It took me about 6 months but I finally got around to cleaning up my list'o'blogs. I had accidentally deleted half the page and helpful Blogger auto-saved. Rage ensued.

2 hours of hand coding later, it has returned, and better than ever!

Check it out for some good reads, if you're having a chill weekend and need something to do :)

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!

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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...

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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