overanalyzing part of my brain that wants to feel bad about not feeling bad enough. I'm ignoring that. Death is part of the job, and if I weren't able to get over it when it happens, I probably couldn't be a very good nurse.
Thursday, April 26, 2012
He liked to talk shop about e-books and his new Kindle. He used Facebook to keep in contact with his kids, and grandkids, and great-grandkids. He spent a lot time walking, and fishing, and keeping up his lawn. He didn't eat very much but he usually felt pretty good.
Last week he came to the hospital because he was a little short of breath. The ER did an ultrasound, an X-ray, and a CT. These scans showed fluid on his lung, and possible other issues. Our surgeons did a thoracotomy and placed a chest tube.
When he got to my floor, he was very weak but in good spirits. His respirations sounded awful, but he was breathing okay with just a little bit of supplemental oxygen. The chest tube was draining fluid and his lung was reexpanding. He couldn't move much without assistance, but he put in as much effort as he could manage. He told jokes about all the wires and lines we had him hooked up to. He had no appetite but drank the nutrient shakes we gave him for supplements.
This weekend, the pathology results from his surgery came back. The physicians explained that his cancer had come back, aggressively. This time it had spread to his lungs. Chemotherapy might work, as it did last time, but the chances were poor. Radiation was not an option. Surgery was impossible.
Al took this better than anyone could expect. He was a bit withdrawn, afterward, but he still told jokes. He forced a laugh and said that he beat cancer once before, and dammit, he'd do it again. He seemed to need more company. He found lots of reasons to call me into the room, and keep me there for a while. I didn't mind. I often had some free time during my shift. I spent a lot of it there, just talking with him.
A few nights ago, while we were chatting in the very wee hours, Al suddenly sat up on the side of his bed. He pulled off his oxygen cannula, tossed it on the floor, and started disconnecting his cardiac monitor leads. It was the most movement I'd ever seen him do without help. He said, "Get this shit off me. I know I'm a dead man. I might as well be comfortable."
I explained that we would not do anything he didn't want us to do. If he wanted us to withdraw care, and make him as comfortable as possible, then I would call the physicians and get those orders. But didn't he want to talk to his family first? Would he please, just for now, let me put his oxygen and his monitor back on, so he could be comfortable while we made the arrangements?
He agreed. I got him back in bed and wired back up to the monitor. Then I excused myself and started making phone calls.
The arrangements weren't complete by the time my shift ended. I made sure the next nurse was aware of Al's wishes, and was on top of what needed to be done. Before I left for the day, I went back in to his room, and promised him that we were doing what he wanted.
That day, while I slept, the orders went in. The whole team of physicians spoke with him, in person, in pairs and small groups, going over the exact details of his prognosis and his options. He chose to be placed on comfort care only. His whole family came in to visit. Some of those tried to change his mind. Others just came to say goodbye. There was a large family conference about where Al would live now, for hospice care, once he was discharged from the hospital.
His youngest great-granddaughter brought in a poster she had made from a blown up photograph, of the two of them together, carrying fishing rods over their shoulders. Surrounding the photo were stick drawings of fish and boats and waves. Across the top, in fat blue crayon, childish handwriting said "Get Well Soon."
By the time I came back in the evening, Al didn't look at all well. He had refused to take any breathing treatments all day, or most other medications either. He was pale, and gasping. His oxygen was turned up as high as it could go, without using a cumbersome mask that he didn't want. He didn't respond to questions. His daughter, the only family member still at the hospital, thought he seemed to be pain.
I gave morphine to relieve air hunger. I gave lorazepam to relieve anxiety. I turned on a fan in the room to provide a sensation of easier air movement. I turned off the cardiac monitor and removed the electrodes. I disconnected the IV. I washed his face, and remade his bed, and turned down the lights. He appeared at last calm, and comfortable.
His daughter kissed him goodbye, and left, to take care of the rest of her family.
Once he was alone I checked on him every ten minutes. Only a few rounds later-- less than an hour-- I came in and noted that his breathing was agonal, in a distinctive pattern of sudden gasps. As I watched, he took one more breath, and then no more.
I checked for a pulse on the radial artery, in his wrist. Then the carotid, in his neck. No blood stirred under my fingertips.
I put my stethoscope on his chest and heard faint sounds. Not the two part lub-dub, lub-dub of a functional heart, but a soft single tick, tick, tick, just electrical twitching, too weak to flex the heart or open the valves. As I listened, the tick slowed like a clock winding down, and finally it ceased.
I found another nurse to listen and confirm my assessment.
I pronounced a man dead.
Monday, April 9, 2012
We call ourselves "Great Big Booger."
Monday, April 2, 2012
This was easy to say when I first started school and every single patient was new and exciting. It's also easy to say on the best nights, when I've got "light" patients who are alert, fully oriented, and able to walk to the bathroom by themselves.
But what surprises me is that I still feel this way after the crappy nights.
Even after a night where we've been short-staffed and I've had to take on an extra couple of patients. Or when I've spent the whole night running and never even had a chance to pee. Or when the morbidly obese lady who was constipated for nine days has finally succumbed to the laxatives. Or when I've had confused, agitated, combative patients spend the night trying to hurt me and themselves. Or when a patient's unfortunate physical condition was a close match to my literal worst nightmare. Or when I got to deal with copious bodily fluids of such intense purulence and fetor that even now, the memory alone tries to set off my gag reflex.
After nights like that, sweaty and footsore and brain-tired, I still walk out every day into the morning sunlight and think: I love my job!
They say nursing takes a special kind of crazy. I guess I'm it.
Sunday, April 1, 2012
Tuesday, March 27, 2012
A great example are hospital Emergency Alert Codes. If we need to call for assistance to deal with something unpleasant, like a fire in the building, we don't want to just yell "Fire in room 3102!" over the PA system. That's a good way to cause panic and get people hurt. Instead, we talk about it in code. Most hospitals nowadays are using color names for these-- though they can never agree on which color means what thing.
Apparently the whole thing started with Code Blue, which means a patient in cardiac arrest. It's named after the color you turn when you are getting no oxygen.
Once that rather morbid reference started to catch on, somebody decided it made sense to use Code Red to indicate a fire in the hospital. (It was an improvement over calling for "Doctor Firestone," which was supposed to hide even the existence of an emergency, but which wound up being harder to hear and not fooling anybody anyway.) From there the system has expanded so that nearly every conceivable emergency is labelled by a corresponding color.
At my hospital, Code Gray means a severe storm approaching. It's very cleverly assigned to the color of clouds, you see. We respond by moving the patients away from windows. If it worsens to an imminent tornado, they call Code Black, because black is like gray but more. Then we move the patients far away from windows.
Code Silver is also distinct from gray. It means an armed assailant in the building-- silver for the shiny metal gun. The protocol for this is amusing to read, where it explains complicated procedures like "leaving the area" or "going into a room and closing the door."
Code Pink means an infant missing from the nursery. As soon as it's announced, quite a lot of personnel drop whatever we're doing and go stake out all the entrances, exits, stairwells, and elevators in the whole medical center. This has never actually been invoked for real, but we have had surprise drills every so often, complete with a hired actor sneaking through the building with a suspiciously large duffel bag.
After a certain point, the colors aren't as strongly associated with the event. Some emergencies are a bit too abstract to visualize so easily.
Code Green means security personnel are needed, stat. Note that our guards don't wear or carry anything green, and they certainly don't have green uniforms. I suppose the color is meant to invoke some military connotation.
Code White means evacuation. The best mnemonic I've come up with is to equate the empty building to a blank white sheet of paper.
Code Amber is theft or vandalism.
Code Yellow is a bomb threat.
There's a Code Orange, but unfortunately it's not just a Code Red and Code Yellow at the same time. Instead it indicates a hazardous chemical spill.
Code Purple is an "escalated patient event." Somebody has gotten violently loopy and requires immediate de-looping. This code summons the same security guys who would respond to Code Green, plus a crisis intervention nurse with a set of restraints.
I think my favorite is Code Violet. If this is ever announced, it means a sitting head of state has wound up in our emergency room after an assassination attempt. Seriously! There's a whole set of protocols that specify which of the entrances get locked down, which way we divert incoming ambulances, how many personnel can be coming in or going out at any one time, and lots of other stuff. It's written in such excruciating detail, I bet whoever specced it out is the type of person spends every weekend playing wargames and D&D. (In other words, they're a geek after my own heart.)
And of course, nurses talk about one that is not on the official list: Code Brown. This is completely informal and would never be announced over the PA. It refers to a much smaller kind of disaster-- the kind that necessitates changing a patient's gown and all their bed linens. Time to double glove, watch where you step, and remember not to breathe too deeply through your nose.
Monday, March 12, 2012
Usually this is a good thing. Yesterday evening, I had a patient complain about it. He piped up just moments after I got report and the day nurse left.
Mr. Scribe: "I gotta say I'm really mad. I kept telling that other nurse I have pain and she wouldn't give me any medication at all. I've been suffering all day and I need my medicine right now!"
Me: "Let me check your chart. It says here that you had a couple of Percocet for pain at eight o'clock, then again at two. Is that not correct?"
Mr. Scribe: "Well, I had those, but that doesn't count. Pills are garbage. I need some of the good stuff."
Me: "I also see that you had IV Dilaudid for breakthrough pain at nine, one, four, and again just a few minutes ago at 6:45."
Mr Scribe: "Um... I guess so. But it's so not fair that you write that stuff down. If you were a good nurse you would trust your patients."
Tuesday, February 28, 2012
Friday, February 24, 2012
It's easy to see that you are all terribly cute little creatures. And I appreciate that your arrival here via coordinated navigation and timing abilities is a true marvel of nature. Further, I understand the ecological and climatological significance of your early migration this year, inasmuch as it represents a data point supporting anthropogenic climate change theory.
Anyway, shut the hell up.
The Night Shift
Friday, February 10, 2012
Punch me in the face once, shame on you. Punch me in the face twice, shame on me.
Saturday, February 4, 2012
The staffing office has therefore been calling around to ask the rest of us to pick up extra shifts. At first I was really reluctant to give up any of my precious time off. Then my student loan statement showed up, on the same day as my bill for all that dental work, and I said "Sure! Overtime sounds like fun."
I've now worked 11 days out of the last 14, or some such. Three nights on, one night off, two on, one off, three more on... honestly I lost track someplace in the middle there. We'll just say I have been working my tail off. That's enough detail to go on with.
The money math for this situation is fun to calculate. Base pay for the extra shift, plus time and a half for every hour over 40, plus the night shift differential, plus the weekend differential, all adds up to quite a nice number on my check. But after a couple weeks, the numbers aren't enough to keep me going. The spirit is willing, but the feet hurt and the brain is getting smooshy.
So, now, I'm taking my regular scheduled off days. Worked yesterday and don't have to be back at the hospital until Wednesday. I'd like to say I have fun plans, but most likely I'll spend the bulk of the time under my pillow, just making up for the sleep debt.
Staffing called again this afternoon, asking if I could pick up another shift tonight. I said no, because I was too tired to laugh out loud.
Sunday, January 8, 2012
Last time I worked, by 6:15 AM I was doing my final charting for the shift. By 7:00 I was on my way to the locker room, and I clocked out on schedule for the first time ever.
This morning at 6:15, I was busy wrestling with a disoriented and aggressive patient, trying to hold him still enough that we could get an IV started. At 7 I was still hanging on, immobilizing his arm so he couldn't thrash around and blow the one good vein we'd finally found, and waiting for the half milligram of IV Ativan to kick in. (Spoiler alert: one half milligram is a dose you give to old ladies. This guy never felt it.) Only later, once we had him safely calmed down and breathing well, did I get to finish my charting, pass meds, and leave.
One of these scenarios is much safer and makes falling asleep easier, but the other is a lot more fun.