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undergrad RN
I'm a twenty-something Canadian student. After stumbling through a few years of college, I finally managed to get into the nursing school of my dreams, where I hope to graduate in 2012 with a nursing baccalaureate degree. I want to offer an honest look into how a modern nurse is educated, both good and bad. Eventually I hope to compare my education to my day-to-day career and see how it holds up. Whatever happens, it should be somewhat entertaining. Find me on allnurses.com!
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Sunday, April 4, 2010

Second Rotation: Orthopaedic Surgery on Unit 6R

I've started this post about 5 times now on different days but kept having to try again later. My days are just sooooo busy. I guess having too few hours in the day is a good thing, given the alternative!

My second rotation started in mid-February just before the Reading Week break (that's our Canuck version of Spring Break... only it's in the winter and less associated with drunken bingeing ;) Man, let me tell you, at the end of my first rotation on Medicine I felt a degree of competency I could hardly believe. The nurses on that unit trusted us to do good work. I assumed all aspects of care for my patients and at the end of the rotation I had three. I was pouring meds independently (although we had to get an RN to cosign narcotics and insulin, and our instructor to cosign Coumadin/Heparin). Basically the only time I saw my instructor was a daily check-in to verify my assignment. I felt very comfortable with my patients and their needs and saw and did a lot.

So I had a certain expectation that I would only be improving on the skills, independence, and decision-making that I had been developing over the past 5 weeks.... well, not exactly.

My instructor for the second rotation was an older nurse who'd had her masters for longer than I've been alive! She had been a nurse manager/administrator for more than a decade. Compare that to 3L where my instructor was maybe 10 years older than me and was still in bedside care in the CCU.

This new instructor had a totally different attitude towards teaching. She considered herself more of a facilitator and did not give concrete expectations about anything. It drove us CRAZY. We'd ask what she needed to directly observe, or what meds we could pour, or what expectations she had for the care plan.

Her answer to everything? "It's not about me. It's about your learning."

Um, thanks. Wait, what?

Anyway it ended up that my I-think-I-can attitude from 3L was completely shot because for the entire 5 weeks she insisted on watching every med poured, every dressing change, every bladder scan, every foley/straight cath/IV line prime/etc, (almost) every assessment, and so on. The real problem with that was that we were split between 2 units she would take FOREVER getting from one unit to the other to observe all of these things.

The big difference between the two rotations, I guess, is that on 3L it felt like we were actually somewhat useful to the unit. Handy to have around.

On 6R we were just a pain in the ass. Because she insisted on watching *everything*, that meant a lot of things had to wait. Sometimes hours. Sometimes those things were meds. Some days I didn't pass 0800 meds until 0930. A lot of times I had to ask my buddy nurse to do things that should be Really Freaking Basic because I didn't have permission from the instructor to do them without her and it was something that was urgent.... perhaps a fresh post-op was at 8/10 pain, or the initial dressing was not holding, or something like that. Boy, did I feel great making excuses all the time for why my patient care seemed so crappy. Luckily the patients were really understanding. The nurses? Not so much. Apparently the charge RN took it to the dean (not sure) of my school saying that it was unethical for patients in pain to wait for morphine because the instructor wanted to see it. Especially because school policy says that all we need is ANY nurse to cosign - RN, LPN, whoever is handy! I totally agreed with the charge's opinion. Complete BS, IMO. No patients should have to suffer in pain for ANY length of time just because they have a student assigned to them.

I will say, though, that as much as the instructor's (ahem) 'teaching' style grated on me, she had really valuable insight into people and behaviors. At my midterm evaluation, I was amazed at all the things she had noticed about me. She had things written down from the first day on the unit. She was incredibly perceptive and it was actually really good to hear what she had to say. She said I was a good nurse and that she would hire me if she were still a unit manager. I was completely honored, given her background.

Well! Venting aside, let me describe the unit :)

I think we usually had 19 beds open. The patient population was mostly 60+ and in for elective hip and knee arthroplasties. MOST of the time they were post-op but we did have a few people come in before their surgeries. WOW, what a difference from Medicine! These patients' average lengths of stay were less than 5 days. We would get a post-op in at about 1400, often still numb from the spinal block, and by 1900 physio would have them up walking. I COULD NOT believe how fast their recoveries were. I guess I still had the perception that there was a certain period of convalescing after a major surgery like that - not so, at least not for joint replacements.

Patient care usually consisted of neurovascular assessments and vitals q shift (depending on how recent their operation had been), hygiene, encouraging mobility, assisting with transfers, pain assessments and interventions, and prophylactic meds like Fragmin. And drains. And dressing changes... omg! Dressing changes! Part of me thinks wound care is SO AWESOME!!

I took a picture of the giant Wall O' Dressing Stuff. That was a HUGE learning curve for me. There are dressings for every type of wound. Occlusive, silver nitrate, hypotonic, absorbent, moist packing, protective, nonadhesive... the list goes on and on. I spent literally hours in here (this is the clean utility room) going through all the bins and researching what type of dressing was best for what type of wound. I absolutely loved it. Most patients with a healthy surgical wound, typically and depending on drainage, got their wound aseptically cleaned and dried with normal saline, a layer of Adaptic to prevent adhesion, Cavilon to protect the surrounding skin, and either gauze and abd pads taped down with the sheet tape or Mepore all-in-one bandages. Sometimes I had to get creative and splice together bandages to fit. My instructor had her own ideas about how I should do it, and I usually followed her advice, but when I started sneakily doing dressing changes on my own I did it my way and it looked (and lasted) much better. My sterile technique is completely second nature now. I worked a sterile field sometimes 2 or more times per shift, and it was often awkward as hell with a huge pile of dressing packages and a tiiiiiny little dressing tray for space... I also got to do a dressing change on a central line. The patient thought I did such a great job, he wrote me a letter of commendation! *sniff*

The drains were also pretty cool! I drained and primed a lot of hemovacs. It's amazing to see just how much post-operative goo can come out of someone. The pic on the right was about 300 mLs, I think, drained only about 4 hours after I had already drained 400. She was a fresh post op and quite the bleeder. It looks like straight blood but it isn't; there are tiny bits of bone in there and lipids and lymph. It's quite the cocktail ;) Strange smell to it, too. It smells very strong and very chemical, like a hair perm might.

6R was all about teamwork. All us students got letters when we orientated, stating the rules of the unit. One of the big ones was that we were to NEVER risk our backs. All lifting and heavy patient care was to be done in teams. I was totally impressed with how well everyone worked together. There was always someone ready to help you. The NAs seemed to be everywhere at once.

One of the NAs was a dear older Brit who used to nurse in England. When she came to Canada, her licence did not transfer, so she chose to work as an NA instead of upgrading to LPN/RN. She said she loved patient care more than anything else a nurse was expected to do, and she was really, really good at it. She appeared at my patient's bedside on the first day and helped me give a bed bath, just because. She then instructed me on how to give a really freaking good bed bath. My pt was just about purring by the time she was done. She said that chances were excellent that if you give really excellent nursing care in the morning, patients would be feeling very content and not likely to ring their callbells for the rest of the day. She also said it was very therapeutic for the family as well to see their loved one comfortable and cared for. I completely appreciated her help all throughout the rotation. She was great. I wish SHE was my instructor...

It was amazing how the whole unit acted as a team. EVERYONE went to report, including the unit clerks, NAs, manager, staff nurses, students...

Really the only 'downer' during my stay on 6R was my instructor's desire to see and do everything even though that wasn't physically possible. I'm a pretty gung-ho student. I keep my eyes and ears open for opportunities and make the most out of my rotations. I really liked the unit itself. It seemed like a great place to work, given the helping atmosphere and the fact that most of the patients were there for elective surgery and WANTED to get better and get the hell out of there so they were very motivated and active in their own recoveries. Don't get me wrong, Medicine had its moments, but Surgery didn't have the same atmosphere most of the time.

The other negative about the unit, and it really wasn't about the unit at all, was regarding one of the patients. I really should call him a resident. Actually, I'll call him Mark ;) He was a 60-something man with some severe congenital cognitive impairments. He yelled inappropriate things and was aggressive and immobile. Apparently he had a fall at his group home, fractured his hip, and was sent to our unit after surgery. This was OVER A YEAR ago. The group home refused to take him back (!) because he was so difficult for the staff to handle. Because no one could find him a place to go, he stayed right there on Orthopaedics, probably one of the most ill-equipped units to have a guy like Mark. Everything was so busy that there was no time to just sit and spend time with him and give him the quality care he needed to reintegrate him back into a group home. He was just strapped into a Broda chair most days. You could hear him yelling obscenities from the other unit, and my heart cringed every time I saw a child pass near his chair with no one to make sure he wasn't going to strike out. The hospital did the best it could by assigning an NA to be with him 1:1 as much as possible... but really, he shouldn't be there. Mark is a perfect example of a guy who just fell through the cracks.

I saw a couple of interesting cases during my last week on the unit:
  • One pt was a trauma who was flown in from very, very north (~200 km north of the Arctic Circle). He was, like, the embodiment of the Determinants of Health. He was remote, poor, uneducated, male, and Aboriginal. My Foundations in Health class would have had a field day. He had gotten into some kind of snowmobile accident and shattered his tibia. I was trying to do a thorough neurovascular assessment on him (big risk for compartment syndrome - challenging because of the cast he had on his leg), and there was a whole freaking med team in there discussing his surgery, and the surgeon was pushing consent forms in his face, and my primary nurse was attempting a dressing change. He was a pretty neat guy though. He told me about hunting polar bears and seals and carving traditional bows and knives. He had some epically beautiful pictures on his laptop too. Wow. Kinda makes me want to be a Northern nurse................. lol, yeah right. Maybe if they had sun 12 months a year ;)
  • One of my few sub-60 year old patients was a younger mom with a spindle cell sarcoma in her upper arm. She was in for her second resection to try and remove the tumor. She had gotten a skin graft taken from her ventral thigh, and that was pretty awesome. I couldn't believe how much fluid wept from it. No wonder people with burns are at such a high risk for dehydration! I had to do a dressing change on it because the one done 3 hours prior had already sprung a leak. I ended up putting a medium-sized Tegaderm on it, taping it all around, and then putting a huge Tegaderm over that and taping that all around too to try & seal it up tight. My dressing held quite well actually! She had it on still after I was done my rotation. I was very proud of myself :) I also had a really awesome Nursing Intervention moment. She had her initial dressing on her upper arm for over 5 days. Well, by the end of the 5th day she had a crazy case of the itchies. She looked really uncomfortable. I noticed she had Benadryl ordered for nausea so, with the consent of my instructor, I gave her 50 mg of that. Lo and behold, it worked! Total self high five! No more itching, and she pretty much loved me from then on.
  • My other Really Cool patient ended up being the guy I wrote my care plan on. I got to go into the OR and follow one person through the entire hospital experience. I got to Same Day Admit at about 0800. The first thing that struck me was how young he looked. Comparatively, I mean. He appeared in his late 60s and he was in for a total hip replacement. Turns out he was actually nearly 80!! He had been very physically active for his entire life and now was getting joint replacements because of the osteoarthritis from his sports-filled past. The guy was seriously the fountain of youth. He lived in the mountains and biked 5km every day. He and his wife were adeptly maintaining their home. He looked decades younger than my own grandfather. No lie.


Wow, the operation!!! That was so cool! He was awake through the procedure. I followed him down from SDA to the operating room where I changed into OR scrubs and a hair net. We wheeled him into the theatre and slid him onto the table, and the anesthetist gave him a spinal block (SO COOL - the catheter was massive!!). The anesthetist threaded the needle between the disks and into the spinal column while the pt was sitting leaning forward. Then they laid him down while he could still move, put in a foley, and proceeded to drape the hell out of him. The surgeon was very particular about pressure points from the catheter tubing and clamps etc, which I approved of. I got to stand about 5 feet away throughout the operation so that was very exciting for me. I wanted to be as "in" the action as they'd let me and if I were any closer I'd have contaminated their sterile field :)

They rolled the pt onto his side and clamped him, so to speak, in that position. Then they cut through his skin and down to the acetabulum. And then, oh my god, the surgeon and the resident grabbed onto the pt's leg and popped the head of the femur out!!! It made this nasty thwwwwwwwOP sound that just hit the pit of my stomach and made it churn. Nothing else in the entire surgery hit me quite like that. Once the femur was out (shudder) the surgeon took a bigass bone saw and cut the head of the femur off. I mean off. He plucked it out of the wound and plopped it onto the instrument table. Mmmmmmmmm ;)

Oh! The instrument table! MASSIVE! I was amazed at how the scrub nurse knew what to get and when. There were about 3 tables pushed together, all covered with sterile drills and bits and screws and saline and cloths, oh my!

It truly was like being at a mechanic's shop. The surgeon and the resident and the product suppliers were all talking about the pt's leg and fitting different-sized cups and heads into him. They were moving his leg all around and using power tools on him. It was kind of surreal.

The thing that really got me, though, was how the OR was not really about the patient at all. At that point he was just a Hip that needed fixing. No one talked to him throughout the procedure and really no one censored their conversation to accommodate him. The scrub nurses and the surgeons were talking about some kind of masochistic x-rated somethings at one point. I kind of thought the surgeon was a dick, actually, but he was kind enough in teaching me various things. He was only a little chauvinistic towards me ;)

They sewed up the pt without putting a drain him because he didn't bleed very much, and then I got to care for him for the rest of the week, and I wrote my care plan on him as well. It was great, actually, for both of us. I think he appreciated knowing that I would be there when he woke up in the morning and I knew all of the ins and outs of his surgery given that I had seen it with my own eyes.

Well I guess I'd better wrap up this rambling. Feels like I've been typing forever!

Summary: I definitely liked my surgery rotation. If there's one phrase to describe me, it is Morphine Fairy. I loved giving people pain medications to control acute moderate-severe pain. I loved seeing them grit their teeth while I prepped them for a sub-Q or IM injection and then watching them drift off to sleep within half an hour. I'm not sure if I'm a med/surg nurse, but I learned a TON. Really, I've enjoyed all of my rotations because I'm the kind of person who goes into an experience with an open mind and a humble, 'teach me' kind of attitude. Not like some of the ice queens in my class, but that's a story for another day. Good night, nurses and nurses to be :)

2 comments:

vi said...

this was a great post! i know you're really busy, but thank you so much for sharing. i shadow doctors and i LOVE the OR!

brittanyjoy said...

This post was amazing! I'm a second year student nurse so this was all pretty exciting. I go on my prac in 3 weeks and I'm on general surg so hopefully they let me go watch a surgery!

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