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Category Archives: Nursing School

The “Ew, gross” Continuum

Apparently, I still have a relatively low threshold for being grossed out. Especially when so-called “gross out factor” is innocently paired with “the element of surprise.” When I walk into the trauma room I know, more or less, what to expect. A rush of adrenaline, perhaps a shocking sight, something to brace myself for. If I scour deep into my heart of hearts I am still stunned to find myself in the profession of nursing. I never saw myself in medicine, and it is not without a degree of disbelief that I find myself in one of the busiest ERs in the most populous city in the country. I am happy to be here, but I still feel like I have to prove that it’s not a wild dream to someone (maybe myself.) So, when I walk into the trauma room, along with my gloves, I also don a mask. It is a figurative shield of pseudo-bravery, utter calmness and serenity. Inside, my heart might be pounding and I may be thinking shitshitshit, but no one wants to see that on the outside.

However, I can’t pull on that protective mask if I don’t have a moment of fair warning.

I tried out my first 12-hour night shift the other day. I was paired with a wonderful preceptor, one who has many years of experience under her belt, and has oriented a plethora of new grad and recent-hires. She was very kind, no-funny-business, and utterly confident in my abilities. I did my best to live up to her expectations. I ignored my typical self-doubt and plowed ahead. The night sped by, hours melting away as I focused on remembering my patients, honing my skills, and keeping the facts straight. I assessed, I gave meds, I started IVs, I charted. Our partner on the team took “lunch,” so we took her patients. All along, my preceptor helped me organize my tasks, but took a background role to my work. Soon I realized that I was functioning more autonomously than I ever had before. Granted, I wasn’t flying completely solo, but I hadn’t crashed and burned either. I glanced at our chart rack and realized that I was caring for 12 patients. Twelve! I knew a little bit about each one, and what they needed from me. I felt pretty darn good.

Of course, my very next patient threw me a total curve-ball. A slimy, puss-laden softball. My preceptor told me to go assess a new patient that we had just picked up. There was a scant note from triage about a foot infection, and that he had left AMA (against medical advice) from another local hospital that very same day. She told me to get a history and help the patient remove his clothing and socks. I went in. I blanched at the smell. I stoically held my breath and put on my gloves. Our patient had already urinated in the bed and soiled his clothing. He was incontinent, but not because he was old, just because he didn’t care. I struggled to help pull his double-layer of sweat pants off; he didn’t help me. Suddenly, the fabric came free and I stumbled back a step, sweats in hand, along with one sock. What I saw made me gasp. No time to pull on the straight face. I’ll spare you the gory details, but the gist of it was a VERY fresh, and VERY infected total metatarsal amputation. I soon found out that the infection was osteomyelitis and the prior hospital had tried its full arsenal of antibiotics to treat it, with no success. Gingerly, I pulled off the second sock. My gift was a big toe amputation, in a stage of healing that looked much better off than the other foot, but certainly not pretty. The patient was not friendly, refused care, and stunk. I am embarrassed to say that I avoided his room whenever possible that night. He wasn’t a fun patient to treat, but he is one I will most certainly remember. It reminded me that I am still quite new, I am not an old hat in this business, and I can still feel shocked and grossed out. In fact, maybe I always will. It’s a spectrum, and my gross-out quotient has already improved dramatically. Maybe one day an infected TMA won’t even make me blink. Maybe, but somehow I doubt it.

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Dr. Seuss in room 4 needs emergent care, STAT

biggest smile of the day

No…I didn’t take a picture of a patient. But, I did take a picture of what, or whom rather, a patient left behind. Upon our 7am arrival, there was a patient sleeping off her intoxication. Not a rare occurrence in the ED, despite what one may assume is the purpose of the ER (emergencies). My preceptor sent me in to this room to see if I could elicit any information from the patient. Since most of my encounters with drunk people in the ED have been less than pleasant (think: belligerence, lechery, obstinate and loud) I was expecting more of the same, and braced myself. But when I walked in, I saw a middle-aged lady, with hands folded primly above the covers. 1st clue that things would go differently. I asked her about how she arrived here, and if she knew where she was. I was right in assuming that she was oriented times 3. And then she took me for a trip down storybook lane, telling me all about how she had no idea why EMS picked her up, she only drank 3 beers, she was in her own home, alone, not disrupting anyone. To top it all off, someone had stolen her pants and shoes. She was bottomless. Scratching my head in some confusion, I left the room, promising to seek out some clothing for her. I reported back to my preceptor about what I thought was our mistake. My preceptor laughed at me and then very gently pointed out the 28 prior encounters in our EMR that this very same lady had been in for intoxication. I had been hoodwinked. Sober patients are night&day different from their drunk counterparts. After finding this patient a set of bottoms and sending her on her merry way, I noticed the stuffed animal left behind. I guess she didn’t need it anymore. Another nurse set the Dr. Seuss character up in bed, as you see above and closed the curtain. When the 11am shift came on, this same nurse told one of her coworkers, “There’s an emergent case in room 4. Can you go assess, stat?” The nurse agreed and quickly went over to room 4…to find our little friend, all tucked in, with a flat-line for O2 saturation…

Ah, the joys of the ER.

 

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The Emergency Room or a Comedy Club?

Is that man being rolled in on a stretcher by EMS really singing opera? (Also noteworthy: he had a surprisingly good alto soprano.) If you happen to look in his triage record, which I did while puzzling over his diagnosis, you would read that it states simply and accurately, “Loud and singing.” Really?

Is this lady really refusing to remove her diarrhea-saturated panties and jeans because she has money in the pockets?  Upon closer examination, the pockets are actually safety-pinned closed at least 10 times on each side. Maam, do you honestly think I am going to steal your diarrhea-saturated money? Really?

Is that man-struck-down-by-car in the trauma room really arguing with approximately 10 residents and nurses and 3 attendings about the need to lie still while he is being examined because, as he (rightly, as it turns out) states, “I am a physician and I know exactly where I am injured!” He then proceeds to sit up on the bed, ignoring all protest, and removes the C-collar himself. Really?

While I wasn’t present for this, the story is far too good to go unshared. Young drunk lady comes into the ER asking every nurse/resident/doctor that she encounters, “Wanna see my kitty?” Despite stern admonishing, by a nurse that she needs to lie still and keep her gown on, she repeatedly keeps pulling it up while squealing, “Wooooo!” Finally an exasperated nurse says, “Put away your cookies! No one wants to see them.” Too true. But still, really?

Is the nursing student soon-to-be-nurse really still puzzling over the diagnosis of our lovely opera singer? Ah, drunk, yes, that took about 20 seconds too long. Really.

 

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Two Traumas, Lots of Drama

11:09PM, 1 hour after getting home from a 14-hour shift

Well, I am already behind on my pledge to document this ER experience. Little did I know just how draining 12-15 hour shifts can be. Especially as a nursing student fresh off the press, I almost feel like I am being thrown to the wolves every morning at 7am when I walk onto the floor. Luckily, (most of the time) I have a very protective preceptor who keeps me close under her wing, but it’s still a lot to take in for a newbie.

Today the trauma room saw its fair share of blood, gore and more. And I saw far more than my typical allotment. First a man came in who had fallen from a 30-story building. That didn’t last long. While in my freshness I was very much distracted by the nearly-severed foot jutting out from a protruding tibia and fibula and a matching skull flap, the internal injuries were the real outcome-predictor. Seasoned nurses told me that shearing forces can cause the entire aorta to rupture. I only spent a few moments in the trauma bay on that case, but it was more than enough time to be imprinted in my memory. The second case was more hopeful. A middle-aged man came in to the ER already in cardiac arrest with CPR in progress. Lost in the hubbub of the moment was a warning from a veteran RN for us NOT to cut off the man’s down jacket. But once the presiding resident made the call, all hands were on board cutting off and removing clothing at lightning speed. Soon there were downy feathers snowing down and nestling in every crevice. In an already chaotic scene, the sight of the feathers made it even more absurd. I served as the scribe, which was an excellent way to follow the rapid-fire succession of events. From no pulse and asystole, this man was successfully revived and stabilized with a v-tach rhythm before he was quickly shipped off to the cath lab. This was a much better outcome to be a part of. Minus the bird feathers and blood that tarred the floor at the end of the code…

One sad event that really stuck with me and I need to unload before going to sleep. We discharged a young woman who came in for seizures. Since we weren’t on her team prior to discharge, we asked for a brief history. She said that she fell down a flight of stairs during the seizure. My preceptor asked if she hit her head on the way down and the patient nodded, like it was obvious. She asked how she got help and who found her, and this poor young lady said, “What do you mean, who found me?” I took care of myself.”

My preceptor tried to clarify, and asked, “Oh, ok, but who called the ambulance?”

She responded simply, “I got myself up, and called it myself.”

For some reason that really sounded sad to me, and more so when my preceptor asked how she was getting home. She had no one to come pick her up and she didn’t feel safe going to the subway because of all the stairs, and her discomfort around trains. Even though she lived less that 2 miles from the hospital, she barely knew the bus lines. Taking her out to discharge, I glanced through the glass exit doors to see a dusky sky, quickly turning black. My sadness for her was almost overwhelming. No one should both come to the ER and leave completely alone, yet too often this is what happens.

Let’s leave this entry on a funnier note. My first patient of the day was a loud old blind man with an Albert Einstein-esque hairdo, who compensates for his lack of sight by screaming all the time. Anytime a shadow of a person walked by his room, he would yell, “NURSE, NURSE! CAN I GO HOME YET?” When asked to lower his voice by my sweet and mouse-like preceptor, he would yell, “I CAN’T HEAR YOU! WHY DO YOU TALK SO QUIET?” She would reply, obviously bothered by his loud volume, “Why do you talk so loud?”

“I STILL CAN’T HEAR YOU! WHEN AM I GOING HOME?”

“Sir!” Finally reaching to the top of her internal volume modulator, my preceptor gathers all her strength and yells back, “We can’t send you home until we have your lab results. Sir, we are getting them as soon as we can!”

“OH OK! FINE, WELL WHY DIDN’T YOU SAY SO?” Exasperated, my preceptor escapes the room. Thinking it’s over, I go onto the next patient, but it’s not two minutes later that I hear him again, “NURSE, NURSE, I AM READY TO GO HOME. CAN I GO HOME NOW?”

I don’t know why this was so funny, but somehow it was, and we were all laughing. In an ER, where things are so emergent and tense for so many people, sometimes you just need to take things a little more lightly and help others see the small humor in daily things as well. I find that I say cheesier jokes in the ER, and brace myself, expecting a courtesy grimace at most, but I actually get more laughs there than I do at any better jokes that I ever crack outside of the ER. Happiness is a hot commodity in the ER and it’s in demand. I like this work because no matter what, I always find reasons to smile.

 
 

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Entering the Emergency Room

In the wake a devastating tsunami, the nuclear reactor disaster and all the events that have succeeded the earthquake in Japan, it seems somehow appropriate that I begin my integration period tomorrow in the Emergency Room of a bustling metropolitan hospital. When I told the director of my program that I was very interested in Emergency Preparedness as a subspeciality, I had no idea that she would take my interest so seriously and give me an eight-week ER clinical placement. I feel so lucky, and also SO nervous. I am going to try to document this experience, as I work eight weeks under the tutelage and supervision of a RN. I will be taking her normal hours which means 12-hours shifts for a total of 36 hours per week, for 8 weeks.

In my anxiety-flavored preoccupation over what tomorrow will hold, I called my grandfather, for some sage words of advice. In typical fashion, he proffered a few more that I initially asked for, but absolutely helped to assuage my fears. When I told him I was afraid, he reminded me that it was normal to feel scared in a setting where everyone is having personal crises. Nerves run high, but he told me that among emergency personnel, calmness and composure are paramount. He reminded me that people work together in the ED like a well-oiled machine, and that I will never feel stranded. I hope this last part is true. He also told me something that I know: I will feel uncomfortable. I will not feel proficient. I will make mistakes. But then, I will ask questions and I will learn from these mistakes. If I don’t ask a question when I have one, that is the biggest mistake I can make. This is my time for learning, and I will learn.

He also told me that he knows I will be calm in the face of a crisis. I don’t know how he can be sure of this, since I am certainly not sure of myself, but then he told me about the night when my grandma took his own hypertension medication accidentally, and how terrified he felt. In response, he called his cardiologist at home (ah, the benefits of having doctor colleagues) who told him that he could manage the situation on his own, rather than bring her into the ED so late at night. So, my grandpa pushed his fear back and kept it at bay throughout the night while he stayed awake and cared for the love of his life. He told me that he fed her so much coffee, that by the morning he had induced hypertension in my grandma. Not exactly the most settling story for a granddaughter to hear, but very sweet all the same especially since the outcome was good.

My goal for these few weeks is to chronicle my experience, writing down the wisdom of veteran nurses for my future practice as well as the more fun and interesting cases that I run into. Now I just have to wait a few more hours to see what tomorrow has in store…

 
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Posted by on March 21, 2011 in Hospital, Memoir, Nursing School

 

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Bearing Witness

Beyond the overt medicalized interventions that drive healing, I see a role in nursing that now seems so obvious, but was completely elusive to me until recently. The far more abstract responsibility of “bearing witness” serves a number of purposes in this profession. My fresh eyes as a novice student nurse have already witnessed both ends of the spectrum, from a wasted young man’s body ravaged by AIDS to the most beautiful and awe-filled hour of my life: childbirth. Both hold their own meaning and purpose and both have a story to tell. Meanwhile, I have also struggled with my own friend’s disease process, faltering when trying to define my role in the difficult contours of her illness as well as in coming to terms with its unfairness.

In the realm of my friend’s illness, I have realized that right now I can’t be both her nurse and her friend. I live too far away to stay constantly updated on her care. I simply cannot travel to her hospital every weekend, because I have my own health and well-being to tend to as I wade my way through this strenuous program. It has taken a long time for me to fully appreciate, and believe, that I can only give what I have to give. Right now, I can be her friend. I hope that’s enough.

In difficult moments in nursing, I can do more than be a compassionate nurse. I can write about it, a catharsis for me and hopefully an advocate for someone. I can bear witness to the pain, suffering and disease. This is something I first started thinking about when listening to a presentation from Doctors Without Borders (MSF). I used to believe, incorrectly, that they were an organization that just ran into a country in crisis and provided brief, unsustainable interventions. Good first aid, but not long-enduring change. My opinion is beginning to change, especially after listening to an incredibly thought-provoking discussion on bearing witness. Do we provide humanitarian aid to the victims of human-devised tragedy like genocide without taking a political stance? Where do we stand? Who do we treat? I can’t answer these questions for MSF (nor would I even remotely want to try) but I like the concept of retelling the stories, bearing witness and trying to be ethical. I think that some of the “psychological first aid” that they provide in crises actually comes from the re-telling of the stories afterward, in words that reverberate across headlines, blogs and lectures like the one I attended.

 

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The Ilk of an Interview

There are so many kinds of interviews. From the factual nature of a journalist’s interview to the nurturing version of a therapist’s, I never considered all the different kinds that exist until now. The quality of interview that a nurse performs is unique in its own right but is also reminiscent of the compassionate contact that a friend might provide. In the didactic portion of nursing school, they teach you an alphabet of acronyms to remember, so that you don’t forget a single sign or symptom to ask for. But OPQRST, MAKING IT P, and OLDCARTS only get you so far. For me, the letters get jumbled in a heap in my brain and I can hardly extract one without tripping over another. It can be difficult to recall that the interview you are conducting is hardly more than a conversation. And most of the information you need will be provided if you just ask the right questions. Most of the questions we are told to ask are basic common sense.

Still, when my new nursing instructor for Med Surg charged us with the responsibility of taking a comprehensive patient history, the task was daunting. I went into my patient’s room timid and bashful, hoping that I somehow, impossibly, exuded confidence. My patient initially seemed reluctant to speak with me, a mere student, after he had shared his story probably a gazillion times before with people much more “important” than me. After a few minutes of probing gently, I was ready to throw in the conversational scalpel and call it a day. I had the basics: his chief complaint was chest pain that radiated down his left arm. He lost consciousness while doing pull ups and didn’t remember the specifics of his initial symptoms, but knew what it felt like when he regained consciousness. His past medical history consisted of a TIA when he was 30 years old, and an amputated leg from 1988. He is currently not much older than 30. Too early for a stroke and possible AMI? It seemed that way to me. Especially considering that he works out religiously, dare I say compulsively, six days a week. Genetics couldn’t be the sole cause of his problems. He is in good shape and it seems impossible that lifestyle factors play a big role. In asking about his nutrition (his cholesterol leaves room for improvement) he reported that he never cooks with salt, prefers to cook for himself than eat out, and consumes vegetables indiscriminately (except spinach, he amended with a shudder). We laughed together, and had a brief moment of friendly banter — about spinach, of all things! Without realizing it, our conversation began to flow. Soon I was able to insert more sensitive questions about drug and alcohol use without an inward cringe that he would close up tight like a clam. He responded well, albeit in the negative for drug use. Still no progress on why he was experiencing cardiac symptoms. Finally, I addressed the elephant in the room, his prosthetic leg.

By this point, our conversation was running smoothly like a well-greased bicycle. I was confident but still faltered over the question, not knowing what answer it would elicit. It was my patient that led the conversation now. He told me the story, with barely a word from my end as I listened and absorbed. As a young, prepubescent teen, he had been playing a game called “quarters” with a few friends on the sidewalk. Oblivious to their surroundings, they didn’t even look up as the events occurred around them in mere seconds that would change the lives of these young boys drastically. A drunk driver ran a red light and was T-boned by a car that had the right of way. The drunk driver’s car flipped up in the air and landed on the sidewalk, where the boys were playing. They were all hit. A few died instantly, a couple walked away virtually unscathed (physically, at least) and my patient was pinned between two cars. He spent two years in a hospital, recovering. One leg was mutilated beyond repair. The other one was in bad shape as well, but miraculously they salvaged it. His skull was “crushed,” although I didn’t get the specifics of what this meant. But suddenly, it all became clear. His early onset TIAs and unstable angina must be due, at least in part, to the trauma and stress he underwent as a young teen. All of this history-taking was essential for complete understanding of his current diagnosis and hospital admission. When I went to his chart, in hopes of filling in the gaps, I realized that I had more information in my head than was written anywhere on paper. Certainly I couldn’t interpret the troponin and creatinine kinase levels as well as one of his medical providers, but I had his background and health history, an essential part of his focused physical assessment. I felt like this was quite the accomplishment for my first day on the floor. I sincerely hope this bodes well for my five-week-speed-read immersion in the catchall speciality that is fondly known as “Med Surg.”

Now, if only I could take 30 minutes for history-taking with every patient, even after graduating from nursing school…Hey, a girl can dream.

 
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Posted by on January 7, 2011 in Hospital, Nursing School

 

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