Sunday, January 31, 2010

The Importance of "Why"

Yesterday I was informed, by someone on my school EMT squad, that I should focus less on "why the patient has symptoms" and more on "just getting their vital signs and getting rid of them. It's not our job to care about WHY they have them". At first, I was only mad because of the implication that I wasn't doing my job well.

And then I started thinking- I'm angry for a deeper reason. I CARE ABOUT "WHY"!!! (not to mention, my blood boils every time someone tells me something "isn't my job" or "isn't my place"- it's like saying "don't you worry your pretty little head about it. just take his blood pressure, and we'll do the rest")

"Why?" MATTERS. Ok, a 24 year old woman calls 911 for chest pain and "palpitations". You COULD just treat the chest pain per protocol with aspirin, take her BP, run the vitals, but it matters WHY her chest hurts! Maybe her boyfriend beats her up, and punched her in the chest! Maybe she has Marfan's Syndrome, and her aorta is tearing open! Maybe she just had a fight with her mother, and is having a panic attack! Maybe she has a congenital heart defect! The symptoms themselves are just that - SYMPTOMS. Of some underlying PROBLEM. If we content ourselves as health care providers with putting bandaids on the symptoms, we are doing a massive disservice, both to our own intelligence and to our patients.

Take back the "why"! Ask questions! Join the resistance!

Thursday, January 28, 2010


Yesterday I had a 34 day old patient. The problem with babies is, they're adorable, and make great patients. I was SO spoiled. Her mother changed her, cuddled her, and all I had to do was assess her, take her vital signs, and do actual LEARNING. It was wonderful. The poor little thing had mastitis. Yes, an infected BREAST. This is highly unusual, was 34 DAYS old, not 34 YEARS, and breast infections are really really rare in people who don't even know where their feet are yet.

A little clindomycin seemed to clear it right up.

I'm still unsure if i want any of my own, but babies make delightful patients.

Monday, January 25, 2010

Cultural Competency

Today at Worlds Greatest Childrens Hospital I had my very first patient, an adorable 5 year old who only a spoke chinese dialect, and whose parents didn't speak english either. This may have contributed to the fact that this was her THIRD trip to said hospital in the past three weeks for asthma. THIS time, someone actually admitted her, and did a screening. She has RSV (its a virus that causes flulike and chest-cold symptoms in little kids. pretty much everyone gets it at some point or another, 80 percent of us before age 2) as well as her asthma. THIS time, REAL translators were brought in (hard to get them down in the ED on short notice for her dialect of chinese). Her parents were painstakingly taught about how to care for her asthma, and it was impressed upon her father that he MUST stop smoking in the house. Hope he takes THAT one to heart.

She was a BEAUTIFUL little girl, and HATED it when people used stethoscopes on her without her help. To "help" she would grab the bell end of the stethoscope, and move it across her chest. Thing is, she did it RIGHT, unerringly moving it to the exact spot I wanted. What a pro. I had the interpreter tell her she should study hard to be a nurse or doctor herself someday.

I hope life treats her well, she's due to be released tonight.

Sunday, January 24, 2010

Student "Health" Services

I give up. I really TRIED to like our student health services nurses. Really. I'm still a nursing STUDENT, and it kills me to think badly of members of my profession-to-be...

But they're idiots. Over the past week we have transported no fewer than SEVEN students from the health center to the LOCAL EMERGENCY ROOM for complaints so non-emergent as to be head-against-wall laughable. These have included: 1 cut finger, three weeks ago, scab removed by the genius student, so it started bleeding again. (yes, but why do you need AN AMBULANCE?) 4 students with upset stomachs that the health center felt "needed further evaluation"- just a tip: THEY HAVE A STOMACH BUG, and a few other random things like "arm pain".

This is par for the course. We just assumed that, for liability reasons, they HAD to get cleared by the ER, and we had resigned ourselves to this state, until yesterday. Yesterday we were called up to the health center for a young female, fell three days ago playing soccer, and since then had been suffering MEMORY LOSS, VISUAL DISTURBANCE, an inability to focus on anything, sleeping 20 hours a day, and "when I close my eyes i forget i have hands".

The problem is, this girl had ALREADY been to the health center, the day of her head injury...and after taking one set of vital signs, they LET HER GO. Without even a friend to make sure she woke up frequently during the night.

My faith in their clinical judgment is shot, and now I feel like I have to keep even more on my toes so these idiots dont kill someone.

On another annoying note, someone has to have a chat with our dispatcher. For the last week, EVERYONE has been dispatched either as a "transport to the ER" (no, you cant dispatch us for that, you need to tell us WHY they need to go) or as a "sick person" (C'mon! HOW sick? Stomach? Head injury? Boo-boo?)

This ends now.

Thursday, January 21, 2010

It was a LONG day

Yesterday started out "bright" and early at 520AM, as I blearily stumbled out the door to the school parking lot to meet my carpool. Then FIVE of us jammed into a compact car, miraculously surviving the Schuykill Expressway and getting to 5 East JUST in time. Since yesterday was Shadow Day, we were each assigned to a nurse, to "get a feel for what they're doing". My nurse was a new grad, and really wonderful. She was willing to teach me (my non-emergent pediatric knowledge is LIMITED) and fun to work with.

We had 3 patients, ages 6, 13, 17, ALL with sickle cell. Woah. The hardest part of taking care of the OLDER two patients was the persistent desire to smack both of them upside the head. They seemed totally uninterested in the world, but avidly watched the clock waiting for the magic q3hr mark, when they could get their beloved M.orphine bolus. Now I understand that this disease is RIDICULOUSLY painful. I understand that a vaso-occulsive crisis is actually causing ischemic damage, and is totally uncool. I do. I get it. But the parents wouldnt' even help us kick them out of bed! And they KNOW better. You see, if a sickle cell patient (or really, ANYONE) just lies in bed, Bad Things Happen. Bad things like blood pooling (which, yanno, makes the clotting worse), lung problems, pneumonia, Bad Things.

Even so, the mother of the 17 year old boy wondered if we could give him a BED BATH, because he "didn't feel like getting up". This is a boy who was scheduled for discharge today or tomorrow. And he wont get up and move, even though it is the ONLY thing that will actually help his recovery. His mother glares at the nurses, and wants TWO to be present for everything, including connecting saline to his IV. According to the nursing staff, this patient is a frequent flyer, and doesn't WANT to be discharged- home is lacking in room service, unlimited cable tv, and m.orphine. Go figure.

The bright spot in my day was my youngest patient. This little boy had a VERY low hemoglobin- low enough to need a blood transfusion. What was his reaction? "I had breakfast. I ate it ALL. I don't WANT to stay in my room, the other kid (the 17 year old) is BORING. Can we go play?" My reaction: "Lead me to the playroom!"
We made mutant Mr. Potatohead dolls, with airplanes for arms, AND invented obstacle courses to navigate one-handed (his other arm was wrapped in an IV-protector, much to his annoyance). This kid was unstoppable. AND totally hilarious. His attitude was "there's a giant playroom here, and my mom is here. Whatever you people need to do is ok, as long as I get to to play afterwards". He's awesome.

AFTER clinical, I ran home, showered, threw my stuff into a duffle, and went back over to campus for my overnight VEMS shift.

THREE BLOODY CALLS on a Wednesday night! First one was simple: fairly obvious tib-fib fracture, kid was in a LOT of pain, but still apologized for swearing when we picked him up (they're cute when they're polite). Second AND third calls: one young freshman girl, food poisoning. We took her from her dorm to the health services building, per the request of public safety, who were afraid she would puke in their car. THEN 15 minutes later, the health services nurses (we really need to have a chat with them) CALLED US BACK to say they "couldn't care for her" and we should take her TO THE HOSPITAL. Seriously. She'd vomited FOUR TIMES...and had admittedly painful abdominal cramping, but clearly epigastric, and she was currently menstruating, so that would rule out most appendicitis AND tubal I don't really know WHY our nurses refused to keep her- except to wake us up TWICE in the middle of the night.

So I'm tired, and cranky...but feel VERY accomplished.

Saturday, January 16, 2010

I was THAT kind of little kid

Over this past break, I got to perform TWO (TWO!) whole medical procedures BY MYSELF. Why? you might ask, would ANYONE let an unlicensed nursing student perform a medical procedure on them? Well, because my father hates going to doctors (45 minutes each way in travel time, and he claims they "never do him any good anyway").

When I got home for winter break, dad was complaining of severe ear pain, with loss of hearing, consistent with cerumen impaction. In other words, his habit of wearing wax earplugs at night had jammed lots of earwax together, and it was stuck deep in his ear. I knew this, HE knew this, and the doctor to whom he reluctantly dragged himself could see it with the otoscope. But this VERY new doctor had never actually TREATED a cerumen impaction by himself before, and didn't have the cool little wire tool used to dig them out of ears...but he did try. He told dad to get some Debrox, use if for 4 days, then come back and he'd try again.

It's really hard to put Debrox in your own ears though, due to head tilting, and the severe vertigo that can come from putting water in your I did it for him for two days. On the second day I was curious about something: Debrox is really diluted hydrogen peroxide, which is a liquid that bubbles. The ear canal can be straightened, by manipulating the pinna (outer ear)...ergo...I started playing with the ear, while instilling the Debrox, and squirting the ear canal with the bulb syringe (WARM water, thankyouverymuch)...when lo and behold...


Seriously, it was huge, like the size of several cashews. I have no idea how it fit down there. "EW!" I yelled, rather triumphantly, immediately hiding the thing from dad, who gets REALLY grossed out. "I GOT IT!" Dad cancelled his follow-up appointment, and has been telling everyone that I "might make a decent nurse practitioner someday".

I also got to give him his flu shot, the first he has ever consented to receive. My parents are so supportive they let me practice on THEM. :-D

Friday, January 15, 2010

Child and Family Nursing

Okay, I get it. Patient-centered care in pediatrics includes the parents. Really. I DO get it. The problem I have is when HALF of the slides on yesterdays powerpoint for class said that it was important to do "whatever the parents want"- namely, if the parents want you to change their child? you do it. If the parents dont want to feed their child because they are tired, you do it. If they want you to page the doctor, change the bedsheets, or give their child pain medication, apparently we just "do it".

I understand that the number one concern of parents for their hospitalized children is pain control. Except "pain control" isn't what most parents want. They want pain RELIEF for their child. As in, NO pain. And as medical providers, we've kind of sucked at explaining that, in many cases, total pain relief is impossible, due to the danger of, say, respiratory depression. Or death. I just wish they taught us more about using our clinical judgement, and a LITTLE less about how we should do whatever parents tell us to. I'm all for working with families, and feeding and changing kids doesnt bother me, but please...teach me to respect that I have knowledge that is valuable, beyond the fact that i have two working hands to change bedding.

Monday, January 11, 2010

Pediatric Clinical Placement

You want karate? Sorry. I don't have any. But I DID get my clinical placement for my pediatric rotation this morning: World's Greatest Children's Hospital! ~insert squeels of glee~ it's the best Children's Hospital in the country, POSSIBLY the world, and I GET TO LEARN THERE!! WHEEE!!!

I'll be on 5E (i think) which is hematology/general peds. I'm not sure how i'll like it, being more of a critical-care girl, and I REALLY don't know how i'll like dealing with parents- most of my experience in that line has been "oh your child is sick? we'll take him/her/it to the hospital. You can ride in front."

Here, the parents are PART OF THE CARE PLAN or some such. I have visions of parents going "you missed a spot cleaning behind little Johnny's ear" or "are you sure you're feeding him right? have you ever done this before? where's his REAL nurse?"

My plan is to smile brightly, and inform them that they're WELCOME to wait for the "real nurse" to get to them. When said nurse has a minute. Which might take a while.

Friday, January 8, 2010


So I spent the beginning of this week in Portland, ME, looking at a pair of hospitals, and shadowing an Emergency attending (friend of the family) on an evening shift, to get a feel for the department. LOVE their ED. I have a SERIOUS case of emergency department envy. It's brand new, cavernous, but extremely well laid out, with WINDOWS. Doesn't feel claustrophobic at all (thanks to the aforementioned windows and nice high ceilings), and manages traffic very very well.

The attending I followed is wonderful, and has a good relationship with and respect for nurses. She even let me yell at her residents for saying "oh we'll just do this here, and let the nurses clean it up"...including one bright young doctor who said an elderly patient could just defecate in the bed if he didn't get around to telling a tech to bring a bedpan, and that then the nursing staff could "just clean it all up". My response? " you REALLY want to be the most hated resident in the department? REALLY?" His attending started laughing, and said she'd make HIM clean up, since the nurses had plenty of THEIR OWN WORK to do. (Have I mentioned that she's awesome?)

Saw some really interesting cases, including an exceptionally elderly gentleman who presented with what looked like TERRIBLE pneumonia, like, die in an hour or two pneumonia, resps in the 40s, BP crashing, HR 160s...a mess. And HIS brilliant resident discovered a massive bowel obstruction, that was causing his abdominal contents to compress his lungs, so they DEcompressed him, his abdomen shrank by a good 4 inches, and his vital signs stabilized so that he could wake up and recognize his wife. He may WALK out of the hospital in a few days. How cool is that?

All in all, one of the Portland hospitals and one Vermont hospital are the top of my list.