I'm about halfway through my nth shift delivering flu shots to the masses. Although it is monotonous at times, I've actually found it to be a pretty good experience. I work casual hours which means I can pick up shifts as I like, and I can even cancel a shift if I get too bogged down in school work. I've met all kinds of people, and gotten semi-decent at small talk. I've also developed a mighty smooth IM technique!

Things I've learned from flu clinics: I have absolutely no desire to work with children. Even if the kids are behaving perfectly appropriately for their ages, I find them stressful. Let's not forget the parents who try to convince me that their 7 year old sniveling kid will sit still by himself for the shot.... Not falling for that one again!

I actually find the flu clinic kind of an enjoyable escape from emergency. After the first week, most sites have been VERY quiet. My stress level right now is about -10. After my high-stress city job and a summer in emergency, I almost feel guilty that they pay me to do this....... Alllllllmost :) my favorite part about this is that no one treats me like "a student" here. I'm a member of the staff, I do my own thing unless I have a question. I can make normal conversation with the nurses, for probably the first time ever. It's great.

In other news, it's about 3.5 weeks away from the end of the semester! this semester has been RIDICULOUS. I was walking to school this morning in the pitch black cold and I thought to myself.... Man, 4 years is a long time. I've been standing on this same sidewalk waiting for this same light to change in this same crappy weather holding a coffee from the same Tim's since 2008.

The workload has been a steady insane pace for the last 2 months, and it's shifting into overdrive for the rest of this month. I have 2 more group presentations, 3 more papers, and a bunch of quizzes and minor assignments to complete by December 2. I also have to finish my oncology nursing certificate by the end of November, except that's impossible so I will have to extend it until January.

BUT. And here's the big but.

I have my preceptorship placement confirmed!

I am going to Oncology!

I am so excited!!! The cancer care center here is huge and highly respected. I also had such a good experience with the oncology nurses that I met at the CANO conference in Halifax. With any luck, I will knock their socks off, and be offered a full time line after I am done my preceptorship hours. :)

Assuming I like it there, of course. But I am feeling very, very positive about it.

Honestly, after some months away from full time emergency, I'm starting to wonder if there's a better fit for me. I mean, emerg is AWESOME experience and I can't say enough about the expert knowledge there. The nurses are mostly super kind and helpful. I will absolutely stay there on a casual basis. But, something's missing.....

.... The kind of relationship building that you get with inpatients. The chance to see the results of your hard work. The possibility of being on a first name basis with your client in a real kind of way. The opportunity to really, really talk about health promotion with your clients, the kind of deep talk that happens at 0-dark-thirty.

I mean, those things do happen in emerg, but rarely. The norm is that I'll round on a patient 2 or 3 times and then they'll be discharged. The ones who come back, our lovely frequent flyers, don't usually come for the witty banter or healing presence of yours truly ;)

I guess it's that some of my classes this semester have struck a chord. Especially in my Chronic Conditions class, we really talk about primary health care, and I want to be more involved with my patients in that kind of way. Obviously inpatient Oncology isn't really the place for that. But it's got a chance for that kind of relationship building, and I see a lot of opportunity for primary health promotion at the community level.

I've got my orientation for the hospital at the end of November, and I'm super pumped. It's for the inpatient-side, so I guess that will be a lot of the really-sickies, palliative care, that kind of thing.

Can't wait! Getting so close to real nursing!

So it was SO FREAKING BUSY the other night. The back was stuffed full of sick people and new ones were coming in the door so fast we had two nurses out double-triaging for almost 2 hours. The theme of the night seemed to be chest pains or lacerations secondary to kicking glass/tables/sports equipment.

There were the usual WTF visits, like the mom who ABSOLUTELY had to get her kid "tested" for celiac disease in the middle of the night. At the ER. Where people were practically hanging from the rafters in the waiting room. The urgency? Well, she Googled a new diet and wanted to start him on it the next morning... "Can't I just see the doctor real quick?"

"No. I'm sure the other 25 people in the waiting room would like to see the doctor 'real quick', too." Then, after lipping off the triage nurse, she stormed out. Bye...

And I'm still troubled by it.

A young woman was brought in by police a self-inflicted laceration. At first it just seemed like your run-of-the-mill angsty teen cutting.

So I brought her in, pulled up a chair, and said..... "start from the beginning".

And she talked, and I listened, and she cried, and I held her hand.

http://www.twloha.com/vision/

Turns out this young mom, just a few weeks postpartum, was beat up by her husband. Lumps and bruises all over her. We had an inservice last term from a nurse who works in a women's shelter who talked about the dangers of strangulation in family violence; she had a big hand-sized bruise across her throat.

"But don't write any of that down," she said. "My hormones got the better of me. I was asking for it."

I told her about her resources and her options, but she didn't want to hear it. She didn't want to acknowledge that her husband laid his hands on her, hurt her, scared her. Hurt her so much that she told me "if he hurt me, why shouldn't I hurt myself?" and she cut herself to cope.

I know family violence happens. I know that women statistically have to ask for help 7 times before they commit to a change... but part of me just wanted to shake her and say "you can do better than him! He CAN'T do that to you!"

I know all that but I still wanted to go and knock him out. I was really upset and talked about it with my fellow students and nurses, but man. I'm really bothered by this one.

At the end of it, I told her that if she EVER felt like she had nowhere safe to go, she could come to our ER and we'd take care of her. She burst into tears. What more could I say?

You need to know that rescue is possible, that freedom is possible, that God is still in the business of redemption.  We're seeing it happen.  We're seeing lives change as people get the help they need.  People sitting across from a counselor for the first time.  People stepping into treatment.  In desperate moments, people calling a suicide hotline.  We know that the first step to recovery is the hardest to take.  We want to say here that it's worth it, that your life is worth fighting for, that it's possible to change.  - To Write Love On Her Arms

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.




http://bareessentialssportsmedicine.com/



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...

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.

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....

So I had TLC's Untold ER Emergencies (or whatever it's called) going in the background while I cleaned the house yesterday. The case patient had occasional episodes of catatonia and paralysis of a limb. It was a different limb each time. The patient's husband was a super-seekrit military pilot who went away on missions for weeks at a time and he had no contact with his family.

Immediately, sez I, "CONVERSION DISORDER"

25 minutes later, after all the exciting build-up of symptoms and escalating drama...

Yup, it was conversion disorder.

Here I thought I forgot everything from Mental Health!

---

Speaking of mental health, I summoned every ounce of courage I had and volunteered to do the admission for someone who was suicidal the other day. It was optional for me but one of the nurses encouraged me to go for it.

Even in my Psych rotation I never asked anyone if they were suicidal.

It truly wasn't the difficult conversation I thought it would be. Patient was an older lady, landed immigrant, here for 30 years, her only family was her husband and children. She missed her extended family, missed "back home".

I just kind of winged it but I asked her lots of questions about her mood lability and got her to rate her emotional intensity. Then I asked if she ever thought of hurting herself or anyone else when she felt like her emotions were out of control. She answered in the negative and we moved on in the assessment.

If she'd have answered yes, my next question would have been "do you have a plan?" and we would proceed from there.

Honestly, the hardest part about the question of Are you suicidal? is asking it.

So last night was super busy, again, only it was more busy than I've ever seen it, and with actually sick people. So as a UNE, my big helper job is to reassess patients in the waiting room as their names come up on the triage screen.

Being at the window facing the waiting room, of course, means that I am that I am the prime target for those asking how long the wait was going to be. I'm still trying to find a way to say "a long time" or "hopefully soon" without actually telling them a TIME because that's when they will be coming up to the window thinking they are going back. And unfortunately the back was full of really sick people who weren't going anywhere.

I call up one girl to the desk for reassessment and she is doubled over in pain, dragging her feet, arms over her tummy. She sits down and I reassess her vitals. Abdo pain is increased since arrival. Feels nauseous. Has not vomited. She had to wait quite a while to get to the back, because of the dearth of beds.

So a while later, I am zipping around cleaning rooms and I walk by hers.....gown on the bed.

"Wha?" I said, possibly out loud. I don't remember her being discharged. I go to the computer and she is still showing as admitted.

Mystified, I go back to the room to make sure she hadn't gone to x-ray or something. Nope, gown on the bed, and hey, is that her IV ripped out? Yes, yes it is.

Has the rapture come and stolen her away? She seemed to be really in pain. I asked a nurse who said she'd gotten a morphine shot and her kids were fighting so she decided to go home. Without being discharged? Okay...

---

In other news, last night was the night staff started calling me out on mistakes. Which is good, and all, but I felt a little blindsided because they were things no one had previously told me about.

For instance I was asked to bring some people back and I wrote them up for the chart. But I didn't start nursing notes on them because I thought that was done by the nurse on that team. So picture my surprise when I am in the middle of a dressing change and a (fairly intimidating) nurse comes up to me and asks where so-and-so's nursing notes were, because he'd been back for a couple hours and they needed to chart his vitals. Then when she learned I hadn't started them, she walked away saying "bad nurse, bad nurse". Unfortunately there was a little kid also sitting there who then asked her mom what "bad nurse" meant. Umm..

Then the charge saw me and told me I needed to start nursing notes on all the patients I brought back, because so-and-so was a Triage 3 and he was being transferred out, and he hadn't had vitals done in however-long. I think my cheeks were a new shade of red.

Later, I was sitting at the reassessment window and a guy comes in with a kid. I see the kid and he looks pale but alive. Dad says "hey, my kid's having an asthma attack". I pause, at a loss for what to do. No one has told me what to do or who to call if this happens. The triage nurse is busy with another person and the last time I interrupted the triage nurse (a different one) with someone who was worried, she told them to sit down and wait for triage. So I told this dad the same thing - just wait in the chairs and the triage nurse will assess you. The dad kind of glowered at me but they went and sat down. Then the kid got triaged a few minutes later satting at 88% with decreased air entry, tripodding, and in-drawing. Oh my gosh I felt so bad. I talked with some of the nurses about it later and they said that there was a sign for SOB/chest pain to report immediately at the window. The kid was admitted quickly and stayed back for pretty much the rest of my shift. I was also quite humbled because when I looked at the kid briefly, he looked fine to me. I obviously have a lot to see and learn about kids and SOB in general.

Then I was asked to bring another person back who was a ?cardiac patient with history of stroke. I did her ECG, brought her back, put her in the room they told me to, put her on the monitor, wrote up her chart, AND yes I wrote up her nursing notes. Then, a few hours later, a different fairly-intimidating nurse comes up to me and says hey, you need to report off to one of the team members when you bring someone back. What if she crashed and we didn't know what was going on?

So again, I felt like I screwed up without knowing that I was screwing up because this wasn't something that they really emphasized in my buddy shifts.

So I learned last night that it is better to communicate TOO MUCH than NOT ENOUGH. Tell at least 3 people what you're doing, and possibly also the charge nurse. Don't feel bad about interrupting, when necessary, because the alternative is not good.

Lessons learned in the ER.

It was 4 in the morning and we'd been steadily bringing patients back all night:

• a very large woman with a nasty wet cough satting around 85% on room air (her chest x-ray was almost white)
• a frail grandma who had just finished radiation for cancer, who came in at midnight because she couldn't sleep and felt nauseous
• a kid who'd been maced (by security?) at an event
• a guy with inverted P waves admitted for stabbing chest pain - turns out someone placed the ECG leads wrong, he was fine with some Toradol
• a young couple and their weeks-old babe with diarrhea
• a gangbanger who punched through glass instead of his girlfriend, but seriously sliced his arm just proximal to the medial epicondoyle - deep lac was about 4 inches long and gaping about 3 inches wide - the police found him by following the trail of blood down the street

It was hopping in the ER. I was running ECGs back-to-back, taking specimens to the lab, and herding someone's 5 children under the age of 10 that she decided to bring with her to the ER without extra supervision. One of the docs left at 0300 so we were down to just one doc until 0600 and of course that's when things started to get hairy. Our nurse at triage decided to hang out in the back and keep an eye on triage using the security cameras, because all of the people with sore throats and vomiting in the waiting room kept shooting her death stares.

We had one lady on cardiac observation, the guy with the inverted P waves taking up our peds trauma bed, and another guy came in about 2 weeks post-CABG with crushing chest pain, tachycardia, and a-fib (tachy a-fib? or is it just that it was reading the extra atrial beats as the actual pulse rate? forgive me, cardiology nurses, for I know not what I don't know!), the gangster with the arm lac woke up from his drunken snooze and started howling, the grandma who couldn't sleep still hadn't been seen, the kid who got maced needed a shower, all 5 of the loose children started getting tired and cranky, and the young couple thought we were ignoring them and kept hovering around the desk with babe in arms.

So despite the madness of those three hours, I rolled with it, because the staff were so awesome to witness. This wasn't their first barn dance. With one swoop, the nurses got the kids cozy with some coloring books, told the young couple that they WOULD BE SEEN but not NOW, got the maced kid into the shower, buried grandma in 5 warm blankets (and lo, she fell asleep!), soothed the gangster back to sleep until he could be seen, and all of a sudden the charge nurse pulled me into the other trauma room and said "watch this".

The guy with a-fib was just signing his consent for conscious sedation and attempted cardioversion. They placed the electrodes sandwich-style on his left chest and back, snowed him with fentanyl and propofol, and set the current. Then the physician gave the go ahead. The nurse called CLEAR and made sure we were all back before pushing the shock button. The guy went rigid and then limp.

"Owwwwww," he groaned, motioning to his chest.

We all watched the rhythm as it settled into normal sinus for a few beats....and then blip, blip, blip-blip-blip his heart rate climbed back up to 140 and we saw the beats become irregular again.

The physician ordered a higher electrical current. ALL CLEAR! Shock given. Normal sinus, and then a-fib.

Again, higher current, shock, normal sinus, and then a-fib.

The physician decided to discontinue the cardioversion and instead just hold the patient until he could be admitted to cardiology in the morning.

A couple of hours later, the new doctor was coming on so I pulled someone out of the waiting room for the first time in hours. I looked in the chart. Sore throat x 3 weeks with slight cough, no fever, nontender palpation of lymph nodes. Came in at 0300 on the Saturday of a long weekend (and waited 3 hours) for....what, exactly? A throat swab and dispo with abx...

And then it was 0700 and the gangster was getting his arm stitched up. I played doctor's helper and held the pt's arm in an awkward superman position, while also running to grab sutures and stuff since, although the doc had the suture cart right there, he had managed to turn it so I couldn't get into it, and he was sterile so away I went. It was worth it though because it was awesome to watch him pull the lips of the lac together and get it sewn up. There was a large vein that had to be tied off. He started in the middle of the lac and guessed where to start sewing. After a couple of false starts he got it evenly joined and worked his way out to either end, and then filled in the gaps. All together I think there were 10 sutures. It was neat to watch him pull the edges together , all the subcutaneous fat kind of popped out and sqooshed all over the place. Once he was done, it looked amazingly clean. Especially considering the amount of blood I'd washed off his arm, and how much had caked onto his pants.

I applied a dressing of adaptic, 2x2s, 4x4s, and cotton wrap. Then the oncoming day nurse told me to go home.... so I did :)

*Pinches self* I can't believe I get paid for this. I LOVE EMERGENCY NURSING!

Captain's Log, 0350, 13 May: Halfway through first night shift, ever. Total census: 1 stable patient held overnight for observation. Studying for Sociology midterm in 5 hours. Feeling good about my risky move to work the night before a test.
-- from the cellular desk of undergrad RN

I am super pleased to report that my first buddy shift on the floor was absolutely awesome. Emergency nursing is like nothing else I have experienced in clinicals. In one shift, I was exposed to so many different presenting complaints and patient populations, it was like my entire clinical rotation on fast forward. Nancy, my precepting buddy nurse (it changes every shift) last night, was really great to work with. She's been at this ER since it opened and has been an emergency nurse since forever. And, importantly, she still loves it. I didn't get the whole burnout vibe at all, from anyone.

So for anyone who hasn't had exposure to emergency nursing before, I will try to elaborate what the flow is like. This particular ER doesn't assign specific patients. They have recently implemented team nursing, so a bunch of nurses will be assigned to a wing and work together to meet the needs of all of those patients. My preceptor was assigned to float between the two teams, as well as cover charge and triage for breaks.

My shift started at 1530 and we took report from the off-going charge. I noticed that the report went very quickly, identifying only the chief complaint and how long they'd been there, and any labs that needed to be drawn.

We toured the unit and she pointed out all of the equipment in the different rooms. I've been volunteering on that unit since November but it was cool to see it through fresh/knowledgeable eyes. There is a minor procedures room, orthopedic casting room, EENT (eyes, ears, nose, throat) exam room, 4 stable beds, 4 fast track beds, 4 monitor/observation beds near the desk, 2 gyne/peds rooms, 2 trauma/resuscitation rooms, 1 reverse isolation/positive pressure room, and 1 secure room with superstrength door and optional camera monitoring.

morganlens.com

After the tour, we got started with the day. Nancy went out to the triage desk to admit the first patient. We had a look at the rack of charts from the triaged patients and it wasn't too busy. She picked a triage level 5, a young guy who got some metal in his eye while welding. We called him from the waiting room and saw that his v/s were taken less than an hour ago so we didn't need to reassess them. We took Eye Guy back to the EENT room and I gave him a Snellen test to assess his bilateral visual acuity. It was cool because he sat in a chair like at the optometrist and I flicked the different letter sizes across the wall in the dark. Not something we learned in clinical (it had been briefly mentioned in lab, I think, in our assessment class in second year), and here I was administering it to my first patient on my first day :) Nancy was very supportive of me doing my own thing to help out instead of just being her shadow and I was glad for her guidance. You know how it is, sometimes you just need that push to go out there and put theory into practice!! There was some talk about administering a Morgan lens, as we learned about in orientation, but I'm not sure what happened with him after all.

Like a lot of you, I think, I have followed a ton of emergency nurse blogs since well before nursing school in 2008, including those of the illustrious Nurse K, Girlvet, and NNR, newer ones like newnurseinthehood and Maha, and newer-to-me torontoemerg. Like you I have uttered many a guffaw and/or facepalm at the stuff people do to end up in the ER at odd hours when other people, such as myself, would much rather be home in bed. I am (pleased? saddened? resigned?) to report that I saw several examples yesterday in one shift alone that amazed me, especially in terms of my rosy nursing school glasses.

My next admission was a young man with throat tattoos (listen, I LOVE tattoos. I have two large ones myself. But I have never seen a throat tattoo that I didn't immediately associate with Tapout) dressed head to toe in Ed Hardy who came to visit us with a migraine. Okay, I've had migraines as a teenager. All I could do, once I got the visual disturbance aura, was get home ASAP so I could lie in bed in dark silence and barf my guts out while praying for it to be over. Seriously, the ED is the LAST place I'd want to have a migraine. This young man did not exhibit any of these symptoms. I'm not sure what he got discharged with, but I think he waited a while.

San Francisco General Hospital

I saw my first conscious sedation, an older man who tripped and fell and dislocated his wrist. It's the first reduction I've ever seen. The physicians snowed him with fentanyl/propofol until he would not react to them touching his eyelids. They then grabbed his little frail old arm and reefed on it until it went back into place with a couple of clicks. One guy held traction down on the wrist while the ortho tech put on a cast. First time I've seen all of those procedures. It was very cool. Initially I was squirming inside because the patient was obviously feeling the pain of the reduction, moaning and grimacing. It kind of flew in the face of everything I've seen so far. One of the nurses caught my expression and said "don't worry, he won't remember it." And he didn't - I walked past his room an hour later and he was sitting up admiring his new cast and chatting amicably with the physician who had been poking him in the eyeballs to check his response.

Another interesting thing was a little boy who had stuck a not-so-little bead up his nose. I have never worked in peds before outside of postpartum and preschool participatory observation for a few days. I had no idea what they would do. The RN grabbed him and wrapped him in a full-size swaddle, pinning first one arm and then the other as they rolled him tightly into a sheet like a little sausage. I helped to hold him still as the physician tried to excavate the bead via suction. No dice, but one of the nurses found a metal tool that bends at the tip when you press the trigger and they threaded that through the bead. Success! I was amazed at how big it was. Wonder how it fit up there in the first place!

A few other things I saw -

• The ortho tech showed me how to do a wrist assessment to help decide which carpals were affected, and determine which x-rays to order
• Nancy starting IVs so fast she made it look easy, and I was consumed with envy
• A roughed-up prisoner who got into quite the scrap (I've never seen someone look that, well, beat up before)
• A little baby with a case of Grade A diaper rash
• Oozing shingles pustules
• An ECG on a woman with a heart condition and chest pain - she was graduated to an observation bed. Her husband peppered me with questions about why she was getting a N/S infusion and why they ordered what tests they did, and, MOST importantly, how long they would have to be there. Apparently there are places more important to be than in the hospital ruling out MI...
• Query fish bone stuck somewhere deep in a guy's upper GI, not sure what they did with that one
• Nancy also volunteered me to admit a query anaphylaxis reaction. Lady had hives on her tongue and reported throat closure/swelling. I was pleased when my brain suggested I auscultate and listen for evidence of decreased air entry. So I busted out my stethoscope and listened to her perfect breath sounds all the way down to the lower lobes. Nancy approved of this and had me chart it. I think my hand shook a little as I signed my new designation, haha :)

My shift was a total whirlwind. Literally every admission was different from the next. We covered triage for a while and I was a bit taken back by how every sick person coming into the ER was seriously inches away from our faces. Yuck. One of the nurses told a story at lunch about how an angry guy with "back pain" launched himself at her, through the window, when she wouldn't put him back right away. Yeah, past the gray diaphoresing guy reporting crushing chest pain.

I saw way more things in one day that I saw in weeks at clinical. I seriously loved it, every minute. I was also super grateful for the extremely kind staff who were more than happy to show me cool things and ask me tough "thinky" questions.

I can't believe I get paid for this!!! I would have been there for free. Wait, don't tell that to my boss..

Can't wait for my next shift tomorrow :)

Today was my Orientation.

We spent 7 straight hours going through (literally) STACKS and STACKS of HR stuff, paperwork, and all kinds of tips and tricks for assessing different populations and situations. I have 3 stuffed folders and I think I will take some time to organize them into binders because they seriously gave me some of the best reference material I've come across since starting school - and free!

Orientation was provided by the clinical nurse educator, herself a very knowledgeable ER nurse with floor experience in critical care, trauma, and flight nursing. It was like my assessment course and my acute care course plus lots of extra information all rolled into one day. I was on learn overload. I am SO excited to see this all in action.

I also saw educational videos on some kind of contact-looking-thing that fits over the eyeball and hooks up to NS to flush the eye of chemicals or debris, and how to install/use an intraosseous (IO) infusion set. Then I played with the drill. No needle ;)

So my next step is to book my buddy shifts (2 days, 2 evenings, and 2 nights)... and then after that?? I don't know yet. I don't think the unit manager knows yet, either. It seems like a gongshow-kinda place. I think I've been spoiled for the last 5+ years I've been in quiet offices with orderly HR and management processes...

I sent an email to my other job letting them know what days I was free. I shall see what they say. I am looking forward to not working there anymore, but prudent thinking suggests that I will benefit from working so much this summer, and I can quit with a clear conscience and a full bank account for the Fall term.

Firstly, THANK YOU for all of the kind words re: my summer placement.

Since Zazzy asked, I'll define UNE - "undergraduate nursing employee" is my province's designation for a 3rd year student nurse; since BSN was made entry-to-practice for RNs in this country, it's how we can get paid experience working in an RN-type role before we graduate.

The UNE position does not fall under the auspices of our regulatory college or union; rather, it is a protected position that is only available to regular-entry BSN third year students (not LPN-RN bridging students, or accelerated BSN students) and it is designed to be temporary (cannot work full-time for more than 3 months, less a day, per UNA guidelines - this is to make sure that a UNE does not take the place of an RN or LPN position).

The UNE takes on a lighter load than an RN, with lower acuity, and is responsible for patient care for anything he or she has been trained to do already in school. For example I can do anything I have done in clinical before - foleys, wound dressings, IMs, bladder scans, etc. Things I have not done before I can watch and learn, such as placing NGs. Things that are outside of my clinical scope I cannot do as a UNE. Such as IV push meds or defibrillation - which is totally okay, I'm in no hurry for that kind of responsibility.... lol

Otherwise I function in my full clinical scope. I can do planning, teaching, skills, and nearly everything an RN would do. I'm not totally sure what I *can't* do, yet, because I think that's probably specific to the type of environment I will be working in. I've never had a rotation in Emerg, or spent any significant time there outside of my volunteer position (which never exposed me to much except where the supplies were, really). It won't be like my med-surg experiences with paging the docs and stuff. I like this particular environment because the nursing station is combined with the physician desks. It will be an excellent opportunity to learn by eavesdropping on everybody, especially because curtains aren't particularly soundproof! :)

So yes, I will be working 0.5 FTE from May through August (that's about 20 hours a week) and mainly evenings and nights. I have never worked overnight before. I've worked late-as-hell (6 PM to 2 AM) and early-as-hell (6 AM to 2 PM) but never crossed that barrier. If you have any tips please share. I am concerned that I will turn into a surly, cheerless, friendless prickle. My plan to also work 3 days per week at my desk job, likely in midmorning-afternoon, kind of hinders the idea of turning full-on vampire. I'm not sure how this will work out. If something has to give, I will stick with Emerg.

Oh! That reminds me. I was going to write up some of the interview questions in case that helps any of you out in the future. I have them scrawled on a notepad somewhere...

At any rate, as per the title of my post, I am technically supposed to be writing a ten-page critique of a research report right now. It's a self-imposed deadline for the research class I'm taking by correspondence. Knowing myself and how I am, I booked the final well before I finished any of the projects, so that I would HAVE to finish it. So now I HAVE to finish it, or fail the course, by Thursday April 28............ but it's only the 17th, and of course you see my temptation :)

Before I get back to the slog excitement of critiquing research, I guess I should also update you about my clinicals, which are (surprise!) still going on until the end of this week.

Yeah! Bet you thought I was done, based on the crappy posting of late...

Nope, I am 4 weeks out of 5 from being finished my Community/Public Health rotation.

Tuesday is our oral report about the agency placement with the preschool kids, and our teaching plan re: toothbrushing and washing hands. Wednesday is our actual presentation to the kids. Thursday is our final evaluation, and Friday is a long weekend, my last before I go back to work.

(For the record, I took a leave of absence from my desk job for the months of March and April in order to focus on clinical, and it was the BEST THING I EVER DID for myself in school. Hands down. Last year my hair was literally falling out. This year I am able to attend my horse-riding classes, work out, make healthy food choices, take on 2 correspondence classes, AND do a decent job on my clinical projects)

In regards to Community Health, well... I have felt like I could fit into every clinical placement I've had so far. Even postpartum which I honestly thought I would hate (thanks CC for helping me consider otherwise :)

But, man, Community Health has absolutely NO appeal to me. It could be that I've worked desk jobs for about 6 years now and I'm numb to the pride I once had about having my very own cubicle. I can't stand office work or office gossip. I hate photocopiers and water coolers and I REALLY hate getting emails from people who don't know what Reply All means. I realize that there is a hands-on component in public health, i.e. when you actually go out and assess babies or teach college kids about STIs or do an immunization clinic for Grade 5 kids.... but that seems to be only 10% of the job. The good 10%, IMO. The other 90% of the time seems to be spent in the office, trying to round up resources and liaise with other people and hammer out meeting times and set up appointments, etc, etc.

Maybe CHN/PHN will be appealing to me when/if I have family responsibilities or am tired of running around all day.... but for now, get me back in the hospital, stat.

I shadowed one day last week in the Hip & Knee Clinic, where people go for pre- and post-surgery teaching and assessment. It was actually a really cool experience, especially given my rotation in Orthopedic Surgery last year. I got to take out some staples and do a dressing change. Compared to the rest of my rotation, it was practically critical care in there! lol!

Okay okay, I'm going to go write a paper now. Honest....

OH YEAHHHHHHHH

I went in there and blew their minds with my clinical genius!

Okay, I was pretty nervous but very prepared.

FYI - I read a tip about putting baby powder on your hands to prevent clamminess. I suffer from seriously sweaty palms when I am under the microscope so I tried it. It worked very well. No one got grossed out by shaking my hand for a change...

At the end of the interview, they offered me the position, on the condition that I am:

A) not a criminal, and
B) not lying about being a nursing student

So orientation's on April 26 and 27!

Unfortunately the position (like every freakin' position in this province) is only a 0.5 FTE. So I will also be keeping my regular job for another summer. Still, who cares! I get paid to go to clinical! :D

I have been waiting for this opportunity since before I started nursing school. I remember Googling like crazy to learn about what it meant to be a student nurse in this province. I found the UNE position and told myself - that's what I want to do in my 3rd year of school. And here I am!!!

This is a great day!

My interview's at 3:30 this afternoon.

My hair is done. My clothes are pressed. I am wearing my STTI pin for awesomeness.

I am browsing my blog archives to try and remember some of my more influential nursing moments.

..........and I am freaking out!!!

I fired off an email to the department for the ACCN certificate, asking when I could theoretically begin some of the coursework.

Their reply: "You would need to be in your final Year (4th year) of your Degree program to take the ACCN courses. You would be able to take some of the theory course prior to graduating."

Okay, so I have a year to consider my options. This is good. I have an ICU theory term and clinical rotation in the coming year, so I can make a more informed decision at that point.

A lady at work yesterday saw me reading my latest textbook for my correspondence class. It's dry stuff, but at the same time interesting. The current chapter is examining paradigms and methods of scientific inquiry. It is making me wonder how on earth I'll ever get to the point that I can identify a knowledge deficit and choose to research something real and relevant. This is something I'm going to have to tackle in a Master's program. I guess that's why they want me to have a year's experience in my specialty before applying. But I digress...

She asked me how much longer I had to go in my program. "2 years!" I cheerfully replied, and then we were both a little surprised at how fast the previous 2 years have gone by. A lot of the ladies at my work are very old-school (I am one of the youngest people there, by like 20 years) and they seem to have a real reverence for my being a student nurse. It's a little unnerving. No matter how much I tell them that I actually don't know anything, they want me to shed light on various medical concerns they have - my office has a LOT of medical concerns. In fact I have been clamouring for them to get an AED there specifically because I work with a lot of overweight older adults.

However I was actually able to provide some good information to a co-worker whose dad was in end-stage cancer, receiving palliative care. He lived in another province. She was pretty distressed and didn't want him to die alone in a hospital bed. I told her to inquire about home care nurses in that area.  A few months later she told me that home care allowed him to die peacefully in his own home with his own family present, and she was very pleased with the supportive environment. I was glad that I had managed to pick up SOME little tidbits from Med-Surg, lol :)

I don't know if you guys have looked. I'm SURE you have. I'm sure you're all just as concerned as I am about where the hell you're going to work once you've got that shiny degree on your wall. I'm only halfway done and I'm already panicking!

My *ideal* career path would be a year or two in Med-Surg, while building foundational skills, and then to grow into a CCU nurse. I'm not 100% sure if CCU is ultimately the kind of nurse I'd like to be (who can be that sure, anyway?) but a lot of things about it are appealing to me.

Certainly, one of the best days I've had in clinical was when one of my patients had higher acuity and I had to manage him, his family, and my interactions with the rest of the care team very diplomatically and with as much knowledge as I had. Everything that came up with his care made me ask myself questions. I spent my breaks researching. I loved every second of it, even though it was a very difficult time for him and his family. One of the weird things about nursing, I guess - some of your best days are some of your patients' worst.

My career path has always seemed pretty workable. Get a job in something basic, then specialize, while continuing my education. Ever since I realized that I liked learning, I haven't wanted to stop. Sure, some days I wish I was done school so I could have time to myself and actually have a life, but on the whole I've loved every second of it. Stop at my BScN? Hell no.

Unfortunately, with job prospects dwindling and having heard nothing back from the internship I applied for, I'm starting to actually get a little spooked. Our schools keep churning out new grads and I haven't found a SINGLE RN job posting that didn't require at 1 year experience. In fact I haven't found a single RN posting that was in anything other than a specialty.

The job market tanked in the last two years. One hopes it will float again in the next two.

However, in case it doesn't (or in case any market improvement is only temporary) I am considering pursuing this certification on a part-time basis next year as a senior student. I am hoping it will give me a leg up over the ~150 nurses also graduating with me. There are some theory components but most importantly, there is a 210-hour clinical component.

AKA networking opportunities.

Eventually I want to obtain my Critical Care Nursing certification through the CNA.

Alphabet soup? As long as it brings job security and a paycheck, I don't mind one bit :)

[photo credit]

The other day, Tuesday, I walked in to work loving my life. Everything seemed to be coming up roses. I loved my office, its proximity to school and my home, the pay, and the fact that my part-time request had been granted without hassle.

I left work that day in a crumpled ball of tears and tissues (um, Kleenex, not 'bodily tissues').

All because a frustrated person chose to vent at me! At the start, I was professional and empathetic, and all the other usual crap that they teach you in Customer Service class. Murmurs of assent, giving the audible equivalent of nodding my head in sympathy. What a horrible day this person must have had, and I am sorry it had to be him, etc etc. But then he started manipulating me, telling me that the call was being recorded for the media and thank you for giving us this sound byte on behalf of your organization, and the like. I KNEW he was manipulating me and bullying me, but I felt powerless to stop it.

The weird part was not that he was bullying me, but in how I responded. I was just looking around for help when one of my coworkers locked eyes with me and I fell into complete meltdown. Blubbering, tears, snotty nose, the works!

The scary part was, this is over the phone. If someone starts giving me shit face to face, I figure I'd last maybe half that before needing to 'exit the situation'. I read nurse blogs where the folks in charge rehash tales of giving it right back to the complainant. I just can't see myself being able to not only handle that kind of treatment, but let it roll right off me and get down to business.

Maybe my problem is that I'm just a big ole softie, who wants to do what's in the interest of my client (or what they feel is in their own best interest, which is probably a little dangerous). And when I feel like my hands are tied because of policy or hierarchy or whatever, I feel like I'm getting screwed from both ends... so to speak. Meltdowns may be quick to follow.

I hope they teach "Cojones 101" at school. I hate feeling so powerless over my emotional response to these types of interactions. Someone please tell me that it will somehow be different once I am a nurse... please??

In other news, this weekend my wonderful boyfriend is leaving to a college 5 hours away from me. We are moving him into residence on Sunday/Monday. For me, it will be 4 more lonely sleeps until orientation, and 5 more lonely sleeps until classes start! Mixed feelings abound.

Today I set as D-Day to tell my supervisor about going to school, and that I would need to drop to part time.

She congratulated me on being accepted, and told me to forward my new schedule to the department leader.

She didn't even blink!

Well, this is shaping up to be excellent indeed.

An open letter to those who use any chance they get to be socially inept (and more than a little creepy).

Dear Freak:

I am happy that you finally reached a technical support rep who speaks - how did you put it? - "American". I'm even happier that I was able to fix your ancient computer's innernet connection and get you back onto your AOLs. I know that missing out on a long night of internet poker games would have been really detrimental to your customer experience. You might even have asked to speak to my manager had I not come to a quick resolution with the teeny bits of fragmented troubleshooting you let me do! Lucky me.

Lucky you, my company has recently instated a policy which allows you the benefit of contacting me directly via my company e-mail at any time you should so desire. Even better, this e-mail contains both my first and last names so that you know exactly who I am.

However, this is not an opportunity for you to use my name to harrass me on Facebook or Myspace in hopes of developing a relationship (or whatever it is you are trying to accomplish!). In what dimension is it socially acceptable for you to e-mail me a picture of me and my dad? My involvement in your life ended when you hung up the phone. That is all.

*looks wistfully at calendar*

Only 6 months and 18 days until I can get a non-responsible, school-supplemental, menial job at a grocery store or something.

I hope I can make it.