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

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 :)

I am leaving in a little bit to my first buddy shift at the ER! I will report all soon :)

I have also just started taking SOCI 271, Intro to the Family, during the spring session at school, as credit for my senior elective. I am SO THRILLED to report that I have begun my 4th Year courses!!!

(I also love spring session because it's 3-hr lectures, 5 days/week, for 3 weeks. Bliss.)