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.
I love nursing.
Now onto the good stuff.
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....
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....
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3 comments:
That was really interesting, thanks!
Wonderful perspective! Am forwarding to my nursing students :)
As a pre- nursing student I really appriciate you taking the time to write this out. This IS the stuff that I want to know about! :)
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Thanks for your thoughts :)