About Me

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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Saturday, June 25, 2011

Looks like chicken

Saw my first compound fracture. The patient was in a looooottt of pain (probably made worse from the psychological aspect of seeing your bones). The proximal interphalangeal joint of the first digit (aka thumb joint) was dislocated and completely out of the skin. There was a very neat horizontal laceration. It just popped right out of there.

I was struck by the whiteness of the bone. Looked like a chicken bone.


The dislocation was reduced, the lac was sutured, and I think the pt was referred to an orthopedic surgeon and/or plastics for follow up.

More tales from the ER...
Tuesday, June 21, 2011

A nurse's day in the ER

This is my 7th week in the ER. Adding up the hours, I'm probably at the equivalent of 4/5 weeks if this were a clinical rotation. I don't know how this has gone by so quickly. I only have 9 weeks left before I am finished my UNE position and I'm back in school for my final class-based semester. HOW did this happen? I look back on blog entries from 2 years ago when I was powering through Anatomy and Physiology. I walked into this school only knowing media concepts of nursing, and now I'm a neophyte, not-yet-licenced, practitioner of health care for real live people.

It's a privilege and responsibility that's come with some staggeringly heavy lessons, as well as some of the most inspiring opportunities of my life.

I love nursing.

Now onto the good stuff.

As a pre- and first-year nursing student, all I wanted to read were first-hand accounts of day-to-day nursing. The interesting stuff and the mundane. It was all new. I wanted to know how nurses spent their time, from report until shift change. Stuff that I'd now consider boring to the general universe, I remember as being absolutely fascinating.

Note: I may have obsessed a little a lot over everything about nursing. So this post may bore you normal people. Don't say you haven't been warned..... ;)

In our ER, all the shifts are pretty much the same. The only differences between days, evenings, and nights are the volumes of patients and the amount of sleep you get. For convenience, I'll describe a day shift.

0715: Oncoming nurses arrive. This hospital hires LPNs to cover peak periods at night, and UNEs during the summer (like me!); otherwise all nursing staff are RNs. Oncoming nurses are laden with junk food and Tim Hortons coffee.

0730: We gather at the nursing station for report. The off-going charge nurse gives report to the oncoming charge. She pulls up the electronic ER management program on the computer which shows a map of the ER with names, ages, triage scores, and triage notes for the admitted patients in their respective rooms. She goes over every patient and mentions pertinent details: when and if they've been seen by the MD, lab and x-ray results, precautions, assessment details, and discharge planning. The ER truly is the kind of place you start planning discharge as soon as they are admitted (mostly: how are they planning to get home?)

0745: Report's finished, so we clear out of the room so the off-going nurses can grab their stuff and go home. We gather at the charting station and scan over the charts there. Sticky notes are posted to each of the charts to remind us when the next set of vitals are due, what the last chem strip (aka blood glucose) was, or whether we need to hang a second bolus after the first one's finished. We usually check vitals q2h.

0800: V/S are all caught up and the unit clerk puts up a chart in the rack for Team 1, which is one side of the ER. Team 1 has 3 different nurses, and I float between Teams 1 and 2. So, whoever is on that team (or floating) and happens to be near the rack at that time will take the order, and this time it's me. I grab the chart and put on my MD-handwriting-analysis goggles. I decipher that the patient is to receive 30 mg of Toradol IV. I scan the initial assessment and see that the patient was admitted for back pain. No allergies to NSAIDs. I quickly check the previous orders and see that she has a 1L bolus of normal saline running already. Since I can't give IV push medications, I decide to hang a mini-bag secondary infusion. I check the parenteral manual and see that it can be diluted in 50 mL of N/S and calculate the drip rate. I head over to the Pyxis and pull out a vial of Toradol 30 mg/1 mL, do all my checks (I'm OCD about checks - terrified about med errors). I mix up the bag, label it, and prime the line. I head into the room, explain the med, do my final checks and then hang the mini-bag.

0825: Another order's up. It's a discharge for the patient in room 2 with a tooth abscess. She's to get 2 Percocet tabs now and 5 "to go", which means we send them home with PRN instructions. She's also got a prescription for Keflex and a referral to a social worker, which I interpret to mean that she probably can't afford a dentist. I pull the Percocet and put 5 into an envelope with instructions to take 1-2 tabs every 4-6 hours for pain. I bring the meds and give her our narcotic info sheet to sign. It basically says that they are not to drive or make life-altering decisions under the influence of narcotics. I explain the PRN instructions and give her the Keflex prescription, giving a quick and dirty explanation of the importance of taking all the antibiotics. I discontinue her IV and send her home. I quickly strip the bed, wipe everything down, and put on new sheets for the next person.

0845: So we now have an empty bed with 10 people in the waiting room. Room 2 is a "general use" kind of room (it doesn't have any specialized equipment), so I head to the rack at triage and pick up the next chart. It's a little boy who presented with a temperature of 38.9°C, with a dry cough, sore throat. He was given Tylenol as per the triage fever protocol, so I call him up and reassess his vitals before bringing him back. Temp's down to 37.5 (yay!) and I bring him and his mom into room 2. The little boy is "ILI positive" (influenza-like illness) and I place them on contact and droplet precautions. I chart my preliminary assessment at the bedside - antipyretic medicine effective, skin warm and dry, back of oral cavity is red and child c/o pain on swallowing. Neck nontender on palpation. Immunizations are up to date. Child is voiding regularly. Eating and drinking with no nausea, vomiting, or diarrhea. Mom was concerned because he had a history of febrile seizures and thought she should get him "checked out". Child has no allergies or medications that he takes regularly at home. No previous medical history except for the seizures.

0910: I head to the charting station and complete the chart and nursing notes, and report off to Team 1 on this new admission. There are no new orders so I catch up on reassessments on the admitted patients.

0930: No new orders, no patients to bring back, and the waiting room has 13 people in it. I head up to triage to help reassess those patients still waiting. The computer assigns timers to each of the triage code, so higher-acuity triage scores get flagged for reassessment more frequently. The trouble with reassessments is that people hear their name and think they are going into the back. They don't like returning to the waiting room. Another nurse tells me to call them up as "Mr. Franklin, for REASSESSMENT!" and set expectations from the get go. I get through about 5 reassessments and we are all caught up. I don't like sitting at the reassessment station because it faces the waiting room and I get evil death stares from the patients, and lots of people who think the ER is a turn-based facility and get angry when people go straight back from triage. I have a long history in customer service and it feels very, very good to let the customer know they are not always right.

1030: Break time! I get 30 minutes. I occasionally ride my bike to Tim Hortons for a steeped tea, yum! Before starting in the ER it was hard to convince myself to actually take breaks - too much to do, too much to see. I'm starting to appreciate them now, though ;)

1110: The charge nurse urges me to duck into the trauma room where a young person is getting an I&D on a massive leg hematoma. The MD uses procedural sedation and then incises the top of the wound. He laughingly tells us gawkers to stand clear because we could get hit with the spray. Between much bubbling, gurgling, and massaging, copious amounts of old blood and black clots come popping out of the wound. Amazingly, there is no smell to it. The MD packs it with not one but TWO full bottles of packing. We clean up and I dress the wound. The patient's leg is about half the size. It is amazing what the human body does.

1205: I pull Gravol and morphine to administer IM to a woman who scalded herself with the deep fryer. I am amazed at how quickly I can landmark ventrogluteal injections now. She doesn't even flinch, I'm not sure if that's a compliment to me, or a sign of how much pain she's in.

1235: A young guy is wheeled back from triage, after presenting with a sore head and neck after a MVC at 80 km/h. He was t-boned by a truck that ran a stop sign. He needs an IV started and I get all excited because he's under 30 and a weightlifter.... therefore great veins. I dash into the room with the IV cart. It still takes me forever but I am pleased to hit a vein on the back of his hand with minimal discomfort to him (or me). A senior nurse was waiting to push some morphine and she said she was pleased with my technique. Anytime a nurse with that kind of experience has something kind to say about a nursing-related topic, I always look over my shoulder wondering who they're talking to........

1305: A volunteer is wandering around the department looking bored. As a previous volunteer in this very ER, I know *exactly* how they feel. I make a point of delegating fun-yet-simple tasks to them. Please: Escort patient to x-ray. Make soup and toast for room 10. Clean suture tray from the trauma bay. I like talking with the volunteers because a lot of them aspire to be where I am - on the payroll :)

1340: Reassess vitals, hang new IV solutions, push meds, run ECGs as necessary. As a UNE, I'm like the go-to helper person. I can't do everything that an RN can do but I am an extra pair of hands.

1400: Break time! I have lunch in the break room with some of the newer grad RNs. Several of them were UNEs like I am now, and they came back to work in this ER because they loved it. So do I.

1435: A guy walks in from triage. Chest pain since last night. Patient is a 49 year old male, overweight with a lot of abdominal fat, diaphoretic throughout the night, family history of acute coronary syndrome. I get him into a gown and run an ECG on him. I'm not very good at interpreting rhythms, but even I can see that the time elapse during the QRS wave is loooonggggg. I don't know much but I know bad when I see it. We move him into the trauma/code bay. MD says it looks like an NSTEMI. The RNs begin the heart response protocol and get multiple IV accesses. Someone thrusts a bottle of nitroglycerine at me to hang. I've never hung a bottle before. I poke at it a couple of times and then give it to an RN to show me how it's done. I can, however, prime a N/S line, so I do that while I watch. Once his lines are in, I stand by the chart and write down all the stuff as it's called out - vitals, new line insertions, nitro drip started at 1450, etc.

1525: Oncoming shift has arrived! They pile into the report room.

1530: The unit clerk has booked transport for the NSTEMI to be transferred to a cardiology unit at a major hospital. In the meantime I round on the other patients. It's amazing what a warm blanket will do for someone who feels like they've been waiting too long.

1535: I finish rounding on all of the admitted patients and make sure everyone is looked after before shift change.

1540: Transport arrives. They pack the patient into the EMS stretcher, receive report as they secure him,  and roll him out. I clean the room, ready for the next patient.

1545: I head home, and the next shift begins....
Wednesday, June 15, 2011

Target Practice

So after my IV Start Lab a couple of weeks ago, I headed to the ER for an evening shift. As a newly "certified" (whatever that means, lol) IV starter - and bedazzled with my official IV Certification Pin (no, I wasn't wearing it, I just think it's hilarious that I now have one) - I was pumped to get my 3 supervised starts in and become proficient at that most intimidating of nursing skills: IV starts.

I wish that laypeople would stop using the "IV Experience" as the sum evaluation of their interaction with nurses. How many times have people found out that I'm in nursing school, only to launch into a tirade about their latest hospital stay -

"I had a terrible nurse! She had to poke me with the IV TWICE!", or
"This one nurse was useless, she couldn't get an IV started, so she got another nurse who got it on the first try!", or
"The last time I was here the OTHER nurse had no problem.", or
"The nurse got it in but she must have done something wrong because now I have a BRUUUISE" or,
"My nurse was great. She got the IV started and I barely felt it."

How many other factors are involved here? Location, skill, gauge, hydration, BLIND LUCK? Seriously!

Obviously I'm a little miffed.

So, that shift I picked up a chart and was positively beaming when I saw it was a pt in for IVT who needed a new line put in. So I hustled in there and got all set up, grabbed one of the senior RNs to observe me, got allllll prepped and then....

Tourniquet on.
Examine arms. Nothin'.
Dangle arms. Warm compress to arms. Nothin'.

Except.... the RN peers over my shoulder and points out one tiny thready vein over the patient's knuckle. My very first stick - this could be it! I grab a 22 and try not to sweat onto my patient as I hover the ONC... take aim.... GO GO GO!! And I went. Flash in the chamber and I attempted to thread it and.... nothing! The catheter stopped dead like it hit a wall. Or a knuckle.

Pasting on a smile I deferred poke #2 to the RN. To my relief, though, she also had a lot of trouble finding a good vein - it wasn't just me! That pt took about 5 pokes before we got her with a 24.

That was it for my tries that night.

Sunday morning I'm back in the ER and I told everyone that I was ready to get my 3 starts!!

So the charge RN grabs me at about 1100 to start a line on a guy who was in for severe abd pain. She gives me a 20 and I get to vein hunting. I find a decent one on the back of his hand and prep for the insertion. I am positively STRESSED, though, because the guy was writhing in pain and anxious++ about getting the stick. I'm stressed because he's watching, his wife's watching, and the RN (a very intimidating woman with no real tact filter) was hovering over my shoulder giving very very precise instructions and I just about stroked out from the pressure. I go for the stick and he is actually kicking his feet on the bed. I feel pretty much as bad as can be felt because I can't get the vein. I don't want to be "THAT nurse", the one who fishes the needle around, so I give it about 2 more seconds and I pull the needle out. The RN says she'll take over and she gets a line in. She then yells out and asks one of the RNs to help me do an ECG on him.

That pretty much did it for me. I'm quite confident with ECGs. I do at least 5 of them a shift. So, shellshocked and fighting back my feelings of inadequacy, I "help" the other RN get the leads on him and then bail out of there before I do something embarrassing like cry on my patient.

The charge RN calls me up to the desk - "I need you to document the unsuccessful starts." As I'm standing there, reeling from the overwhelming emotions from the last 15 minutes, she began critiquing my IV attempt. "That's not how WE learned it in school," she says, and I kind of croaked out an answer while trying to keep my cool. She kept critiquing my approach and then one of the newer grad nurses caught my eye with sympathy and that pretty much did it. Yup, I started sniffling, and then a wee tear escaped my eye, and then the emotional dam burst and I got all kinds of upset.

The charge kind of gave me a side hug and told me I'd get it next time, and to go sit down in the back and collect myself. So I went, to try and pull myself together.

But I wasn't upset that I didn't get the IV. It wasn't that at all. It was this overwhelming sensation of being completely UNETHICAL - here I was, barely a full day out of the IV lab with a mere 2 starts on my young male lab partner with great veins, and essentially PRACTICING on patients. Really, that's what it was (and is). I don't know what I'm doing, so I'm practicing on human beings, and it HURTS them, and that's what bothers me most of all. I am hurting people in my attempts to learn. I am more okay with it hurting AND a successful start, but to hurt people like that and to miss the vein.... wow, I hate that so much.

Don't get me wrong. I do completely understand that the only way to learn this skill (and any nursing skill, really, but this is kind of the Big Deal) is by practicing on anybody and everybody. Nobody was born knowing how to thread an 18 into a capillary (I jest ;) but it just really bothers me that my learning is coming at the expense of someone's well-being. More or less. You know what I mean?

I just wish there was a way to get real experience without real people. Those dummy arms are a joke. They help you get the psychomotor action of retracting the needle and applying Tegaderm but that's about it. The "skin" is riddled with holes, the "veins" are rigid and approximately the size of fire hoses, and there is no traction required.

So I was quite emotional from all of these thoughts, plus the incident with the charge, plus another incident that morning where I'd sent a female pt to xray before her preg results had come back (not entirely my fault, plus what the hell does BRV mean, but I still felt awful and had these pictures in my mind of a 17 year old boy with severe deformities because I'd sent his mom to xray without realizing he existed). The results were negative. But still.

Nursing is a tough job. Emotionally tough. There really aren't that many jobs in the world where if you made a mistake, any mistake, someone is instantly and often severely affected. Even if you had no idea you were making a mistake (like how I did not think to check the chart for other orders before I took the pt to xray), BAD THINGS can happen. And they can happen to good people, be they patients or healthcare providers.

Anyway. After all of this went down, all I wanted was for 1530 to come so I could go home and forget this day ever happened.

I was charting when someone tapped me on the shoulder. I turned around to see Michelle, one of the younger nurses on the unit. I'd been buddied with her before and found her to be kind, knowledgeable, and pleasant to be around. She beckoned me into the clean utility room and gave me a great big hug.

"I understand how you're feeling today. We've all been there. But you can do this! You CAN start an IV! You WILL start an IV! And you will be good at it! In fact, it is my personal mission to get you an IV start before I go on holidays."

We discussed my technique and what I was doing wrong. Michelle thought I was blowing the veins by going in at too steep an angle. "But school said we should enter at 45 degrees until we hit the vein, then drop down to 15 degrees to thread it?"

"Forget that!" she laughed, "I almost ALWAYS go in at a low angle, especially those superficial veins."

It was pretty close to the end of the shift so I didn't think that would happen. However, 1500 rolled around and Michelle was waving a chart at me from across the unit. "Do you want to try?" she asked excitedly, "it's an 80 year old man!" She handed me a 20.

Wow. A 20 gauge in 80 year old veins. And with my 6-inch-tall confidence and emotional lability.

"You can do it!"

I walk in the room and find the guy there with his wife. Michelle is right behind me. She's offered to smoothly swoop in if things don't look like they are going well.

Tourniquet on.
Examine arms.

HOLY SMOKES there are ropes of blue up this guy's arms. I feel like I could thread a gauge the size of my pinky in there. Confidence surges briefly. Here we go....

Patient starts muttering that he hates needles. Wife tells him to suck it up.

I aim the needle at 45 degrees, catch myself, and drop it down to 20 or less. One, two, three, POKE! GO GO! I hit the vein right away. I remember to push the needle in a tiny bit more and then thread the catheter, which slips right in. We draw the labs. The vials shoot full of red. We hook up the line and run the bolus, which drips rapidly in the chamber. It was a good one!!!! :D :D I have to stop myself from beaming at this guy and dancing out of the room because I am SO glad that I got my first IV on a real patient on the same day as my bad experience.

So Michelle, although you'll probably never read this, THANK YOU.

For the record, I've had more failed attempts than successful ones, but I've now started 5 IVs, and all the ones I started I got on the first poke. It's getting easier, especially now that I can start them independently. I remember a post I was reading on allnurses to help me get better at IV initiation. One nurse said that when she was working, she told everyone that she got the first 2 pokes on every patient to come in the doors. She didn't shy away from the scary ones because how else was she going to learn?

Saturday, June 4, 2011

IV Start Lab

First we practice on these hole-riddled arms and then on each other! Got my first start on my superkind lab buddy hooray :)

-- from the cellular desk of undergrad RN