Crash-Course In Nursing

Me? I'm Nobody!

2011-10-22T19:26:00.000-07:00

People deal with hospitalization in different ways. Some are patient and forbearing, some have taken that horrible advice from Reader's Digest et. al. ("What Your Doctor Isn't Telling You!" "10 ways to INSTANTLY GET WHATEVER YOU WANT IN HOSPITALS!" etc) and hope that by being the "squeaky wheel" they'll get better "service". Some prefer to take a different tack; or their families do:

I was in a patient's room this morning, my last shift of orientation. The patient was in A LOT of pain. Seems he'd been taking a few more painkillers at home than he had reported initially...oh well, too late to deal with that, it happens. I'm hooking him up to a different opioid for his PCA, and he's moaning in pain, writhing around, refusing to look at/deal with/acknowledge his colostomy (why is it always men who act like someone else is going to change/empty the damn thing forever?), and he says "god i hate people to see me like this!!!!"

Dude...i sympathize. I would rather have all SORTS of pain than have someone LOOK at me while i'm in it- but then his girlfriend (the 50 year old wearing the tweeny bopper sweatshirt)turns and goes "oh honey...it's okay...she's not people...she's just the nurse. she's nobody".

And I got just a little pissed off. I know people deal with pain and stress in different ways. Get mad at me. Swear a blue streak. Remind him that I'm pretty much cool about pain- dude had one HELL of a midline incision...he can get whatever he wants to numb that sucker- see it all the time, he's not my first guy in pain. But please PLEASE don't tell him "she's nobody". That sort of thing encourages people to treat us as interchangeable cogs in a wheel. As brainless automatons. As less than the professionals we are. I was in their changing his meds BECAUSE I CHASED DOWN HIS DOCS AND SUGGESTED THEY CHANGE HIS ORDERS TO A MED I THOUGHT MIGHT WORK BETTER FOR HIM.

But hey- who am I to argue- i'm Nobody.

They Tried To Make Him Go To Rehab...

2011-10-18T10:08:00.000-07:00

I just worked my first two night shifts. They were back to back. At their conclusion I am officially OFF orientation...eek. Also, my "white cloud" status is GONE. Friday night, on report I was given Mr. Detox.

"Mr. Detox is a middle-aged man, who had a lung procedure done. Past history of ETOH abuse...yadda yadda yadda. He's on the Ativan Scale".

For those of you playing at home, the Ativan Scale uses vital signs, plus measurements like "twitchyness" and "sweatiness" plus how much the patient is awake, and how many times he gets out of bed, to come up with a measure of how much he is detoxing. This is done every 2 hours. Ativan is administered accordingly.

"I haven't been giving Mr. Detox very much ativan, because I fear that it makes him MORE loopy"

Alpine: "wait...you think the ativan is making him WORSE? how much are you giving?"

Dayshift: "Just...like...one mg every two, but he just keeps getting MORE agitated!"

Alpine: "oh...goody."

Needless to say, Mr. Detox needed a LOT more than 1mg q2hrs. He was literally BOUNCING around the room, pulling on his chest tube, pulling off his pants, trying to "visit other people in their rooms", gnashing of teeth, tearing of hair. By hour 4 I was calling the doc every 10 minutes, begging for more ativan. My preceptor freely admitted that she's afraid of detoxers and of giving too much ativan. Me, I've seen the amounts given in the ED for acute detox, and I knew we could go A LOT higher, considering that 4mg IV Ativan PLUS 10 MG HALDOL all administered AT THE SAME TIME put him out for...5 minutes. Before he started bouncing again.

It was getting to the point where I was expecting a seizure at any moment, and his temp was climbing. I pulled the plug right there: "Night Preceptor? I want a Stepdown Unit transfer. This isn't safe." The only reason we were able to keep it up till 1 am was that there were TWO of us, so we somehow managed to keep everyone else safe while sitting on him.

He's still in Stepdown. So...good call on our part.

Moral of the story: If they tried to make him go to rehab, but he said "no!", GIVE MORE ATIVAN :-p

Buddha is my co-pilot (actually, my preceptor)

2011-10-12T21:14:00.001-07:00

I may have mentioned this before, but I have the best preceptor in the whole wide world. She actually has me call her "Buddha", because she is, well, Buddha-shaped. Also jolly. She's been a nurse for 35 years, and she knows pretty much all there is to know about surgical nursing. (She also stands up for me to just about EVERYONE- even the manager, the director of surgical nursing, you name it. She doesn't let ANYONE mess with her "babies"...it's like the OPPOSITE of nurses eating their young.)

Today we had The Patient Assignment From Hell...

Our floor is a pretty high-acuity med-surg floor...primarily Gen Surg (bowel surgeries, esophageal stuff, the occasional weird pancreas thing), Thoracic (chest tubes! And stents! wheee!) and Transplant (kidneys and pancreases only, ifyouplease, unless you had one elsewhere, and are rejecting...). But when Frozen Northlands Teaching Hospital gets busy...we get everything. Urology. Trauma. Orthopedics. WhateverTheFuckThatServiceDoes. We can to 3 kinds of drips, for the most part: Heparin (per protocol, q5hr aPTT draws...huuuuge pain in the neck) Diltiazem (lots and lots and lots of HR checks, and BP checks...like, q1hr or q30min) and...Insulin (q30min finger sticks and rate adjustments. Guess what we had? If you said "ONE OF EACH! PLUS WOUND VACS! AND THE OTHER TWO WERE DIABETIC TOO!!!" you'd be right.

The charge nurse actually APOLOGIZED for putting together the Patient Assignment from Hell, but those were the open beds, because that's who we managed to discharge. I was seriously hyperventilating a few times, even with Buddha at my side, nimbly assessing and cranking drips up and down. While helping me trouble-shoot the 2 blocked JP drains, and the wound vac's low-pressure alarm...

She just says "Easy Tigger (she REFUSES to call me "Alpine")! Take it down to Mach 4! This isn't the ER!" then she smacks me upside the head and tells me to go get coffee before i fall over...

We (I, officially) had a 5 pt. assignment, which is standard.

Mistah Unknown

2011-10-12T20:20:00.000-07:00

Night Shift:"Your patient in room 3 is Mister Unknown...pronounced "Unknown""

Alpine: "Um...wait...why doesn't he have a name? Isn't he conscious? Don't we ASK them when they regain consciousness what their names are?"

Night Shift: "Well...yes...but...:sighs: read his chart. He refuses to tell us. Trust me, Alpine, you're going to LOVE this one!"

Alpine: "okaaaaaaay"

So I sat down and read his chart. Mr. Unknown ("Unk" to his friends) is 19ish. As teenage males are wont to do, he gets drunk...and high...and then steals a car...but since this is the rather sparsely populated Frozen Northlands, the cops don't have much to do some evenings. So they chased him. He, naturally, failed to make good his escape. He had LOTSA injuries. A Random Sampling: two collapsed lungs (yeah, that's both of em), bruised spleen, lacerated liver, lacerated kidneys, perforated bowel, and broken leg. He fled the scene on foot, naturally.

So I'm, like, in AWE of this dood- i mean, you have to be at least MODERATELY badass to flee the cops with all your internal organs misbehaving, and a broken leg. But apparently he used up ALL his badassery. Cause in I walk:

Alpine:"Goodmorning Mr Unknown! I'm Alpine, and I'll be your nurse today!"

Mistah Unknown: "fuck you bitch! let me sleep! And give me some pain med'cine!"

Alpine: oh HELL no...he did NOT just say that! "Mr. Unknown...you do not get to speak to the nursing staff like that...if you find your care here to be inadequate, I'll be more than happy to arrange you to be transferred...TO PEDIATRICS!"

Mistah Unknown: "sorry miss...i wont do it again!" (he didnt...btw)

Alpine: "So...would you mind telling me your last name? It's going to be extremely odd calling you 'Mister Unknown' all day..."

Mistah Unknown: "HELL NO! This way the cops wont find me!"

I didn't have the heart to point out to him that he listed BOTH HIS PARENTS as his emergency contacts. With, naturally, their first and last names. I just smiled and went about my day. He spent the whole day asking us to dial outside numbers for him so he could speak to his "friends and his girl"...and then getting pissed and hanging up on them...then immediately ringing the call bell for us to call them back "so they can apologize to him"...seriously, the guy was acting like he was 7!

Please, PLEASE dont do that sir!

2011-09-16T06:13:00.001-07:00

The last 7 (yes, 7) shifts have seen me taking a full (5) patient assignment. I'm psyched, and a bit shaky still, but my preceptor assures me that i'm safe to practice. The hardest part has been that ALL SEVEN of these shifts have been with a patient I'm going to call "Doctor Evil". This is because of a physical resemblance. He is not a doctor. This is important. What he IS is a Maunchausen's patient. This man hurts himself to get surgeries by infecting wounds by putting things in them. He is the patient from hell. Usually I'm pretty zen about my patients. I can't choose them, I can't alter their lifestyles, so I just accept it. But this man decided to make ME PERSONALLY a part of his health-care fantasy. And that is not ok.
He has been in the hospital for, cumulatively, several YEARS of time. So he knows the drill. And he knows how the machines work. So as soon as I would leave the room, having hung a bag of antibiotics...the pump would alarm. And for the first TWO DAYS I thought that I was forgetting to unclamp things...or the antibiotic would mysteriously not have run in...necessitating me standing in the room troubleshooting for half an hour.
One of the other nurses finally realized that he was basically gaslighting me to get attention. That was when I decided I strongly disliked my patient.
So he's been making work kind of hellish, with constant demands, and inappropriate sexual innuendos aimed at myself and the other nurses. But, as my preceptor says..."if you can handle Dr. Evil, you can handle ANY patient".

Patient Advocacy

2011-08-29T19:28:00.000-07:00

As a nurse, what is arguably one of the most important things I can say in the course of my everyday job?

"This doesn't look/feel/seem quite right!!!"

Two days ago, still on orientation on a busy floor, I had a patient who had come in after Very Bad Things had happened to his esophagus. He was two weeks or so PAST the Very Bad Thing, but he was still "a little out of it" and his cough sounded...funky. It was my first day of two with this patient, and I was reassured on day one that his coughing was related to the Very Bad Thing he had come in for. His diet was ordered as Full Liquids, so when his wife asked for a milkshake in the afternoon, I went and made one (i am fully in favor of making food for patients. They get calories, I get brownie points.)
The problem was, after his wife started feeding him, he started coughing milkshake colored sputum. This was especially worrying, as immediately BEFORE the milkshake, his sputum was NOT that color. "But he's had a swallowing test done!!!" insisted his wife.
So I paged my Favorite Resident (he's not only REALLY good at his job, and highly personable and respectful, he's HOT!) and he came over yesterday morning. "Swallow study? well he's had a test to see if there's a MECHANICAL problem (tumor, obstruction, etc)!"
Me: "Um...you mean nobody has done a Speech and Swallow Consult?" (Speech Language Pathology...they RULE- they can evaluate anyone to determine how they can communicate, and if they're safe to be fed)
Favorite Resident: "well damn...I'll order one for first thing tomorrow then...yeah...you're right...if this is a result of his Other Medical Problems, this could be something where he's going to need help..."
Me: "So...no more milkshake then???"

Death

2011-08-29T17:40:00.000-07:00

Sorry for not keeping up...everything moves so FAST in orientation! I'm up to 4-5 patients, which is a full load. I'm the first one in orientation to carry a full load and get out of work on time. Which kinda scares me- am I doing something wrong to get my work done on time? God I hope not. Yesterday I worked during the Hurricane That Wasn't. The nurse in the assignment next to me and my preceptor had a patient on Comfort Measures. She died. My preceptor thought it would be a Good Learning Experience for me.
Thing is, I've seen dead people before-both in clinical and in the field. This time though, there was a difference- our MD was a brand-new intern. Didn't know the patient, since she was only admitted that morning. And, while well-meaning, he's a bit hesitant (I'm sure it will wear off). He had to certify death. He didn't know how. We had to walk him through it, and then I helped prepare the body for the morgue. The patient had had false teeth. The postmortem checklist specifies that you must replace them BEFORE sending the body to the morgue, lest rigor set in, and cause the face to be stuck without its teeth. I really REALLY didn't want to be the one to put the teeth back- after all, what if the patient rose as a zombie?!? WITH MY FINGERS IN THE MOUTH!!!!
I don't know why, but that really stuck with me. My patient could rise as a zombie, and us without a SINGLE machete on the floor!
It was only after we'd put the toe tags on, and the body IN the bag and zipped it shut that he realized he'd never done the formal LEGAL certification of death. So I went and unzipped the bag, exposing the body. He asked me not to leave the room, and help out. So i stood there, reading an instruction sheet aloud. He listened to the heart for a minute. Then the lungs. Then took the pulse.
"what do i do now?"
"You say The Words!"
"What are The Words?"
"You say 'time of death'"
"Time of Death"
"'1901'"
"1901" And with that, the patient was formally dead. Only 1.5 hours after actually passing on. But then, life is strange like that!

I don't think I'll forget this- literally talking a doctor through someone's death. It seemed so silly, since the patient had obviously already passed on. We were the ones screwing around- they were at peace. If I were the patient, I would be giggling in heaven right about now. :-p

Hiking Safety (Revised and Edited from Last Year)

2011-08-10T15:24:00.000-07:00

Last year I posted on Hiking Safely, and after posting, I spent a month and a half working in the White Mountains with my brother as crew in a mountaintop hostel dealing with LOTS of small emergencies, (plus a few big ones) many of them brought on by simple lack of preparedness. This has applied even MORE to my Wilderness Search and Rescue work. It's dangerous out there, people! I don't just mean the bears (BEARS!) moose, rock slides, etc. I'm talking about darkness, cool temps, drizzle, all the things you don't think of when you think "hazards".

1. Pack an Emergency Bivy. Emergency blankets suck. I've used them on car accident victims, and they blow off in even a light breeze. Invest in a "bivy sack" for emergencies. They're under 20 bucks, and TOTALLY worth it. It's basically a metallic sleeping bag-style sack that's orange with reflective stripes. If you were to be caught out or hurt you could climb in WITH all your gear, and survive the night, or wait for rescue. REALLY WORTH IT.

2. LOOK AT THE MAP BEFORE YOU GO. The main reason people call for rescue in MY favorite mountains (the Whites) is that they overestimate their abilities, and get "exhausted" before they make it back to the trailhead. If you've never done more than a mile or two, DON'T plan on going THREE miles to the pretty waterfall without remembering that it's ALSO three miles BACK. If you DO call for rescue, (and can GET a cell signal) it could be some hours before people can get to you. Rescuers are volunteer, and a crew may have to get out of work, pack their gear, and hike in from quite a distance, depending on where you are. Therefore, MAKE SURE YOU CAN SPEND A NIGHT OUTSIDE. If you're not critically hurt (fell off a rock wall climbing, stomped on by a moose, fell in a stream and broke your leg, etc) you should be prepared to spend a solid night outside before you could be rescued. If simple exhaustion is your problem, think about this- IF you could wait overnight, would you THEN have enough energy to hike out? If this is the case, DO IT.

3. TAKE THAT MAP WITH YOU- this will sometimes be ignored (even by me, and ESPECIALLY by my brother), but if you don't REALLY know the territory, have memorized every trail turning and its approximate distance, and feel comfortable getting yourself back out of that area WITHOUT assistance, BRING THE DRATTED MAP!!! Sometimes a trail has a BUNCH of junctions, and without a map its really easy to get turned around. While we're on the subject, LEARN HOW TO READ A TOPOGRAPHIC "topo" MAP!!!!! Those little lines indicate ELEVATION, and are in increments. Someone who can read a topo map is able to summon a mental image of the landscape, simply by looking at those lines, to identify ravines, waterways, ridges, etc. This helps if you get off-trail, and need to know where you are.

4. Backpacker.com has a good list of hiking essentials, but my top gear list would be the following:
NON COTTON clothing (cotton does not insulate when wet, and is heavy)- shorts and teeshirt
-raincoat and pants (dont need to be expensive, but need to keep water out)
-fleece jacket of some sort (the cheap ones work fine)
-iodine tablets (in case you have to be out there a while, to purify water)
-an EMERGENCY BIVY
-headlamp (seriously, dozens of people every year need rescue because "it got dark out"...BRING A LIGHT! Flashlights tend to be heavier, and you need to hold them, which can screw up your balance. Headlamps can be gotten CHEAP, and are worth it. I carry TWO.
-hat and gloves
-plenty of water

that's the minimum. hike in peace, and enjoy the outdoors!!!

Addendum: I carry a bit more than this, just based on my personal experiences-
A. I carry a very light first aid kit, even when I'm not on a rescue, with benedryl tabs, an epi pen, advil, immodium, pepto, a few bandaids, steri strips, and purell. This is because i can improvise most dressings with clothing, but it's internal complaints that will prevent your walking out of the wilderness. Pain meds, and ESPECIALLY stomach/intestinal meds, will give you the wherewithal to get yourself out.
B. In cooler seasons I carry a softshell, and wear softshell pants. Softshell fabric is water resistant (very) but super light and breathable. It's not necessarily cheap (unless, like me, you religiously keep track of clearance deals), but it's worth its weight in gold. You will be dry, not sweaty, warm (but not hot), and insanely comfortable, because most of these fabrics stretch nicely.
C. WOOL. This is my latest revelation. The new technical marino wools (Smartwool, Ibex, Icebreaker, etc) are, quite simply, the Best Things Ever. They do not stink, even if you are a large man and wear the same shirt for a week. They do not get out of shape. They maintain insulation in driving rain, and you can wash them in the washing machine. I am a complete convert. i even wear wool camisoles or long sleeve shirts under my scrubs. i SLEEP in wool yoga pants in winter. It's not itchy, it's AMAZING- like silk, but durable. If you make one "expensive" clothing purchase for the outdoors, skip the fancy raincoat and go straight for the wool longjohns. Plus, lots of it look PRETTY, and I've gone on DATES wearing my wool shirts, and have gotten nothing but compliments.

Hi, I'm Alpine, and I'll be your Nurse Today!

2011-08-10T13:22:00.001-07:00

I still gulp when I say that, because it takes that heartbeat to realize that I'm NOT the student, I'm The Nurse. It has MY name on the whiteboard in the patient's room, just above that of the LNA. I'm still like "woaaaah" when I see it, and half the time I want to erase it, and write in the name of my preceptor, because my name on that board MEANS SOMETHING. It means that I'm actually making some of my own decisions now, (not all, I mean, c'mon- I'm still on orientation) and I go into EVERY patient's room with the thought, deep in my head, that this could be the day I accidentally kill someone, or that someone crumps on me and I have no idea what to do.

Not to say that I wouldn't like to get in on a code one of these days, I just don't want it to be MY patient (again, it's not that I want bad things to happen to people. I don't. I just want to be there if/when they do...because there's nothing that gets my brain going faster than trying to save someone's life in a true emergency).

I have also realized that, by trying to take my dad's advice on Looking Professional, I can wind up looking EXTREMELY depressing- all (ALL) my scrubs (still so excited that I get to wear scrub tops) are either navy, ceil blue, light blue-green, or black. The bottoms are navy, grey, or black. My mother calls me her "little black raincloud", and one of the managers has started to as well. Much as I hate to admit it, this might be a time to get a purple or, dare i say it, PRINTED scrub top (one of those nice Moroccan prints, with solid edging...prints of THINGS make me look like I'm playing dress-up, or that I'm a 12 year old in footie pjs).

But I'm hanging in there. I actually snapped at a neuro-surgical resident yesterday though- I was doing a narc-count for the Pyxis- you know, the ones you have to do after you get a dose out- when he asked if I would pull up a patient's vital sign page in the new electronic record. I held up one finger, trying to maintain my count (seriously, there were something close to sixty pills to count, and i get distracted easily) but he simply didn't get it. He said "NOW if you don't mind, I'm Very Busy!". I kinda snapped- whirled around, told him that I was COUNTING, and had forgotten my number, and now he was going to have to wait while I did it All Over Again. I also pointed out that HE could access the ENTIRE medical record on the computer at his elbow.

After I finished counting, he admitted that he'd never taken the time to learn HOW to use the record. He ALWAYS asked the nurses to pull the page up for him. Somehow this bodes ill for his patients, I think.

I wish I were wrong

2011-08-05T17:46:00.000-07:00

This morning I walked into Favorite Patient's room, after a day off. What I saw mildly alarmed me- surely his eyes didn't quite look like THAT on Wednesday...so I pulled open all the shades in his twilit room, letting in the full sun. His eyes were...well...yellow. Ran LFTs. Total bili of 9. Yeah...the mets ARE in his liver, and they're hitting the bile ducts. I don't think his self-prognosis of "6 months to live" is going to work. I think he's got WEEKS.

He was angry with me for the rest of the day, since it wasn't "real" until I documented it. Apparently HE was hoping it was a trick of the light too, when he saw it yesterday, and never mentioned it to the nurse.

He still can't put weight on his left leg, because the spinal mets make it hurt too much. Radiation hasn't helped him, and it's been a week. I give it a 50/50 shot that he gets out of our hospital alive to make it to hospice in Florida...

I'm not an outwardly emotional person, but I had to work hard not to cry when I explained that he really WAS jaundiced.

Then I went home, and explained to Man-Friend (who is a whole NOTHER level of weirdness), and got a hug (did have to explain what Bili means)...but he did make it a bit better. He, at least, doesn't turn pale and get upset when I talk about work.

In Which it is the Small Things That Count

2011-08-03T19:51:00.001-07:00

Just worked two 12.5s, back to back, with the last shift ending half an hour late because our relief nurse was late. Had a fascinating patient who kept desatting every 10 minutes...to the point where i was literally hovering over her bed going "BREATHE...DEEPLY...NOW" and watching her sats drop lower, lower, lower. I bit my thumb and watched.

While I blush and stammer while trying to program a Patrol or Sigma pump, I KNOW how to treat a desatting patient. You give them oxygen. You give them O2, page their intern, and pray they stabilize. The thing is, the patient already has 2 PEs. We just don't know where the big problem lies- we scanned her legs, no clot...scanned her head, no clot. This means that the problem may lie in her pelvis. Her radio-opaque pelvis. That's like...deadly emboli waiting to happen.

And so I hovered...for HOURS. And then shift changed, and I went home.

And I just got a text saying "got stuck helping with a coworker's thesis...can I come over late and snuggle?"

Yes. Because snuggling is never EVER too late.

In Which Life is HARD

2011-08-01T13:09:00.001-07:00

Worked my first two back-to-back 12s on the floor as a New Nurse. Woah. Surgical floors are INTENSE. We had two patients pre-AAA surgery (pressures at 100 systolic? sure sir, i can try to maintain that...no wait...she's back up at 140...give metoprolol...recheck...ok good...no, now she's back up...fuck)

At the same time, we in the Frozen Northlands were involved in a rather large search and rescue. As a result I am exhausted. And it wasn't a good outcome either way, though lord knows we tried...and we didn't miss the subject where we were looking, they were simply elsewhere.

On the bright side, I haven't screwed up yet.

Hot Enough For Ya?

2011-07-24T16:40:00.000-07:00

Yes, even here in the (often) Frozen Northlands, the Heatwave From Hell has taken its toll: I personally don't function particularly well over 85 degrees, nor can I sleep if it's over 80 in my bedroom. BTW, the roommates and I have no AC in our otherwise charming house- the vast majority of the time YOU DON'T NEED IT: for the 5 or so days it's really stinking hot up here, we gently perspire and drink iced tea. The rest of the time we open windows, and deal.

Just to make this more fun, I have caught a summer cold from The Man-Friend. In his defense, he DID warn me he was sick, but being a compassionate human, and trying to be nice, I took care of him, bringing him iced tea, and backrubs, and pretzels, and movies. Naturally, I caught it. On the bright side, he is Very Brave (probably helps that he knows damn well he won't catch it from me :-p ) and is being quite nice about me being all sniffly and gross.

Probably will have to wear a mask at work tomorrow...

Cannon Fodder

2011-07-22T18:43:00.000-07:00

Yesterday, as I was getting a tour of my new floor, my two partners and I were referred to as "cannon-fodder", as well as "fresh meat". My preceptor is on vacation, so today, my very first day on the floor, I was precepted by a nurse who is leaving the floor for another unit in two weeks.

I felt like cannon fodder. I was supposed to be "observing" today, just watching to see how the floor worked. But our patient care tech was "tired" and taking personal calls, and our call bells kept going off, so...patient care it was! It was quite a steep curve- i haven't done med-surg in a year and a half. 3 out of 4 patients had colostomies. the 4th had a chest tube. OMG. Plus, now that I'm an RN, i can do IV push. First time. Today. As far as I know, everyone lived :-p

Woah...we can DO that?!

2011-07-20T19:45:00.000-07:00

Today we were walked through "competencies"- aka, with another nurse watching me the first time, I'll be able to do IV push meds, and...give blood. This is new. Never been able to do it before. SUPER intimidating.

But know what I wont be able to do? IVs. There's an IV team. While I totally understand that, in the interests of having experts do it, and reducing infections and such, I really REALLY wanted to be able to start my own IVs. After a year on my floor though, i can transfer to ER/ED or critical care. THERE you can do IVs. In the meantime, I'll have to ask nicely to practice on my friends.

Man-friend (yes, i have one now) is sick. Sniffling, coughing, not-running-a-fever sick. I am treating him with tea, backrubs, and only occasional sarcasm. If i catch it from him, I'll still have to go to work, but i'll be seriously guilt tripping him :-p

Times they are A'Changin

2011-07-19T14:10:00.000-07:00

Since I last posted, I have gotten not one but TWO jobs- first as a part time school nurse, and now as a Nurse Resident at the North's Best Hospital. I am SO proud. I'll be on a med-surg floor, but it seems pretty high-acuity, and like a great place to learn.

My fellow interns are AMAZING- over half have a non-nursing degree, just like me, and the skill sets are kind of alarmingly high. We have an electrical engineer, a fly-fishing guide, several former financial gurus, etc. The hospital has been nothing but welcoming. In fact, this hospital has kind of a reputation for being super nice to everyone. Doctors smile and hug nurses in the halls, transporters will high-five you, it's a great climate to learn in.

But it's not, naturally, all hearts and roses, and kittens: what with the budgetary crisis all over the Frozen Northlands, it looks like we're going to have a serious budget issue- our jobs are, for the moment, safe (we're cheap, we nurse interns) but...who the heck knows about the future!

I have yet to treat a patient- the first week is all orientation classes, and sim labs, but tomorrow i'm actually shadowing my preceptor on my unit. My two fellow interns on our floor are The Fisher, and M. They're nice, smart, funny, and are going to be a pleasure to work with.

One problem: I haven't had a med/surg patient in...something like a year and a half. Steep learning curves? I has them.

Angles

2010-10-22T10:58:00.000-07:00

I've been training, this past week, for "low angle rescue". While this might seem like an exceedingly easy task (especially if the low angle in question is 'flat'), what it really means is training for rescues on slopes that are a LITTLE too steep to want to walk down them with a rescue litter, but NOT steep enough that everyone is hanging off the ends of ropes. Essentially, it's any situation where, should something go drastically wrong, the people on the ropes would SLIDE, but not CRUNCH. It's fun, and I get to tie knots and use pulleys. Also, here in the Frozen Northland, the mountains have snow. And it's staying cold enough for the snow to STAY. I like this. There were even flurries this morning at home.

I have an interview in NYC for the USPHS on November 2nd. Right now I'm getting my recommendations/references in order from professors.

In Which I Rally

2010-10-06T12:28:00.000-07:00

Sitting around wringing my hands, while extremely satisfying in a "woe is me" sort of way, is not terribly productive. So I have applied to the USPHS Commissioned Corps as a nurse. I mean, I'm QUALIFIED, and if they offer me a good posting/ take me at all, I'll probably take it. By "good posting" i mean either or both of the following: someplace nice and cold, and/or in an ED or somewhere else exciting, like doing epidemic work.

VIVA LA RESISTANCE!!!

Nope

2010-10-06T06:19:00.000-07:00

The hospital where I had an ED application took someone else...didn't even get an interview. Everywhere else is looking for a year of experience. Question: if EVERYONE is requiring a year of experience...WHERE DO YOU GET A YEAR OF EXPERIENCE??? And this isn't for just critical care jobs, I was even looking at med/surg out of desperation. They want experience too.

Search and maybe rescue

2010-10-05T14:45:00.000-07:00

I'm training for a search and rescue team (volunteer) to give me something to do until I'm employed, and also taking the ACLS, and probably PALS courses...hoping it will help. Heres the funny thing about SAR work- if it's a "search" as opposed to a "rescue", there's very little actual FINDING going on much of the time. Picture it this way- you have a missing person, a hiker, known to have been on a trail. Essentially, 20-30 people then walk all the trails nearby, yelling for the subject and blowing whistles, in teams of 3. ONE team will find the person, if they're LUCKY. For the most part, it's a lot of struggling through underbrush with blaze orange on. Not that it's not FUN, it's just not what I'm used to. I'm used to RESCUES more than SEARCHES. With a RESCUE, you KNOW where the victim/patient/subject IS, but they can't get out of the woods or off the mountain on their own. More medical stuff, lots more logistical stuff, and a lot more hands on.

On the other hand, you can't rescue them until you find them...

Alpine, BSN, RN

2010-09-30T09:18:00.000-07:00

Took my boards yesterday. Checked, out of pure curiosity, on the state board website for my name. Found it. I passed. 40 minutes to take the NCLEX, minimum number of questions. HUGE SENSE OF RELIEF!!!

Texas

2010-09-24T10:33:00.001-07:00

Apparently my mom has a contact who works as a bigshot for a big conglomerate of hospitals in Houston. I'm thinking about it, even though the air is supposed to be TERRIBLE there, and it's really hot. At least maybe i could be EMPLOYED.

The Job Search Continues

2010-09-24T10:18:00.000-07:00

Ok. Two years ago they told us that when we graduated we would be able to work in a field that fascinated us. They told us that the days of "you must work in XYZ and be grateful for it" were over. Well...THEY'RE BACK. I've been told by THREE human resources people TODAY (Beth Israel Deaconess, Concord Hospital, Mass General) that "you should get experience wherever you can with this job market. How about working in a nursing home?"

This is a terrible idea on the industry's part. A LOT of us got into nursing because we thought, even though we HATED certain clinicals, it didnt matter because we wouldn't WORK in those specialties. I, for example get insanely bored in areas that don't move quickly. If i worked in a nursing home I'd probably go crazy within a week.

I wonder how everyone is going to feel in a year when many new nurses never work in nursing because they couldn't get jobs...then they'll be shrieking about a shortage all over again.

Sorry About Not Posting

2010-09-22T11:34:00.000-07:00

The fact is, I've done virtually NOTHING nursing related in the last month and a half. I JUST got my Authorization To Test today (yay!!!) the problem: my test date is next wednesday...ON MY BIRTHDAY. Curses. On the other hand, afterwords I'll have a *REALLY* good excuse to party. Assuming I, you know, PASS IT.

Still job hunting. The market isn't great, and nobody's even called me back yet. Yes, this is apparently what I went to school and worked my butt off for TWO AND A HALF YEARS FOR- to be unemployed. If anyone knows any hospitals in the northeast or northwest hiring? DO let me know.

Anticlimax

2010-08-02T16:01:00.000-07:00

Well, since we don't actually HAVE a real graduation ceremony...I'm just...DONE...except that I'm not QUITE done (yet again) because we have this NCLEX prep course weds, thurs, and friday.

This feels decidedly odd. I don't have any more classes before my boards. Verycatholic University actually considers me ready to take care of people.

Woah. That's a headrush.

One More Day

2010-07-31T17:00:00.001-07:00

I feel like singing that song from "Les Miz"...but can't until tomorrow. I have taken my last exam, I have given my last presentation (rocked them both), and all I have left is my Last Day of Clinical, complete with my Last Performance Eval of School. I HATE evals. The profs always make it as scarily awkward as possible so that you always feel like you've failed until the last minute, and the feedback they give they try to deliver BEFORE letting you see your grade. Therefore, the "constructive criticism" aspect overshadows the "but you did great" part, so you're hearing them list and detail your failures for MINUTES before they say "oh and you got an A". It's like- couldn't you have LEAD with that???!! "You did great! You got an A! However, here are some things to work on as you move forward in nursing..." would be a lot less nausea-inducing.

Sometimes I think they just like to watch us squirm. :-p

I'm really ready to be done- picking up my CPR instructor card this week, getting ready for the move, looking for jobs.

Next stop: the mountains. But I really want to be working someplace I love before Christmas, if at all possible, ideally in an Emergency department. :-D

One more dawn, one more day, ONE DAY MOOOOOOOOORE!

What I'm Going To Do On My Summer "Vacation"

2010-07-22T21:16:00.000-07:00

As of this afternoon, I've accepted a three-week position in the High Huts up in the White Mountains...a real gem of an opportunity to do some SERIOUS hiking for three weeks while studying for my NCLEX exam. Also, I'll be the most medically qualified (but least experienced) croo member on my team.

The oddest part? My hutmaster (think "supervisor" or "lord and master") will be none other than my BROTHER. I'm actually looking forward to this. Though I may call him a bit of an idiot, or (justifiably) think that he's a bit off sometimes, I do know that he's one of the finest people working in the mountains anywhere in the world, and I'm actually enjoying working with him...though we'll see how that lasts if he starts saying unkind things about my cooking...

I took my last test of nursing school today, and really enjoyed the questions on disaster triage and communicable diseases. The rest was less fun, but triage is like a puzzle- which patient first? Red, Green, Yellow or Black? It's really quite fun to do on paper (disaster triage sounds like much less fun when you're actually saying that you cannot do CPR on someone due to lack of resources).

So all I have left of school now is three clinical days, and one very immense presentation on community health interventions in a Philadelphia Suburb.

Patient Teaching

2010-07-18T18:39:00.000-07:00

The problem with these last few weeks of class is that I don't get much to blog about- it's just sitting in a room. I WILL have something by tomorrow though- run in with a doc, my preceptor was MARVELOUS!

Dear GOD The HEAT!!!

2010-07-10T16:32:00.000-07:00

Oh my lordie, it's STILL hot. Briefly today, I entertained high hopes of there being a real break in the weather, down to something normal, as it was pouring BUCKETS of rain. While this was a significant improvement in the fire weather warning, it's not been especially successful otherwise. The green is nice though, a big step up from the brown.

I was in NYC for two days, doing an interview with the Feds (USPHS) which was awesome and fun, and something I'm keeping in mind.

It's SO TOTALLY trauma weather- people go a little nuts in this heat...plus the cicadas are now out, and i've heard stories about the sound of cicadas driving people over the edge.

Looking forward to getting REALLY into job searching- i'm actually getting excited about this, unexpectedly!

The Evil Plan

2010-07-05T17:43:00.000-07:00

So...I'm a month from graduation...still no job offers, but then, we're in the middle of a TERRIBLE job market. Therefore, my parents (well, my dad, since he's some kind of evil reclusive genius) have come up with A Plan. This plan involves several aspects of my life: I will live at home with them-( yay! i get to cook! grr! i have no social life!), and spend 8 hours 5 days a week making contacts, and doing a real job search that will also gain me contacts within my profession. This is how dad got his job, and i KNOW it works. At the same time, I will be getting up at 0530 every morning, and exercising for 2-3 hours a day, 5-6 days a week, both going up the Mountain (its quite a small mountain) and doing pilates, and so forth, so as to be "as marketable as possible). With grudging acceptance, I have realized that he's probably right- though I'm not huge, i'm quite certain that if i were in STELLAR shape I would get away with more. :-p Dad calls it "stacking the deck in your favor".

One of the key factors in this plan is that Dad has consistently stressed that I should NOT just take "anyone who will hire me", because that will likely make me miserable. Instead, I should work all the contacts I can get, and hold out for a job I will LOVE, and be psyched about every single day. He has a point- why would I put in all this work and money to be miserable?

Therefore, as this plan goes forward, I will be blogging it. Think of it as Crash Course In Nursing, Part II- The Search for the Perfect Job...coming in Mid August to a monitor near you!

Nursing Skills- I have some of them

2010-06-24T12:40:00.000-07:00

In nursing school one is expected to learn nursing skills. This should be self-evident. By graduation, there is an entire catalog of skills you are expected to have mastered. Now, nearing graduation, I feel compelled to make something of a list, both of those skills I actually HAVE, and ones I only have in THEORY. The reason for this dichotomy is that, shockingly, there is never a guarantee that you will be able to practice a skill in nursing school on a real patient while still in school. You have to be assigned a patient who NEEDS you to perform a given skill, and that's never a given. It does, however, keep you on your toes, as you never know if THIS will be the day you need to perform a skill you learned a year ago and performed once, on a dummy, in a lab. Also, most of these skills tend to be "sterile field" skills, just to make you even more sure you'll kill someone.

1. Catheters- The Theory- a nurse should be able to catheterize just about anything
In Reality- I am comfortable placing straight-caths for urine, in women. I have NEVER placed ANY catheter in a man, and I've never actually done a Foley. This is because the only patients available who NEEDED Foleys were men, chronic foley-users, who had some sort of obstruction or problem with said Foley, and no-one wanted me mucking around with it. Therefore, I live in fear.

2. Suctioning- The Theory- A nurse should be able to do oropharyngeal, nasopharyngeal, and, I assume, MAGIC suctioning with any kind of tube set up, through trachs, ET tubes, adjunct airways, etc.
In Reality- I can do non-emergent Yankauer suctioning and trach suctioning with one of those in-line setups relatively well, and have done it on many occasions. I have yet to do emergency-Yankauering outside the ambulance, and have NO idea if my technique is ok. I have never suctioned an ET tube, and still am convinced I'm going to cause a lung to collapse.

3. Wound Care- The Theory- Nurses, armed only with a set of vague orders "cover with dry sterile dressing (DSD)" should be able to come up with a spiffy dressing setup that prevents infection, decreases healing time, and makes the patient look like a rockstar. The nurse should also apparently be familiar with all sorts of epiffy expensive gear.
In Reality- I can actually do a dry sterile dressing job pretty well, if the wound is fresh (like a recently evacuated pilionidal (sp?) cyst, or on a patient whose wound has been previously dressed by someone competent, so I can just re-create their work of staggering genius. I have NO idea, however, how to choose which kind of dressing, aside from the general theory of "if it's wet, dry it. If it's dry, wet it", and "DONT EVER LET IT LEAK EVERYWHERE". Given the option, i will cover everything with 4-by-4s and tape. Lots of tape.

4. Assessment- The Theory- Nurses should be able to complete a physical assessment on just about anyone, note minor as well as major changes, bring all this to the attention of the proper physician, and catch tiny warning signs before the patient even knows they're sick. They should always be thinking 4 steps ahead to the implications behind each test result, and have plans in place for contingencies.
In Reality- I can do a pretty kickass physical, if I do say so myself. I'm good at details, and I've gotten REALLY good about asking history questions for clues to possible Very Bad Things. I cannot, however, think more than 1 step ahead, and still regard Real Nurses with superstitious awe.

So that's where I am!

Home Health Firsts

2010-06-22T16:17:00.000-07:00

Home health, while NOT my favorite part of nursing, nor something in which I would like to make a career HAS given me a few "firsts". On Friday, I did my VERY first non-supervised wound dressing on something other than a fresh suture-job. On THREE pressure wounds on the same guy, who ALSO had a colostomy. And lived in an exceptionally bad neighborhood. In a house that was LITERALLY falling apart (wet carpet you were sinking into, as if the floor was giving out underfoot, ceilings and walls pulling apart, etc.)

I was proud of myself for doing it, but i was TERRIFIED the whole time. My partner and I got assigned to a nurse who works in BAAAAAAD parts of the city, and we, taking a few of her patients by ourselves, were therefore right in the thick of it. I'm a country girl (not in the southern twang sense, in the "oh look, bears and moose" sense) from an area where People Do Not Get Shot, except in the occasional hunting accident, or by shooting themselves. Nor are stabbings common. Carjackings are virtually unheard of. Therefore, even though statistically the likelihood of getting attacked personally is low, its still scary as hell. But I made it, my last day is tomorrow, and I'm following Hospice around, so its not like I can get into any trouble.

My Mistakes: Unfortunately, the VERY first day we had patients, our professor chose US as her group to supervise. I almost forgot to wash my hands (in FRONT of her, I'd purelled the heck out of them about 5 minutes earlier), and I forgot to make the patient sign for the visit, necessitating our driving around the block and coming back. I was SO embarrassed, and not a little annoyed, because I had given my PARTNER all HER cues so SHE wouldn't forget, then she COMPLETELY FAILED TO HELP ME AT ALL. She apologised afterwards, but said "i was just so relieved to be done with MY patient!" Grrr...i sort of think she just wanted to look better than me...which is a terrible thing to say, but there you have it. I didn't know her before this clinical, we were paired randomly. Grmph.

Hiking Safety

2010-06-13T15:27:00.000-07:00

One of my very favorite non-nursing activities is hiking, and I'm training to do Wilderness Search and Rescue. I guess the love of the outdoors runs in the family, since my "little" brother actually has a JOB in the outdoors. We've been discussing people getting injured and putting themselves in danger for a while, and I thought, since it's summer, I'd just post some general tips for not making yourself into a statistic in the great outdoors.

1. Pack an Emergency Bivy. Emergency blankets suck. I've used them on car accident victims, and they blow off in even a light breeze. Invest in a "bivy sack" for emergencies. They're under 20 bucks, and TOTALLY worth it. It's basically a metallic sleeping bag-style sack that's orange with reflective stripes. If you were to be caught out or hurt you could climb in WITH all your gear, and survive the night, or wait for rescue. REALLY WORTH IT.

2. LOOK AT THE MAP BEFORE YOU GO. The main reason people call for rescue in MY favorite mountains (the Whites) is that they overestimate their abilities, and get "exhausted" before they make it back to the trailhead. If you've never done more than a mile or two, DON'T plan on going THREE miles to the pretty waterfall without remembering that it's ALSO three miles BACK. If you DO call for rescue, (and can GET a cell signal) it could be some hours before people can get to you. Rescuers are volunteer, and a crew may have to get out of work, pack their gear, and hike in from quite a distance, depending on where you are. Therefore, MAKE SURE YOU CAN SPEND A NIGHT OUTSIDE. If you're not critically hurt (fell off a rock wall climbing, stomped on by a moose, fell in a stream and broke your leg, etc) you should be prepared to spend a solid night outside before you could be rescued. If simple exhaustion is your problem, think about this- IF you could wait overnight, would you THEN have enough energy to hike out? If this is the case, DO IT.

3. Backpacker.com has a good list of hiking essentials, but my top gear list would be the following:
NON COTTON clothing (cotton does not insulate when wet, and is heavy)- shorts and teeshirt
-raincoat and pants (dont need to be expensive, but need to keep water out)
-fleece jacket of some sort (the cheap ones work fine)
-iodine tablets (in case you have to be out there a while, to purify water)
-an EMERGENCY BIVY
-headlamp (seriously, dozens of people every year need rescue because "it got dark out"...BRING A LIGHT!)
-hat and gloves
-plenty of water

that's the minimum. hike in peace, and enjoy the outdoors!!!

For New Nursing Students (Some Advice)

2010-06-07T12:40:00.000-07:00

So I've only got 2 more months (actually, slightly LESS at this point) of nursing school. I figure that this is an excellent opportunity to tell all you (theoretical) incoming nursing students a few things I've picked up in the past 2 years which I hope will help you.

1. PAY ATTENTION IN ANATOMY & PHYSIOLOGY!!! - I know you might hate it, I know it's occasionally boring, but dear lord, SO much of what we learn in nursing classes is predicated on the fact that you KNOW your A&P. For example: you have a patient with a heart condition like a-fib, and are giving a medication for it. You need to know your A&P to know HOW the heart works, WHICH parts are the atria, what a-fib IS, and why it is that a particular medication's action HELPS with this. If you snooze through A&P, it's going to SHOW when you take nursing classes.

2. PAY ATTENTION IN CLASS- I recommend NOT using your powerpoints on the computer. Either print them out and take notes on paper, THEN transcribe to computer, or just take written notes (which is what I do). This way you will have NO excuse for getting bored and going on facebook, looking at lolcats, or IMing your friends. Seriously, you're already SITTING THERE!!! Think of it as built-in study time, and pay attention! Worst case, it means you're bored, but have SEEN all the information AT LEAST ONCE!!! I cannot overstate how important this is. The kids who were on facebook the most in my class had the lowest GPAs. Just saying.

3. You are NOT alone- when you start out in nursing school, you have all these horrible visions in your head of killing your patients, of patients with their intestines coming out their surgical site, etc. Even if your patient DOES code, or dehisce (have their wound pop open), THERE ARE ACTUAL PROFESSIONALS AROUND! And fellow students! You can ALWAYS call for help.

4. You and your classmates are a team- deal with it. You're all in this together. And in clinical, you and your clinical-mates HAVE to work together. I had this one HUGE Patient, very complex, lots of work. SIX of my classmates teamed up with me to bathe, turn, change, and fluff his pillows. We were done in 10 minutes FLAT. Then we ganged up on the other patients. It made a VERY tough workload a piece of cake. DO NOT underestimate your classmates. Some of them might have picked up random skills that will really help you. They are also invaluable when you forget your stethoscope or drug guide.

5. There is ALWAYS time to pee- unless you are actually DOING COMPRESSIONS OR BAGGING A PATIENT, there is time to pee. Don't get into the habit of denying yourself basic physical needs like a quick bathroom break, or ducking behind the nurses station or into the breakroom for a bite of a powerbar or a drink of water. You wouldn't deny these things to a patient without a damn good reason, don't deny them to yourself. Masochism is SO counterproductive.

6. You will get through it. Really. Then you'll be panicking about job searching instead. :-p

Intro to Summer

2010-06-06T15:03:00.000-07:00

When you're a cold-weather person like me, hot weather is The Devil- until this year I have rarely slept in weather where it stays above 70 at night. This just...doesn't...HAPPEN at home very often- even when we lived in the Big Scary Desert for a year the temperature would PLUMMET at night to a nice comfy 55 or so.

With the weather this hot, it's time to make sure everyone remembers that Summer Is TRAUMA season!!! Everyone is outside, even if just out on their porches, and the more people out and about, hot and cranky, the more assaults there are, on top of all the usual barbecue accidents, near-drownings in pools, dehydration/heat exhaustion/heat STROKE incidents, and just plain stupid decisions.

One of the big ones in this weather to remember is: If you know any elderly people, CHECK ON THEM FREQUENTLY. They may not sense temperature appropriately, and may forget to keep themselves hydrated and properly electrolyted...(is that a word? I'm going to say it is.) which, given that older people are frequently on electrolyte-sensitive heart medications, is a PROBLEM. Therefore, CHECK ON YOUR ELDERLY RELATIVES AND NEIGHBORS!!!

Also, make sure to REAPPLY your sunblock. My parents both have horror stories from the early '60s, when it was considered "not vacation yet" until they had sunburn-induced fevers. Let's just NOT repeat their mistakes, m'kay?

First day of home health tomorrow- orientation at the place (Way Catholic Home Care)

The Climate

2010-06-05T18:35:00.001-07:00

This week has settled it. No warm climates for me, unless they come with a GUARANTEED constant sea breeze. Good lord, it's been HORRIBLY hot for the whole week here, and I feel like I'm melting. Really really melting.

As a result, and the temp being almost 90 all week (if not above), my brain isn't working. Coherent posting will resume when the weather breaks.

Home Health Intro

2010-06-03T10:58:00.000-07:00

Okay, yesterday and today were my orientation for my VERY LAST nursing classes (of my BSN). Here's what I have learned so far about home health:

1. We may be going into Bad Neighborhoods, but, in the words of my professor, "I don't care how much you cry, or if your parents call the dean. You are GOING to your assigned locations, or you don't graduate. So deal."

2. Wound / ostomy care is SO not going to be my specialty. It's not very fast paced, and, frankly, it smells bad.

3. I am most definitely going to get lost trying to get to these people's houses

4. It is UNLIKELY (but in no way impossible) that people will have guns sitting out on tables. If they do, ask them politely to put them away. This has only happened once so far to my professor.

5. This is going to be a long three weeks if this heat doesn't break...its REALLY FREAKING HOT here.

Falls

2010-05-24T05:43:00.000-07:00

So up here in the Not Currently Frozen Northlands (it's supposed to maybe hit 90 today...ew) trauma weather is in FULL swing. I do not have a problem with this, as trauma is something we can FIX (sometimes). Yesterday I was dressed nicely, for me, in a cute scoopneck and jeans with a great necklace coming home from doing chores with my mother when she spotted M, one of our EMTs going past with his lights on, back to the station, 200 yards away. I spun the car around, and hopped into the rig with M, and NO idea of what we were actually responding to...a FALL FROM A HORSE!!!

The woman's only complaints were pain at the costo-vertebral angle and both wrists. She hadn't really moved much, but we could clear her C-spine, and only short-board her. M and I were really only worried about her kidney...only time will tell!

In Which I Clean Up My Act

2010-05-13T09:32:00.001-07:00

During the semester, my apartment (flat, for any Brits) often appears as if a small tactical nuke has detonated in the center. It's never DIRTY, but stacks of papers pile up, especially patient records that I keep so I can shred them properly. So now, with my parents coming into town tomorrow for "graduation" (I dont ACTUALLY graduate until August 2) I find myself having to dig through 3 months of accumulated debris...some of it hilarious.

Case 1. Patient notes I took on a post-partum patient before I actually knew what half of the abbreviated words MEANT. Therefore, there are statements like "she was induced for postdate and she's a TPAL 1122" with notations like "post what?" and "what does TPAL mean? How many kids is that?" Now i know that "postdate" means the docs started her labor because she was after her due date and hadn't given birth. TPAL is a way of noting Term (t) Preterm (p) Abortions (misscarriages or therapeutic) (a) and Live children (L). Sometimes, as I learned, the numbers DONT add up, then you have to go in and ask the patient to repeat HOW many children she has, how many times she's been pregnant, et cet. Very odd.

So now, as I move on to Home Health (shudder) and Health Promotion (postpartum unit, as it turns out) I realise just how much I learned in the past few months. Woah.

In Which I Have Seething Rage

2010-05-11T21:07:00.000-07:00

Dear VeryCatholic University,

I understand that our health promotion and home health class begins June 2nd, and that we have VACATION until then. Therefore, to email me TODAY and tell me i need to research and write six pamphlets before MAY 24th to then EDIT AND FINISH THEM before June 2nd, and PRINT 50 COPIES OF EACH AT MY OWN EXPENSE all on my vacation

is not ok.

No, in fact it is WORSE than not ok, it is unethical. The university isn't actually OPEN, and we need to have our site approved, which might take another day or two. This means we actually have more like a week and a half to do OUR ONLY PROJECT for a semester that DOESNT START YET and for which I will not be GRADED until August 2nd.

Furthermore, I have WORK lined up for the next few weeks, AND i'm TRYING to...um...GET A JOB! Plus, my financial aid still hasn't come through. Again.

So yeah, VeryCatholic University. Just TRY calling me again for a "class gift". I think I'll just go cry now.

Enjoy Your Stay

2010-04-29T09:54:00.000-07:00

Over my past few shifts in Mid-Size Non-Trauma Center, I have noticed a few common questions and requests from patients that I would like to address:

1. "Can I have something to eat/drink?" - This is a perfectly reasonable question if you've been in the ED for a few hours, and haven't been allowed anything pending test results or some such. It's going to SERIOUSLY PISS ME OFF if it's the first thing out of your mouth when you walk into the ED. Here's why: if you've WALKED into the ED, you got yourself to the hospital. On your way, you passed LOTS of places to get a drink of water/juice, or a snack. If you're sick enough to be here, your snack should really NOT be your primary concern.

On the other hand, i make plenty of exceptions for: people brought in by ambulance, especially for fainting- maybe hunger or dehydration MADE them faint, so I'll do my best; Pregnant women- snacking helps with morning sickness, i get it; The Elderly- sometimes they have been brought in without much input on their part, and havent eaten in AGES.

2. "When will the doctor be here?"- Another question that sounds perfectly reasonable, except when whined repeatedly by someone who came in for narcotics over FOUR HOURS. The doctor (nominated for sainthood) had checked on him EVERY TWENTY MINUTES, but he still felt it was unreasonable that the doctor "wouldn't really help"- the doc exhausted like, 7 DIFFERENT pain management techniques INCLUDING a lidocaine patch, toradol (allergic, but not to codeine with tylenol, or to vicodin), pain management referral, etc. I was sorry that he was in pain, but...we cannot just keep giving him narcotics for his complaint of "the last doctor pushed REALLY HARD on my abdomen and it hurts". Seriously, try a heat pack. The doctor even went in and explained "i think you have a problem with narcotic addiction, and I would like to refer you to somewhere for help". The patient spat at him and left.

3."Can't you just look it up?"- with regard to medications the patient is taking. The emergency departments of the world do not, as a rule, have access to magic 8 balls, or necromancy to divine patient records from world war 2, other states, other hospital systems, or other planets. While this DOES put the burden on patients to know what they've taken, what they're allergic to, and if they still have an appendix, until we get a centralized national system patients are just going to have to try to help us out. Again, free passes are given for people too sick to remember anything, 90 year olds taking 40 meds with memory problems, or anyone unconscious.

Death 2, Little D, 0

2010-04-28T21:05:00.001-07:00

Today was another fine day in Mid-Size Non Trauma Center's ED. Coffee in had, I stepped bravely into the department following a TERRIBLE night, waking up every hour with a recurring nightmare that I had overslept and gotten thrown out of clinical for tardiness. Auspicious start to the day, I must add.

Upon arrival my coffee and I were shoved into the doctor's dictation closet, because JHACO/TJC were expected to do an inspection of Stroke Center Procedures, and Coffee In Public Areas is not permitted when inspectors are present. Seriously, I think that medical and nursing professionals without ready access to coffee are a FAR bigger danger to their patients than coffee cups on the nurses stations. I mean, we're talking about alertness here, people!

Death's first victory was an elderly woman, past 80, who came in with mild stomach pain and more serious back and flank pain, presenting with an inability to get up off the couch. COPD? No. CHF? No. Diabetes? WRONG AGAIN!!!

AAA. Yes, an abdominal aortic aneurysm (never seen one before!) of 7cm, already popped. According to the (VERY excited) doc, she was currently stable because a clot had formed over the popped bit, rendering her sort-of hemodynamically stable-ish. No problem. We know JUST what to do with her- a quick-as-HELL trip up to the OR! Or...not. See, she was a Jehovah's Witness, and they cannot accept blood products, which obviously sort of limits the operating rooms that are willing to take a shot at an operation that ALREADY has a greater than 50% death rate. Half an hour of frantic phone calls later and one of the Large Impressive City Hospitals agreed to try a "bloodless" surgery on her. We managed to keep her alive out the door, and she actually survived the surgery, much to our surprise. Unfortunately, she suffocated 10 minutes later from a hemoglobin of .8- she literally had NO blood cells left, and was circulating saline. Even though I don't necessarily understand her beliefs, I have to admire how she and her family stuck to their beliefs in the face of death.

Death number 2 was much less exotic- a code that really had died at home, with paramedics working him on scene for HALF AN HOUR without ever getting a rhythm back. His family refused to let the paramedics pronounce him, and insisted on a hospital transport. I'm not really sure how that works, legally, but they were still coding him when he arrived, and were getting a VERY nice waveform on the monitor, complete with femoral pulses with compressions. On the other hand, his skin was mottled and grey-green. While part of me grieves for the family, and can understand that "letting" the paramedics call time of death would make it all "real", the rest of me wonders how they could have thought that he was anything other than dead. Live people don't look like this man did. I've seen living people, dead people, and dying people- even the woman with NO BLOOD LEFT, for all her pallor, still was unmistakably alive. This man was, just as unmistakably, quite dead.

I just hope that someday soon I will actually see a SUCCESSFUL code. Death, next time I'M cheating.

That's Just Unsanitary!

2010-04-25T12:44:00.000-07:00

Friday was another 12 hour shift in Midsize Non-Trauma Center's ED, and while there were only two people I would actually be able to label "True Emergencies" all shift, there were some VERY interesting cases in other ways, which was impressive given that when I walked in at 645, there were NO PATIENTS IN THE DEPARTMENT. I curled up on one of the swivelly chairs and DIDNT SAY ANYTHING for fear of jinxing it, but as predicted, the "quiet" (oh no! i typed it!) only lasted about half an hour.

The first truly bizarre/awful case of the day was a 500 some-odd pound man, brought in for, ironically "failure to thrive". This MUST only be a social designation, since in neonates "failure to thrive" means they're LITTLE...not this particular gentleman's problem. His problem was bilateral cellulitis of the lower legs. REALLY GROSS cellulitis of the lower legs. They were wrapped in biohazard bags by the medics, who promptly ran outside and started shaking their clothes off on arrival...which is NEVER a good sign. Apparently this gentleman had ROACHES LIVING IN HIS SKIN FOLDS.

The truly odd thing about this large man was that he was COMPLETELY LUCID, and convinced that we were "making a big deal out of nothing!". He was caked in dirt, apparently from "pulling himself across the floor" which he didn't seem to think was a problem in and of itself, and was FURIOUS that he'd been taken out of his house. It took us (me, my partner and three Real Nurses) almost an hour to get him all cleaned up. He was really quite polite, and seemed lucid, albiet with a HUGE blind spot about how bad his house and hygeine really were. He was admitted to med-surg, for placement in assisted living, and may lose both his legs to gangrene.

I learned that the smell of gangrene actually does not upset me nearly as much as I had originally thought. Good to know! On the other hand, I have also learned that I will be itching for the rest of any day when a patient has bugs.

Its tough to know how to feel about a patient like this- on one hand, you KNOW they cannot take care of themselves, because...well...he was dragging himself across the FLOOR in a filthy house! But on the other hand, now we're taking away all his perceived independence. Tough call.

Finals

2010-04-22T14:51:00.000-07:00

In senior year at Very Catholic University, finals are EARLY. Today i had both my Ob-Gyn test (the FINAL for OB/Peds is TUESDAY) and my FINAL in Leadership/Management. This is because MOST people have their leadership clinicals next week...unlike me, and I'll be FINISHED for the WHOLE SEMESTER on the 30th of April. Yeah. Next week. Then all I have is Home Health / Community Health this summer.

So I'll be (NCLEX willing) A NURSE at the end of July. Yes, JULY. THREE MONTHS AWAY.

I'm sort of scared now.

Cootie Shot

2010-04-21T17:33:00.000-07:00

So I've now spent 3 fridays at Mid-Size Suburban Hospital's ER/ED, and there are two patients, very much alike, who have me wondering one simple thing:

Is it REALLY that hard to avoid getting Syphilis?

I mean, although it's an EXCELLENT learning opportunity for ME to give large IM injections of painful antibiotics into the butts of young men, it CANT be a good sign that this many of them are presenting with "testicular pain", burning on urination, or REALLY REALLY OBVIOUS SYPHILIS CHANCRES. One of these young men (23 or so) BROUGHT HIS MOTHER WITH HIM. That must have been one interesting conversation...and makes me really wonder- if he's that big a mamma's boy, why didn't she teach him how to avoid these things?

The OTHER unfortunate young man had his syph shots and promptly went into anyphylactic shock. The intern LOUDLY says, at the nurses station, "well that's ONE way to teach someone about the dangers of STDS!"

So really, people, WEAR A CONDOM. Because as much as I appreciate the practice, your butt is going to be sore for a week.

The Month From Hell

2010-04-20T16:26:00.000-07:00

More accurately, the week from hell. First, for most of this month my blog keeps trying to send me to another website when i try to view it, and i'm HOPING that it has been fixed so i can start posting again.

Just THIS week, i have been through the following: During my Leadership Clinical in the ER i had to pick up a miscarried placenta from the FLOOR (it done fell out) while comforting the poor woman it fell out of, find a jar with formaldehyde to put it in, then got yelled at by the woman's nurse who WENT MISSING FOR AN HOUR while this was going on, but was upset that the charge nurse had had ME take care of it, since it was "her patient". Sorry, wasn't going to leave the placenta on the bathroom floor. Seemed unsanitary.

Then, THREE WEEKS after my observation day in the NICU, a nurse said i told her i did something REDICULOUSLY stupid, which i didn't do. Like, never get my nursing license and possibly get sued stupid. And i didn't do it. So yeah...i'm still panicked that i'll get thrown under the bus for this, even though it was just a miscommunication where the nurse thought i said i did it, and i was ASKING if one would do it, and i hope my instructor irons this all out. Of course, at THIS point, i dont REMEMBER what exactly i said, because IT WAS THREE WEEKS AGO.

THEN, now that i'm completely emotionally a DISASTER AREA, i decided to get my hair trimmed, so i could pamper myself a bit, and feel better. Besides, my hair hasn't been cut in 4 months.

She ruined it. It was a simple, slightly layered shoulder-blade-length cut, and now she cut MOST of the hair short, but left a FEW long pieces...basically the OPPOSITE of what i asked for. My hair has a SHELF. I'm now in tears AGAIN, and have to wait to drive home to my parents to have my MOM'S lady try to fix it, which will probably involve trying to make it look like Ginnifer Goodwin's in "He's Just Not That Into You", because it's too short to do anything else.

I think i need a hug...and for this to be fixed. I'm afraid they wont let me be a nurse...AND i have bad hair!

OB-STOP BEING DISCOURAGING, DAMMIT!!!

2010-03-26T12:16:00.000-07:00

Yes, I'm pretty psyched to be doing my OB rotation and Major Urban Medical Center...but boy are they ever INVASIVE with their patients! I did TWO straight-caths on one woman in labor (to be honest, the pt. asked me to, since she couldn't feel her bladder what with the epidural turned up so high)...and every time I have spoken to about half the nurses about natural childbirth, they laugh and tell me "oh sweetie, you don't know what you're talking about. The pain is like NOTHING you can imagine! Don't get your hopes up when you have kids someday! You WILL get the epidural!"

This is why patients come in panicked, at 2 centimeters, with the baby floating high, begging for an epidural "before it gets bad". Because we get told we CANNOT POSSIBLY deal with a natural childbirth.

My mom did TWO- myself and my brother. She says yes, it DOES hurt like hell, but being tied down would be WORSE, and anyway, it went faster since she could walk around.

Seriously, what's with tying all the women to the bed with the heart monitors? They're healthy, they're young, WHY DO THEY HAVE TO LIE THERE? Is the world going to END because we cannot see everything for 10 minutes? Is it?

Although I'm gaining a LOT of experience fast, this place makes me NEVER want to have kids- it seems a lot like they torture women for the hell of it.

Time Flies When You're Up To Your Eyeballs in Work!

2010-03-11T19:28:00.000-08:00

So spring break FLEW by! I have an interview for the Job Of My Dreams next thursday, it's an ER internship up in Vermont (i really really really want it).

I also had my first day at Really Big Philadelphia Urban Medical Center for OB. It was pretty cool, but I have a strong (STRONG) feeling I'm going to spend a lot of time biting my tongue about unnecessary interventions into uncomplicated labor.

On the bright side, we apparently get lots of really "interesting" cases, and when I said that ED was my dream job, she said "well by all means, if someone codes, or we get a hemorrhage, jump right in and work them!". This is the very first time an instructor has given me blanket permission to assist in an emergency beyond "push the help button". I mean, a hemorrhage, as far as we students are concerned, mostly means "push the help button with one hand, massage the uterus with the other"...but its still a step up.

We did a newborn exam on a baby in the nursery...rather a suprise when we unwrapped him- POLYDACTYLY!!! (SURPRISE! EXTRA FINGERS!) They looked like tiny little cat-toys dangling by skin tags off the distal side of each pinky. VERY cool. This bodes well for the rest of the semester.

OH! and yesterday I found out that i got an EMERGENCY DEPARTMENT PLACEMENT FOR MY LEADERSHIP CLINICAL!!!! WHEEE!!! It's not a trauma center (none were available for placements), but i got one of only 3 spots for the whole year. GO ME!!! The downside: its 12 hours every friday until may. Yeah. My workload just went up again.

Something Every Man Fears

2010-02-25T17:55:00.001-08:00

Today I pulled at the Campus EMT squad, for lack of a car. I slept there last night, so as not to miss my 0830 midterm this morning due to inability to get there on time...and just stayed, because we're kind of having another snowstorm, and why not.

Our first call of the day was both wince-inducing and possibly a real emergency. It was called in to us from the student health center as an "abdominal pain" which turned out, when we got upstairs and got accosted by the questionably skilled nurses, to be TESTICULAR pain, possibly a torsion. A testicular torsion is A Bad Thing. In fact, it's a surgical emergency that has to be corrected pretty damn quick, or you lose the testicle involved to ischemia. The poor kid was really scared, and I don't blame him. I DO blame the nurse, who kept us outside the room for a minute, telling us "dont ask him any questions or examine him, just take him to the hospital. He's embarrassed".

No. If you want a TAXI, you call a TAXI. If you call an AMBULANCE, you get asked questions, vital signs taken, and assessed for any immediate problems. Can you imagine if an ambulance pulled up at the ER, and just unloaded the patient to the ER nurse saying "well, we dont actually KNOW what happened, because we didn't want to embarrass the patient. No, we didn't look at it either, cause the nurses at school said not to!"

The patient himself was quite cooperative, although he did refuse a physical genital exam- two women on the crew, i'm not sure I blame him, it's only a 5 minute hospital transport. i DID manage to elicit a possibly important history though- when he was a baby he had an inguinal hernia repair on the OTHER side...maybe this is just a hernia, not a torsion! I do feel sorry that he was embarrassed, our driver S is a guy, and he was practically wincing the whole way to the hospital, in sympathy. Still, better a little embarrassment NOW than a bigger problem later.

So there you have it. EMTs DO try to assess their patients. If you want to just get a ride, call a friend or a taxi. We're better than that. We'll try to help save your life if you give us a chance.

When it rains...

2010-02-25T17:52:00.000-08:00

Yesterday afternoon my car decided to stop working. I was planning on being home by now, up in the Frozen Northlands, but I decided to make a food run for road supplies, and my car stopped shifting gears. I drove my poor little Civic straight to the dealership down here, and they diagnosed my brave little car with having her wires chewed through by mice. It's going to be 500 dollars to fix. Dammit. I really don't have the money to spend on it, but no choice. I need my car to work, so...there you have it. Really hoping I can pull some calls as soon as i get home, to earn some money to make up for it. Grr...

Done With Pediatrics

2010-02-24T11:22:00.000-08:00

Today was the last shift of pediatric rotation. I learned a lot about human development, I played with some cute kids, and World's Greatest Children's Hospital was MARVELOUS as a placement- the equipment all worked, the kitchen was stocked, the staff was top-notch- but I'm glad to be done with it. Floor nursing just isn't for me.

Today I had a mixed bag- one GREAT patient, one Exorcist patient. The great patient was a 10 year old girl, one day post-op for a splenectomy, who let me get her out of bed (in spite of some serious pain) to help her to the bathroom, let me take her to the play room (she needed to sit up straight for a while to prevent Acute Chest Syndrome), and basically coped pretty well with her treatment, said please and thank you, the whole bit.

Her roommate, a 10 year old boy, needed FIVE NURSES to restrain her to take ONE ORAL DOSE of a not-bad-tasting medication. He simply did not wish to take it. He took it yesterday, without a problem, said it didn't taste bad, but today he was clearly possessed by DEMONS. He spat at the nurses, tried to bite, and basically was AWFUL. His mother just stood by the bed saying "he likes to play". Clearly this is where he gets his fabulous attitude. I asked the mother to either help us get the meds in, or leave the room. She refused to do EITHER, and just stood there laughing as I got spat on and kicked, and the doctor got punched in the chest. He had shown up hen the kid started screaming, to lend a hand.

Next is OB. Hopefully less kicking.

Conversion Disorder

2010-02-22T17:19:00.000-08:00

Conversion disorder is when someone (usually an adolescent, and female) takes some sort of outside stimulus (school bullying, or puberty, or nerves, or whatever) and manifests it as physical symptoms.
ALL nursing students suffer from a bit of this, when we worry ourselves sick, or we give ourselves headaches, convinced we're failing a course. This is not a disorder.

A patient today DID have the disorder. Breaking the odds, he was male, 13 years old, good student, all that. And he was dizzy. REALLY dizzy, especially when he stood up, or was made to do anything he didn't want. Suprisingly, even sitting up or standing or walking, he had NO problems, as long as he was goofing off, or talking on his cell, or looking for snacks. Assess him, or let anyone in a white coat enter the room, and suddenly he was "super dizzy, weak, and unable to stand on his own".

I feel bad for the kid. If he had an organic problem, there'd be an easier fix...with this, he's got to use meditation and biofeedback, and possibly wait to grow out of it.

Modern medicine mostly sucks at behavioral conditioning...except when it involves training people to take medications...

Age Differences

2010-02-15T19:35:00.001-08:00

The strangest thing about pediatrics is the developmental difference between our patients. In adult medicine, even if two patients have ages 15 years apart, their care remains pretty much the same. A 65 and and 80 year old heart attack patient are treated with the same drugs, in the same approximate amounts, with predictable effects.

In pediatrics, on the other hand, it is possible to have EXTREMELY different patients. Today, mine were 2 years old, and 18 years old. One pulled at my earrings, and tried to RUN AWAY from the blood pressure cuff, the other was worried about missing his chemistry class.

It's actually kind of amusing, once you get past the shock of going room to room and adjusting speech patterns and priorities by age. For the teenagers, you need to emphasize (against the express dictates of Very Catholic University) sex education, good decision making, and independence. For the toddlers you focus on SIMPLE choices: "do you want the BP cuff on your ARM or LEG?" or "temperature BEFORE or AFTER I count your pulse?"

All in all, I like pediatrics, except for the teens in Status Dramaticus. They drive me NUTS! After all, if your pain level doesn't CHANGE after you've received a MASSIVE dose of painkillers that makes you REAAAAAALLY high, and you STILL rate your pain level as "the same! 10!", what would the point be of me giving you any MORE pain meds? If you're breathing at 6 when you sleep, due to the sheer amount of narcs, we CANNOT give you more! Plus, don't think I didn't notice that when I was not within view, you were giggling, laughing, eating a FULL lunch, and chatting with your friends about how you were SO getting "the whole week" off from school. Yeah. I told your doctor. :-p

My So-Called Snowpocalypse

2010-02-11T18:33:00.000-08:00

I spent an unintended 24 hours on call yesterday afternoon into today at the ambulance. I left my car at the squad building Tuesday night, intending to pick it up Wednesday and return it to my apartment building after we were plowed out, walked the mile from my apartment to campus yesterday afternoon aaaaaand...promptly got told NOT to walk back, as it was quite windy and snowy out.

Since I only had half a change of clothes (so that I'd be dry after I got there), I had to run upstairs to the student health center and borrow a set of scrubs from the nurses (they keep a supply for sick students to wear) to wear as pjs. Then we realized that the ambulance was grounded (only allowed to move in an emergency) which meant WE were stuck in the building too...except for me, as I wasn't officially ON duty...so I wound up tramping across campus to a dining hall, and scrounging food for the whole crew. They were WONDERFUL, and gave me about 5 POUNDS of chili-mac and cheese...plus apples, crusty bread, and dessert. FABULOUS.

We only had one patient, in spite of the massive amount of partying expected on campus, due to classes being canceled for today as well. We attribute the LACK of mayhem to the fact that everyone drank heavily TUESDAY night, in anticipation of having classes canceled WEDNESDAY....except that YESTERDAY, the liquor stores were closed. This meant no-one could restock on alcohol, so, being an intemperent bunch, most of the students were OUT OF ALCOHOL! OH NO!

A Guide for College Drunks

2010-02-05T17:05:00.000-08:00

Hi, drunk college students! In the interests of making all our lives easier, here's a little advice:

1. When you decide to go out in the middle of the week, go EARLY in the evening, so that you can get wasted, stumble back onto campus, get picked up by public safety and taken to the hospital in time for the rest of us to get some sleep.

2. If an EMT tells your slightly LESS drunk friend to "please just stand over there and put on a coat, it's freezing", cussing the EMT out and muttering snarky things under your breath will NOT endear you to either Public Safety officers, or the other EMTs. Hint: either you dont mutter as quietly as you think, or you might want to remember that when you're drunk, you tend to lose inhibitions. I hope you enjoy the 500 dollar fine.

3. If you're going to lie and give us the birthdate from your fake ID, show a little spine and give your fake AGE too. If you give us a REAL under-age age, and a FAKE birthday, a little simple math makes you look even MORE like an idiot.

4. I know it's a cliche that you should wear clean underwear in case you get into an accident, but really, EMTs dont WANT to look at your underwear, so a skirt that is wider than your average belt would be great

5. If you're worried about a friend who cant hold their liquor, don't worry. We WILL come out and get you in the middle of the night, and do whatever it takes to keep them safe. Just...try not to let it get that bad. You guys might swear at us, and hate us, and think we're all out to get you busted, but really, we just want to make sure that all of you who go to bed get to wake up tomorrow, hangovers and all.

Entitlement

2010-02-02T19:29:00.000-08:00

Yes, I know I've already posted today, but this was getting to me.
This evening, Very Catholic University (VCU) was playing a home game against Some Other University (SOU). This meant that the parking lot next to the Student Health building was PRIME parking real estate. Now at Collegiate EMS, we dont actually HAVE our own garage, we have a lovely set up with a massive parking space on the lower level of this covered garage, which we have marked off by cones as well as flourescent parking lines saying "NO PARKING- AMBULANCE" all over them.

Needless to say, as we are near the Home Stadium, the Health Services lot becomes "The VIP lot" during games, and VIPs tend to be...well...asshats. I spent AN HOUR AND A HALF this evening kicking people out of the CLEARLY LABELED ambulance spot. Once, I even had to go yell at a guy who made his 10 year old kid get out and start MOVING OUR CONES so he could park in the spot. I bounced out the door, ran over, and knocked on his window: "Sir! You can't move the cones! They're there to help you notice the 'NO PARKING- AMBULANCE' sign!"

"But..." says he, irritably, "all the other spots HERE are TAKEN!"

"The ambulance needs to plug in to this plug here, sir, or the epinephrine we keep on board freezes, and the next kid with a nut allergy dies in agony" I replied. Entitlement to VIP parking is one thing. Believing that you have a god-given right to park in an emergency vehicles zone? That's a whole NEW level of evil. Next time I'm not going to warn him, I'm going to tow his car WITH THE AMBULANCE...into the dumpster.

My Kingdom For An Accurate Dispatch!

2010-02-02T17:44:00.000-08:00

Today was another episode of Fun And Games with the collegiate EMS dispatcher! This time, I was OVERJOYED to have a call for a -gasp- actual medical complaint! "College EMS, please respond to On Campus Nursing Home for a Really Old Dude with a witnessed syncopal episode!" 'WHEE!' I thought, 'an actual call! where I might be able to perform interventions! And help fix someone!'

No such luck. Upon arriving at On Campus Nursing Home (seriously. It's a nursing home, on campus.), we find Really Old Dude (ROD for short) sitting up in a chair, looking really lousy. "Hi, ROD!" I said with my best jaunty EMT grin, "I'm Little D, and I'll be your EMT today! When did you faint?" And that's pretty much when it all went pear shaped.

"Oh no, he never FAINTED!" Piped up the nurse at his side, "ROD got sick last night, and hasn't gotten better!" "Define 'sick' for me" I asked, warily. "Oh he's been vomiting, and having diarreha, isn't that right ROD?"

Oh great. Here we go AGAIN. "Ho ho ho!" Replied ROD, perking up a little bit. "Sir, how are you feeling?" I tried again, "You've been a good little girl! I'm feeling fine! Merry Christmas!"

Yes, ROD thinks he's Santa Claus. "ALTERED MENTAL STATUS" I wrote. "Um...ROD always thinks he's Santa Claus" interjected my partner. Peachy I thought to myself- nausea, vomiting, NO syncope, AND he think's he's Father Xmas. This is SO my day.

We dropped ROD off at the hospital as requested. This may be his last visit, as people with "Alphabet Soup" rarely do well. A SMALL sample of his PMH revealed the following: BPH, COPD, HTN, CHF, NIDDM, GERD, and PEs, and multiple DVTs, as well as at least one CVA.

This time the dispatch mixup was not all the dispatcher's fault. Apparently the nurses called in for a "Sick Episode". Seriously? A SICK EPISODE? What's next? A HUNGRY episode? This has to stop.

In other news, my morning at the Greatest Pediatric Facility In the Galaxy went extremely well.

The Importance of "Why"

2010-01-31T10:35:00.000-08:00

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!

Babies

2010-01-28T19:22:00.000-08:00

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, as...um...she 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.

Cultural Competency

2010-01-25T13:24:00.001-08:00

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.

Student "Health" Services

2010-01-24T09:34:00.000-08:00

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.

It was a LONG day

2010-01-21T08:26:00.000-08:00

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 pregnancy...so 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.

I was THAT kind of little kid

2010-01-16T12:12:00.000-08:00

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 ear...so 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...

THE BIGGEST MOST DISGUSTING THING I HAVE EVER SEEN IN AN EAR SURFACED!

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

Child and Family Nursing

2010-01-15T09:05:00.000-08:00

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.

Pediatric Clinical Placement

2010-01-11T18:37:00.000-08:00

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.

Portland

2010-01-08T06:57:00.000-08:00

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? "Um...do 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.

The sort of night firemen fear

2009-12-29T19:32:00.000-08:00

It's at least -5 degrees Fahrenheit out there, with a sustained windspeed of 20-30mph...ice cold, clear night, with everyone in the whole state firing up their woodstoves to keep warm. This is the sort of night where improperly sealed chimneys have their seals freeze and crack, leading to housefires. And then the firemen get cold, slip and fall on ice, and wind up swearing like sailors.

I've got my BDU pants out, with long underwear, an extra warm coat, gloves, hat, boots, AND a thermos for hot cocoa if we get called out.

Last time we got a fire in this weather, it was a (thank god) uninhabited house, the propane tank blew up, and 10 firemen fell over like penguins on an iceflow from surprise. It was hilarious, but only because nobody was hurt. I was tucked up in the ambulance, watching from a "safe distance".

May I state again, for the record that it's EXTREMELY cold outside? It's also cold in my BEDROOM- 33 degrees F to be precise. I'm beginning to think that there's something wrong with the insulation. And possibly that, due to our wood stove being very efficient, they dont turn the heat on in the house, so it never reaches my bedroom.

It's not QUITE the backwoods, but dear god it's close

2009-12-27T19:30:00.000-08:00

I'm home for break, I'm working on the ambulance squad, just as usual. The call we got most recently was complicated by a few things:
1. the temperature- it was about 10 degrees out.
2. the fact that we werent precisely sure where the hell the address WAS, as it was a made-up road, named only because 911 needed a road name.
3. the 'house' was actually a WAY sub-code former barn with holes in the floor
4. the patient couldn't stand up or walk, nor could he lie down, due to emphysema.

The patient was having an emphysema problem...but also probable H1N1. So he couldn't lie down, or face not breathing. On the other hand, since he had taken about 15 ampules of albuterol over the day to try to fix his breathing...he couldn't walk. So it took 4 firemen, plus our 4 person crew to get him out to the truck.

Just another nice "warm" day in the far far north.

MERRY CHRISTMAS!!!

Nightshift

2009-12-04T16:43:00.000-08:00

Last night i worked the 18 hour overnight on the campus EMT squad again. We only had two calls, but they managed to keep us awake for most of the night. First call came in at 2 AM. We had tucked ourselves in around midnight, having remained up until then because we were anticipating a frat formal getting out around that time, and being dragged out of a bed you've JUST climbed into is awful.

Contestant Number 1 was a drunk young man, who consumed the traditional "two beers", prior to apparently CRAWLING up the stairs to his dorm. He wasn't THAT drunk, so I got a refusal from the doc at the LocalHospital, which allowed us to let him go off to bed...and probly get cited for drinking.

We got back to the squad room, only to find what one crewmate described as "a caterpillar as big as a mouse"- the woolly kind. This elicited everyone standing on chairs until somebody picked it up and put it outside. The giggling kept us all awake for about half an hour.

Contestant Number 2 was also drunk, and the call came in at about 315. THIS winner had somehow fallen and smacked his head on a curb, and got a quite impressive 10cm lac to his occipital region. We found him in his room, with his roommate holding a teeshirt to his head to stop the bleeding. My instincts said he was probly fine (aside from the lac- i swear i saw bone in there), but on exam I found horizontal nystagmus...and a three hour time lapse in his memory.

For these findings, plus the fact that the fall was unwitnessed, he won a middle-of-the-night trip to Downtown Philadelphia to a Trauma Center!! This would have been fine, except that on the way back, at 415 in the morning, we got lost. And I didn't get to sleep until 5 am, then got BACK up at 10 to do my reports.

I feel like i've been beaten with noodles.

When Things Go Badly

2009-11-22T08:53:00.001-08:00

For ethics class I'm writing up a case study of a patient who is brain dead, but whose family does not believe in brain death as a criterion for determining "actual death". This is the sort of thing that is quite tricky in modern medicine- after all, "brain death" never used to happen: as soon as your brain lost control of your breathing center, YOU DIED. We never used to have the problem of a dead brain with a body kept more-or-less fresh with Science. While the part of me that LOVES a little Mad Science thinks that this is actually pretty nifty in a Frankenstein's Monster sort of way, the part of me that hates to see wasteful useless medicine practiced cringes at the thought that people are "maintained" on ventilators when they are actually corpses, all because the family simply does not believe that they are gone.

Plus- if they're DEAD, who is PAYING for all these interventions? Probably not insurance, as I'm fairly certain that they stop paying for procedures for deceased people.

Its not an easy decision though, because families may have valid religious reasoning behind their views on death, but that should never trump the fact that we CANNOT allow ONE person to be dead and ONE to be alive under the same conditions and circumstances. Death HAS to be universally applied, or things go downhill fast.

De-Escalation and Defense

2009-11-18T13:20:00.000-08:00

Today we learned how to (WITHOUT hurting the poor "innocent" patient) get out of holds when people are trying to grab, choke, pull your hair, or bite you. Normally, I'd respond by doing whatever the hell is necessary to keep the person from killing me...but this is psych, where apparently pushing on somebody's jaw hinges to get them to release your ARM from their TEETH is "assault". Whiskey. Tango. Foxtrot. If somebody is BITING ME, I think I'm allowed to poke at them a little.

BTW...I RULE at making people stop, according to this class.

But you know what my number one self defense technique is? NOT LETTING PEOPLE GET BEHIND ME OR NEAR ME!

Things That Make Life Harder

2009-11-15T16:41:00.001-08:00

I am not a large person. I am, in fact, rather short and curvy. This makes things like 1. lifting a stretcher with a 250 pound person up to its full height 2. reaching the turnout gear in the TOP compartment of the back panel of the ambulance 3. climbing into the driver's seat without hopping like I'm on a vaulting horse VERY challenging, and sometimes near-impossible.

What do you do? You put up with being laughed at by your fellow EMTs every time something like this is required, try to get somebody else to pick up the stretcher for you, and pretend NOBODY saw you almost catapult off the ambulance seat.

Tomorrow is psych clinical again, and lets hope I set my alarm properly. Last week I managed to set it to PM instead of AM- this clock doesn't do a 24 hour clock, which i use on EVERYTHING else, so I didn't notice- and wake up at 645, when I'm already supposed to BE at clinical. The only reason I am still breathing and did NOT get a nasty note in my file is that, by some grace of some deity, my instructor lost track of time, and was LATER THAN I WAS! Coincidences like this do not happen more than once to a student, so I'd better not screw up again!

You Know You're in EMS When...

2009-11-13T20:12:00.000-08:00

You're out bowling with your entire squad, somebody's HOME pager goes off, and 20 people bounce to their feet, reaching for their hips, to see WHO is getting called out. Additionally, half the people look really disappointed that it wasn't us.

Then today was our Mock DUI demonstration, for which we had 7 fire/ambulance apparatus, and PENNSTAR!!!! We landed them right in the middle of campus, and the pilot buzzed us first, which is one of the single coolest things EVER. Just to make it look even COOLER, they let us climb inside, AND i'm going to get to do a fly-along!

God I love helicopters!!!

Special Olympics

2009-11-11T15:28:00.000-08:00

This past weekend was...intense. So intense that posting has taken me a few days. I pulled Friday night 18 hour shift, and before that did Golfcart Standby crew for the beginning of the Olympics, as well as pulling for the Opening Ceremony. And as a result I am in love...or at least the victim of a massive crush on my overnight partner. It's been a LOOONG time since I dated anybody, but for this guy I'd make a serious exception. ~deep girly sigh~

So we had two Olympics-related calls in the evening, which resulted in me nearly getting into a fight- with the "Medical Coordinator", a nursing student a year behind me. The patient was post-ictal, known seizure disorder, but, you know, they CALLED THE EMTs, so I had to EXAMINE AND SPEAK TO THE PATIENT. This girl refused to let me speak to the patient, OR give me her written medical history. Why? Well she didn't want me to "upset" the patient by asking her questions, and as to the medical history? SHE WAS USING IT TO FILL OUT PAPERWORK.

After those two it was just drunks. And I'm only JUST recovering my energy.

Florid Psychosis

2009-11-05T19:02:00.000-08:00

Yesterday my partner and I did the nursing intake assessment on a new patient to the adult unit. The nurse's advice? "Be CAREFUL girls! Don't let him get between you and the door, he's got a history of violent outbursts, isn't medicated, and is bigger than you".

Because that's going to make us feel REALLY comfortable.

So we sat down, carefully, and began our assessment. "You two are students?" he asked. "Yep!" I replied, knowing that Truthfulness Is Important, "GET OUT WHILE YOU STILL CAN" he said, admirably demonstrating pressured speech and delusional ideation. "THEY MAKE YOU KILL PEOPLE!!! AND THEY GIVE YOU MEDICATION THAT MAKES YOU NOT LIVE FOREVER WE CAN ALL LIVE FOREVER YOU KNOW" he said, at the top of his lungs.

A few minutes later, we were done, worried, and sent to keep the rest of the ward from hurting each other.

It's quite a rotation...

Over My Dead Body

2009-11-05T11:49:00.000-08:00

Today we are learning, in Trends and Professional Nursing class, about how IMPORTANT it is that we practice "Consumer Centered Care", where the "client determines quality". Man, SCREW THAT. Ive had plenty of patients whose idea of "quality" would be higher thread-count sheets, perrier water, and me, running to cater to their every whim no matter how sick my fellow patients were. This should determine my practice? MY practice is based on providing safe and effective care to my patients, with their physical wellbeing placed FAR above any stupid ideas of customer satisfaction. You may hate me for not giving you water, but I dont care- if you're fluid restricted, you are not getting extra water. You may WANT it, you may DESIRE it, but you could go into a CHF crisis. The consumer is not always right, and pretending that the patient should run our units is dangerous and unsafe.

Just my student opinion, but it feels WRONG.

Its the Pandemic, Stupid!

2009-11-01T19:45:00.000-08:00

Today I learned that a colleague on the campus EMT squad pulled an 18 hour shift last night with what is almost certainly an active case of H1N1. Without a mask. She was running a 103 degree fever this morning, according to her. She said "i didn't want to get people mad by calling out of my shift". Oh I'm mad as HELL now! She exposed another medic (one of our FIVE current drivers, due to how long our training program for driving is) AND her probie AND her observer/student to H1N1. If they catch it they'll ALL be unable to pull duty.

I am SO pissed at this! I'm stuck here with bronchitis, unable to think clearly for longer than 10 minutes at a time, and she's out there making people sick, and I can't STOP her without exposing MORE people to this bug! GAAAH!

Please people- if you're sick, dont hurt other people. Find an excuse to wear a mask if nothing else. Really. Just...wear a mask. This winter is going to be hellish enough for a HEALTHY squad- and we're dropping like flies here.

It's Bronchitis

2009-10-30T14:10:00.000-07:00

I still don't feel terribly sick, but my mother (rather overprotective), convinced me to go over to the Health Services building to get checked out. As expected, it's bronchitis. As far as I'm concerned, it's probably viral (for chrissakes, most things ARE) but because of the asthma, they wanted me to take antibiotics, "so you dont wait too long to go to the ER, which you KNOW you will, while claiming it's "not really that bad". I guess they do have a point. It sounds like something I'd do.

So no Halloween for me. Trick or treat???

Hi, I'm Unresponsive!

2009-10-30T07:58:00.000-07:00

Last night, in spite of (ok BECAUSE of) The Cough, I acted as a spare victim for the EMT class on campus. My friend Meg was assisting with teaching, and needed a person upon which to demonstrate a Rapid Trauma Assessment. As I cannot currently run away, that person was me.

The RTA involves touching just about everywhere quite rapidly on a person, palpating and skimming to look for "DCAP-BTLS"- deformitites, contusions, abrasions, punctures, burns, tenderness, lacerations, swelling. Essentially, it's summed up as "well THATS not good". Meg is a rockstar, and was demonstrating to these VERY nervous students how you can do a complete assessment without your victim feeling sexually harassed. It helps that they dont make the students strip the mock victims, although one girl was HORRIFIED to learn that we strip ALL trauma patients. He he he he he!

I only vaguely remember being that green. The problem with those of us who are nursing students as well as EMTs is that we keep adding to our field assessments- no longer is it "lungs clear and equal bilaterally", its "lungs CTA, decreased at the bases, suspect atalectasis from stasis"

I Dont YET Have The Flu

2009-10-29T11:16:00.000-07:00

But I do have some sort of violent cough- mild, almost unnoticable congestion in the nose, just mostly a VIOLENT (sounds much worse than it is) cough. For the past three days. At this point I'm pretty damn sure it's NOT the flu, but the looks people are giving me are pretty awful. I mean, ive been asked 5-6 times if i have "The Flu", though i'm not actually that sick. Two people bucked the trend, and notified me that I could have walking Pneumonia.

It's getting to the point where I'm almost tempted to go to the Student Health Center so that they can TELL me I dont have anything wrong with me, and write it on a slip of paper...last year people would have asked me if I had a cold. This year they think I'm Typhoid Mary.

Go figure.

Dear God The Exhaustion (Part 2)

2009-10-24T07:10:00.000-07:00

Last night I worked as Standby Crew for a campus event to kick off the basketball season, and that is always followed by a brief musical performance (usually by someone we've never heard of). "Oh! This will be easy!" I thought. After all, the event started at 7pm, and would be over by 10! What could POSSIBLY go wrong???

We were there for FIVE MINUTES before we had TWO patients, both found in the bathrooms puking their guts up (thank heaven for small favors- they made it to the bathrooms) because THESE geniuses thought that aggressive drinking was the best way to attend a basketball event. The irony is, they were so sick, and so drunk within the first FIVE MINUTES (ie. before anything had HAPPENED at the event) that they missed the whole thing. Local Hospital was being EVIL and on full diversion (we're not sure why...we think it's because they dont like us) so our Duty Crew (the people who were on the actual night shift) were taking two patients at a time to a farther hospital, which turned the whole thing into a Mass Casualty Incident.

The thing about MCIs is that you have one as soon as your number of patients overwhelms your resources and personnel. We were at that point about 15 minutes into the event- public safety officers were scouring the building for sick or drunk people, and kept calling us. We had 7 EMTS, working in 3 teams (3 on the rig, two pairs with a jump-kit each)...there WAS another crew, a paid professional squad, but they were technically on call only for the athletes and the entertainment, NOT for the students. As a result, they wouldn't transport for us, leaving us at several points with patients stacked up waiting for rides to the hospital.

By 10 pm we had upward of 12 patients, and 7 VERY testy EMTs. I'm exhausted, and I just slept for 8 hours. Ugh. I hate hate HATE drunk students.

Dear God The Exhaustion (Part 1)

2009-10-23T12:04:00.000-07:00

Last night I pulled an overnight for the campus EMT squad- it was a Thursday, so I expected SOME drinking, but to get some sleep. Apparently the gods of EMS did not favor us. Our first call came in at 1230, after we were all tucked into bed- me, one of my favorite girls on the squad, our HILARIOUS driver for the evening, and R, the best looking guy in the whole nursing school, who also happens to be hilarious. We were paged to UPSTAIRS, in the student health center, for a kid who "hurt his ankle" and was in 9/10 pain...while munching crackers and sipping gatorade. "9/10 you say?" I asked sweetly "Oh that must be SOOO awful for you- I'm SURE you have no appetite with pain like THAT!"
"Oh no- I'm STARVING!" my patient replied happily. That's -2 pain scale points for you, plus ANOTHER two dropped for making coherent conversation without wincing when we moved you. 5/10 sounds about right.

2nd call came in about 220, once we were all BACK asleep, the first of the inevitable Intox Evaluations- a bunch of frat parties at bars off campus had gotten out, and two prize human beings had decided to pee in the parking lot...in front of both campus security and the local PD. Yeah. Bad idea. Took the one who looked worse off to the hospital, left the other one to be arrested, then BACK to campus for ANOTHER drunk, discharged because he wasn't THAT drunk, then back into bed by 310...only to be awakened at 530 for ANOTHER drunk, stumbling around shoeless. By this point we were all so punch-drunk that L started giggling at the patient and couldn't ask him any questions.

I've had 4 hours of sleep...and I'm working a standby tonight.

I am going to DIE!

PSYCH!!!

2009-10-23T12:01:00.001-07:00

Wednesday was our first day of psych clinical at Hospital Nobody's Ever Heard Of. For the first few weeks I have been assigned to the adolescent unit...which seems to be entirely populated with kids committed for 1. violence and/or 2. sexually inappropriate behavior.

I was propositioned in the first 5 minutes, but apparently I have the Icy Glare of Doom that makes most of the guys back the hell off. I dont really like being touched, so the "stay an arms length away from the patients so they cannot attack you" rule is just fine by me.

I'm already wondering what the hell we're supposed to be doing here...aside from the one REALLY COOL thing we get to do, which is Crisis Descalation class, which involves both verbal AND physical de-escalation, which sounds fun.

What I Did On Fall Break

2009-10-18T18:09:00.000-07:00

Up in the Frozen Northlands we had a bit of an early cold snap, which allowed for some early snow-frolicking...which I LOVED, as I am, in demeanor as well as in appearance, pretty much a cross between one of santa's elves (height, and love of winter holidays) and the White Witch of Narnia (demeanor before 8 am, when awoken at night, ok...i can be a bit irritable). I LOVE snow. I love it to an almost unreasonable extent. For one thing, it makes driving WAAAAY easier. This may seem odd, but clearly you are not from the Frozen Northlands. Snow makes reflections on BOTH sides of the road. You simply drive down the dark bit in the middle! This is a serious improvement, as we have no streetlights.

I GOT TO DRIVE THE AMBULANCES!!! both of them! M, my training lieutenant, took me out and let me drive around at high speeds, yelling "STOP!" at random, to get me used to being startled. It was awesome.

We had two calls: 1. MVA of a motorcycle on a notoriously dangerous stretch of a state road that has already claimed 5 critical injuries THIS YEAR. Naturally, we went REALLY fast to get there, only to find a perfectly lucid man, lying on his back NOT MOVING. He was NOT MOVING because his brother, a rather large gentleman, had threatened him with death should he move before the arrival of the EMTs. I LOVE people like this. They make my job easy. We cleared is C-spine, and took him in for evaluation, because he had a crash at 30-40mph off a motorcycle, but he was FINE. Wear a helmet, kids, it really DOES help.

2. Chest pain and epistaxis in a 20 y/o male: AKA cold dry air leads to nosebleed, young man panics because his mother is CRAYZEE, and thinks he's having a heart attack. We explain that "family history" of heart problems (AT 80!!!) is NOT the same as a "previous history" of heart problems, and that he is fine. Really. FINE, and to please go to bed.

other than that, i did TONS of chores, and got to see my beloved Bella, my evil Devon Rex cat. Pretty good. Then an 8 hour drive back down here, because of the GW bridge being designed by Satan himself.

Medsurg is done!

2009-10-07T09:26:00.000-07:00

No more med-surg for the Little D! Finished today by running around doing moderately useful tasks, like finding coffee for a terminal cancer patient, and getting a doc to order nicotine gum. He said she needs a quit smoking consult. I pointed out that with metastatic lung cancer, it's a little late at this point to tell her "i told you so", and just to please order the damn gum. I really think she GETS that smoking is bad for you, what with all the surgery, the radiation, the chemo, and the DYING.

On the bright side, I got an A. ~insert happydance here~

AND I NEVER have to go back to Bob's Hospital again!

After break I'll be going to Psych Hospital Nobody's Ever Heard Of, outside Philly.

Midterms

2009-10-06T18:15:00.000-07:00

Thursday afternoon I'll be leaving for the Frozen Northlands for a week of running around in an ambulance, hopefully punctuated with a nice hike up Mt. Washington with the Little Brother and his buddies. This should be an excellent test-run of our winter gear, and we're hoping for snow.

I MAY be able to post (especially if I get any good traumas) but in the Frozen Northlands the internets are quite temperamental (especially if the weather gets interesting...power, running water, and internets are apparently some things for which my area is simply NOT a priority)

Hopefully tomorrow (last clinical day at Bob's Hospital) will pass without anything icky happening, and with a decent grade...wish me luck!

Patient Assessment WIN!!!

2009-10-05T18:46:00.000-07:00

Today I WON at patient assessment- Moaning Dood was an intractable pain patient- essentially, we pumped him full of more pain meds than I've ever seen given, and he would mutter "it's still an 8"...and then go to sleep.
On one of these visits, the nurse was pushing the IV meds (we DO NOT do IV push, it's apparently a legal risk) and I decided to take advantage of Dood's distraction to do a reassessment of his pulses, dont ask me why. I laid the backs of my hands on his calves and...um...hummmmmm....
One leg was noticeably cooler than the other one! I'd read about it, and been lectured on it, but it was REALLY obvious. So I tried to get a pedal pulse, and couldn't find one, so I ran to the ICU and stole their Doppler...which ALSO failed to find a pulse. At this point I dragged the nurse back into the room to check my findings AGAIN, and when she couldn't get anything with the doppler, we decided it was time to call in the doctors.

It turns out he had been scheduled for a doppler scan of all limbs back on friday...but then it was the weekend and it was never done. He's hypercoagulable. I hope we saved his leg- since it still had capillary refill, some blood must have been getting through, hopefully enough to hold it for a while.

Help Is On The Way

2009-10-04T19:07:00.000-07:00

I've always loved to watch firetrucks and ambulances go past, probably because when I was a baby, and would startle at the noise, my mother would bounce me up and down and say "Help Is On the Way!!!"

I think maybe EMS would be better off all around if everyone thought of it that way- not "oh no! something has gone terribly wrong" but "Help is on the way!"

Two more clinical days at Bob's Hospital- and if we're REALLY lucky (ha ha) the nurses will be going on strike either tomorrow or Tuesday...which will mean we CANT go to clinical, and Will Have To Be Flexible. Because if there's ONE BLOODY THING we learn in nursing school...Nurses Are Flexible!

I am disappointed that I cannot put my feet behind my ears. Apparently flexibility has limits.

ICU FTW!

2009-09-30T19:28:00.000-07:00

The ICU today was FANTASTIC! We were all basically thrown at the unit, and with a 10 bed unit, 8 of us, plus ANOTHER student from another school, pretty much all the nurses had students to do the heavy lifting, which they seemed to really enjoy. MY nurse was totally AWESOME. Our patient was really honestly an ICU patient- she was really truly unstable, with resps in the 30s, HR in the 120s-140s, BP all over the place.
And end-stage MS. Really tragic. She was REALLY young for it- in her 30s, and her "admitting complaint" was MASSIVE pneumonia. She realised upon admission that she was probably terminal, and made herself a DNI...but NOT a DNR. This put us all in a bit of a quandry- we needed to suction her, we could hear the ronchi from the nursing station- but she would fight tooth and nail against the NG suctioning, which would bring up little bits of THICK mucus, but it didn't feel as if we were doing much good. For REAL help, she would need something about the size of a garden hose, which would have to be put down her throat through her MOUTH, but she couldn't tolerate it. She would need to be tubed for us to reach her lungs, which we couldn't do. So...we did our best, rolled her side to side, restrained her arms by tucking them inside the covers (she would rip off her NRB mask in panic, which would make her de-sat into the 70s, even when I would HOLD it there, and remind her that she NEEDED the mask.) The hardest part was that she was mouthing "help! I cant breathe!"
But it was both challenging, and really DIFFERENT...I loved it.

Oh God the Crazy!!!

2009-09-30T19:16:00.000-07:00

For the past week or so, my life has been MADE of crazy. On Monday I had a woman who really REALLY should have been allowed to be a DNR. Unfortunately for her, her family did not have the time to visit grandma, so she was a full code. And I spent the ENTIRE day running to her room as her vent alarmed, jumped into the Iso gown and gloves, and checked the vent, which inevitably was only alarming because of LOL's silent coughing and agonal resps. Of course, the nurse didn't go in ALL MORNING, and only spoke to me insofar as she had new orders for me- i did all her discharge work. Yeah. All of it, except for WRITING DOWN the progress note, which she had me dictate, so it would be in her handwriting. Not fun.
Yesterday was my BIRTHDAY!!! Except I had classes from 8-1, and then I went and got cake to bring down to the EMT building, because eating cake alone is sad, pathetic, and very VERY fattening...except there was an executive board meeting they forgot to tell me about...so I sat outside from 2-530 and studied...and got quite chilled. Then had 20 minutes to bolt down some cake before running to my developmental psych class...then straight off to bed for clinicals this morning.
Today the CPU was actually CLOSED, due to low census, so we ALL went to the ICU, which was half CPU patients, half ICU...and that really should be it's own post...

100th Post, EMS Overnight Shift

2009-09-26T12:30:00.000-07:00

Last night at 6 I went onshift for the 18 hour overnight. Since it's parent's weekend at college, I was thinking SURELY it would be a quiet night. I mean...who would go out to get drunk with everyone's PARENTS there?

Well, as it turns out, quite a few idiots.

First call of the night was the only REAL call- anaphylaxis in progress. The poor guy was on his SECOND life threatening reaction of the day, having had one yesterday MORNING, and only been released from the ED about 6 hours before we got called out again. He still has no idea what he's allergic to, but my god I've never seen hives like that. He was really intelligent though, and had already taken a BUNCH of benedryl before we got there. I'm convinced that it's the only reason I didn't have to hit him with the Epi-Pen. I prefer NOT to do that to people who have just gotten their own Epi Pen prescriptions, because I don't want them scared if they need to inject themselves someday.

Third was a simple cooperative post-vomiting drunk who we promptly sent off to bed after a stable set of vitals.

Second and fourth were the "fun" ones. They were the ones who make you want to smack them a little bit- the drunks who were combative, verbally abusive, and whiny all at once. Number 2 was worse from the "whiny" and "combative" standpoints- engaging in a LOVELY combo of invading our personal spaces and trying to run away, while she sobbed loudly that "now she was gonna be in trouble and it was all our faults". Um...this was going to be her FOURTH write-up. Shes a freshman. That means an average of a write-up per week. In contrast, I didn't get written up AT ALL in FOUR YEARS of college, not counting THIS degree. That means not only does she drink more-or-less constantly, but she isn't very good at staying out of trouble.

Number 4 was actually not all THAT drunk. We were planning on releasing her into the custody of a sibling, but then she said the magic words "It doesn't matter what you do, i'm going to kill myself anyway". Whoop! That, combined with absolutely obvious alcohol intake equals a trip to the hospital. Sorry sweetie, saying "i dont consent! i'll sue you!" is NOT going to get you out of this one. Once you voice a wish to kill yourself, you become legally incompetent as far as we're concerned. Since you're drunk you CANNOT consent or deny treatment, and since you're voicing suicidal ideations we cannot release you to the custody of ANYBODY without a doc's evaluation.
Plus, you called me the c-word. Now I'm not sympathetic anymore. In addition, this being the FOURTH call of the night, it's 4 am and I havent SLEPT YET.

I understand depressed patients, and even suicidal ideations. I've been there myself...but I lose all my warm fuzzies when you start abusing me. Hell...i'm VOLUNTEERING here. I'm staying up ALL NIGHT WITHOUT PAY to make sure you're ok. The least you can do is NOT insult me.

And now...i'm exhausted.

I See JHACO People

2009-09-23T14:02:00.000-07:00

Today JHACO descended upon Awful Hospital (aka Bobs Hospital)...and chaos did reign. The very first thing we were assigned to do (since we figured we had an hour or two before they got all the way up to our floor) was CLEAN UP THE UNIT. Now...I have no problems cleaning, but it was pretty damn clear that nobody gave a damn about making our lives any easier- leaving things for us to collect instead of picking up behind themselves. Once the unit looked pretty good, I was promptly yelled at by Overstressed Clinical Instructor for asking what the combination was to a cabinet, as I had found a PILE of unused saline flushes, and wanted to put them away properly. "DONT SAY 'they just locked the cabinet'! THEY'LL KNOW WE DONT LOCK THEM!!!!"

Look. I'm a student. I DONT know where everything is yet. I DONT have a password to the COMPUTER, much less the combinations to all the cabinets. So...I ask questions! Yelling at me that I'm not supposed to ask questions because the sheer fact that there IS a question reveals incompetence on the part of the unit is SO not my problem.

After the inevitable conflagration over ALL of us having "inadequate" charting (I wasn't DONE yet, I was IN THE ROOM, doing NURSING CARE on my PATIENT), she then continued to panic...and panic. It's not her unit. She doesn't even work there anymore, and hasn't in years, and yet she's going around putting up the JHACO mandated signage in the rooms instead of helping US. My school is paying her to teach US, not to help Bob's Hospital look good.

On the bright side, my pillow-fluffer patient was looking much better today, and actually managed to be cheerful, in spite of pissing me off by pressing THE CALL BELL for "a drink of water" despite said water being approximately 8 inches from his bed, in a cup, with a straw, and plenty of ice. He didn't want to take his arms out from under the covers to reach it...BUT HE HAD TO DO THAT TO REACH THE BELL!!!!

Headbanging on walls commenced. NLN CONFERENCE TOMORROW! HUZZAH!

Pillow Fluffing

2009-09-21T19:42:00.001-07:00

Today we had TWO patients, and i was paired with a different partner. This was ok...we differ on a lot of points of opinion, (she thinks vaccines are scary and evil, I love them) but we work okay together. One patient was a lovely man with lung cancer, admitted for a cardizem drip for new onset A-fib. He and his wife were REALLY with it, asked great questions, took notes on everything the docs said, so that when the NEXT service came by the docs didn't have to go over the same things again and again.

Our other patient wasn't nearly as easy. He weighed at least 250-300 pounds, and was paralyzed from the waist down, according to him. He could, however, feel everything down to the tips of his toes, and i'm not sure how much was paralysis, and how much was deconditioning due to bedrest and pure LAZINESS. Now, I'm a student. I like to give my patients the benefit of the doubt, but this man had two working arms. I know this, because he had the remote control in one hand, and the telephone in the other, and he was holding the phone up to his ear PERFECTLY, and clicking channels...and yet he continually asked to be spoon-fed, and to have his juice held gently to his lips while he sipped.
My answer was simple "oh sir, we're trying to encourage self-care behaviors! Can you please do these range of motion exercises for me? No, I will not wipe your chin for you. Here's a tissue".

And then the call light started going off, while I was helping do the med-pass for my other patient, who needed a blood draw. WHY was the call light going off you might ask?

He wanted his pillow fluffed. And then another DIFFERENT pillow. And then THAT one needed to be fluffed. I understand that patients get lonely. I understand that human contact is important. I am not a candy striper, and taking advantage of the fact that, as a student I HAVE to RUN to answer call lights is just a dick move. No points awarded, sir!

PS- I DID fluff the pillow, btw...I'm not irresponsible! (That and my instructor already wants to kill and eat me)

Advocacy

2009-09-17T18:56:00.000-07:00

From the very first day of nursing school...the very first HOUR, actually, they tell you that you MUST be your patient's advocate- you are the ONLY THING BETWEEN YOUR PATIENT AND A MESSY DEMISE...or at the very least a hospital acquired infection, mental anguish, whatever.

And then, after this indoctrination, you're sent out, bright and shiny and optimistic, into a clinical setting. Where, at least at THIS clinical, you get chewed out if you ever dare to DO any patient advocacy. In this case, it was trying to get everyone to actually glove and gown before coming into the room with someone infected with ESBL...which is a NASTY little bug, version of E. coli...this is in addition to the standard MRSA. I just politely asked a doctor to please put on a gown over his lab coat (which i doubt he ever washes), and was told by my instructor that it was not my place to tell doctors what to do. MY place as a patient advocate is apparently to "Advocate By Setting A Good Example".

So...how are we training our nurses of the future if we start silencing them before they even graduate?

Stopcocks

2009-09-16T18:08:00.001-07:00

I fear the stopcock. Its one tiny bit of plastic, not much longer than a fingernail, and yet it's the bit responsible for keeping a patient's body fluids on the INSIDE of the body. If it's on a PEG tube, it keeps stomach fluids and gastric acid where they belong. If it's on an A-Line, well then it's holding back the flow of arterial blood.
We need to be able to zero an arterial line on a regular basis, to keep the pressure readings as accurate as possible. To do this, one needs to flip the stopcock so that it is OPEN to atmospheric air, but CLOSED to the patient. If, however, someone has turned OVER the stopcock system because they prefer it that way, and you dont check EXTREMELY carefully...you open the stopcock to atmospheric air, and the patient's arterial blood comes spraying out all over the place. OOPS!!!

It would also be terribly TERRIBLY obvious to everyone concerned what had just happened. As nursing students we take a lot of mocking from hospital staff...I dont like to give them any help.

And this is why I fear the stopcock.

Poor LOL

2009-09-14T13:39:00.000-07:00

My LOL from last week was due to be discharged that same day, and, indeed, she was. Back to the Sketchy Nursing Home. She was BACK to the unit this morning, however, once again Uroseptic, with abnormal ABGs. Apparently somebody messed with her vent settings, and her pH was something like 7.22. For those of you who don't know body pH yet, 7.22 is QUITE acidotic. Normal is 7.35-7.45, and you really don't have much leeway. Also, it looked as if nobody had really thoroughly bathed her during that time, as her skin was sloughing off in the most alarming way. It took me about half an hour to bathe her, which is impressive, considering she only has THREE limbs. I STILL didn't get HALF the dead skin off, and then my partner and I put an entire TUBE of aloe cream on her, to help with the itching.
Poor thing is quite heavy too, which makes turning her...tricky. The doctor says that she probably won't get better, and he would very much like to get an End Of Life plan for her, but that her family is dead set against a DNR of any kind, so she remains a Full Code.
Oh! and somebody else coded TWICE today, down the hall in the ICU. They remain alive-ish.
Kudos all 'round.

EKG Interpretation

2009-09-12T10:49:00.000-07:00

I have chosen to do EKG interpretation for my class presentation on Monday, along with Know Your Arrhythmias and Dysrrhythmias. This is because, for some unknown reason, I LOVE EKGs. I find reading EKGs to be both highly entertaining, and fun, especially when I can find even the smallest, most benign abnormality. Maybe this is because I'm new-ish at it, because as an EMT I knew basically two things about EKGs- "this is probably ok", and "OH MY GOD DEFIBRILLATE!". I appreciate the more subtle problems a bit better now, and will happily perch on any available surface to peer over somebody more qualified's shoulder to see new and interesting things.

Things I can now reliably identify:
V-Tach
V-Fib (if you CANT identify V-Fib, you're going to be in trouble)
A-Fib
A-Flutter
PVCs

Things I can Sometimes Identify:
Multifocal vs. Unifocal PVCs
Complete Heart Block

Things I Barely Understand At This Point:
Mobitz
Junctional ANYTHING
Various Types Of Heart Block
apparently none of these will be on the test, but i'm still going to look them up.

The Hard Part

2009-09-09T14:46:00.000-07:00

They say (our all-knowing instructors) that the hardest part of nursing school is learning to THINK like a nurse- to assess WHILE performing all the other tasks set to you, and keep assessing at all times. To prioritize ALL of the things you have to do, and re-organize your priorities on the fly.

I am only just BARELY beginning to get a handle on this. When I'm on the ambulance, my priorities as an EMT-B are pretty straightforward- Airway, Breathing, Circulation, Get the patient to the hospital in a timely fashion. If all of these things are being accomplished, it's considered OK to actually just sit and look at the patient for a minute or two (40 minute transport times, yo). In nursing, (floor nursing at least) sometimes it seems as if you never FINISH doing ANYTHING, even while your basic priorities (Airway, Breathing, Circulation) remain the same. The difference is that there are innumerable other things to do, even for a rock-stable patient. Today was assessment during bathing and changing the patients bedlinens, interrupted several times to suction the patient's trach tube, and once to help save the patient in the other bed, followed by putting her tube feeding on hold, helping give meds, restarting the tube feeding, changing the patient's gown, changing all the wound dressings, MORE suctioning, several bedpans, et cetera. And I only had that ONE patient. AND I had a partner.
I think this is why I like the Emergency Department/Room so much- patients come and go, and I always feel more accomplished after doing a stint in the ED.

Maybe this will change as I gain my time management and mental listmaking skills...on the bright side, once again I made it through a clinical day WITHOUT killing anyone!

Full Code

2009-09-09T08:49:00.000-07:00

Today was our first day with a patient of our own. We doubled up into pairs, since these patients are WAAAAY more complex than last semester. For example, most people last semester could...like...TALK. And breathe on their own.
Ms. E (SO not her real name) reminded me of my Grandmama- tiny, frail and old as rocks. She had what the docs called "alphabet soup"- you name it, she had it: Type 1 diabeetus, CHF, VDRF (vent-dependent resp. fail), COPD, previous history of CVA, seizure disorder, previous GI bleed, liver failure with jaundice, previous UTI, et cet. Oh and ALL FOR STAGES of pressure ulcer, on various parts of her body. Essentially, Ms. E was a mess. A MRSA-positive mess.
Still, she would grin at us as we assessed her, occasionally pointing imperiously to her trach for us to suction it. Then she'd wink. It was kind of a riot. She had just had one leg amputated above the knee, due to gangrene, and I'm pretty sure the other one is going to have to come off soon, if her nursing home doesnt learn how to treat bedsores.
Ms. E was a full code, due to her family wanting to give her "all the chances they could".
Her roommate was ALSO a full code, with agonal breathing on another vent. Both alarms were constantly going off as the two women shifted their heads, or coughed. That's why, since the curtains were pulled around the other bed, I didn't realize that the OTHER alarm was going off. Ms. E's roommate had pulled off her vent, satting in the 40s. I heard ANOTHER alarm go off, with a different tone (the BP alarm) and checked, and then suddenly the room was FULL of people.

"Quick! Grab the AMBU bag, and bag her!" A nurse yelled, so I grabbed the bag, attached it, and began bagging...against very little resistance. It took a minute for my instructor to run into the room...she blinked, and said "What's going on?" I explained that I didn't know that the vent alarm was going off, and so this all was probably my fault.
Everyone laughed. "It's not even your PATIENT, and it's your first day! How were you supposed to know which alarms were for which patient? Next time just run around and check ALL the patients in a room."

She stabilized, and all was well...but I will NEVER let that happen again.

Labor Day

2009-09-07T19:31:00.000-07:00

So the apartment is finally in order! 3 hours of cleaning and organizing, another hour of getting Teh Interwebs installed, and i've got a place to live again! I am SO happy about it, because it means not inconveniencing someone when i come in late from classes.
The downside is that, as I live alone, and am not terribly close with most of my classmates, and the ones with whom I AM are working...I went this whole weekend mostly without talking at ALL.
I did make about 35 drug cards.

Some interesting nursing observations:
Cardiogenic shock is a very nasty thing to get- it basically means that your heart is no longer pumping in a fashion that lets it get blood into all the rest of your body...or at least not enough to get it into all the fiddling little places like does, noses, etc.

Ventilators: Bubbling in the FIRST chamber means an air leak- either its air coming down the pt.'s throat, through a hole in the lung tissue, and out the chest tube, or the tube has a hole. Check BOTH. If it's the lung, this should stop when the lung heals itself. DO NOT PULL ON THE TUBE.

Stopcocks: They are the DEVIL. Make sure they're closed the way you want them to be closed, or SOME nasty liquid is going to get all over the place. If you're LUCKY it'll only be the foul-smelling enteral nutrition junk. Couldn't they make it smell better? Please? (this one wasn't me...my instructor was so busy telling us how to work a stopcock that she turned it the wrong way)

Codes: hospitals have so MANY kinds of codes now (Pink, Blue, Black, Grey, Red, Yellow, Orange, etc) that NO ONE knows what several of them mean...for instance, apparently orange means "patient surge" which i ASSUME means "we're getting swamped, call for more help for staffing" but COULD mean "omg, somebody got accidentally defibbed!" Code pink means "baby abduction". This means IN ALL SERIOUSNESS that they lock the hospital down, and you're supposed to ask people if you can check their purses for hidden babies. Seriously. Hidden babies. I think there's PROBABLY some leeway in saying "ma'am, i think your purse is too small to hide a baby in"...but you never know.