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Craziness and Cookies for Peace

This story does not make me look like an angel. Yesterday, I was severely annoyed by a patient. This patient drove me so crazy that I wanted to pull out my hair, ignore her completely, or worse, make her disappear. It wasn’t that bad from the beginning. While I knew she had a psych history, and had been to multiple ERs with the same complaints, and had same tests done and had been medically cleared any number of times, it’s not in my nature to immediately distrust a patient that I have never met. But with a large load of patients already, and a busy day ahead, it soon became clear to me who was the truly ill and who fell to second (or fifth) priority. And with a steady stream of complaints and demands with seemingly no relief, I soon grew exasperated. Probably more so than I have felt ever before in this setting. It is not a good feeling, and it colored the quality of my care for this patient and tinged my mood for the entire day. I was not at my best. Less than super nurse, to say the least. She was with me all twelve hours, my lovely lesson of the day. She was constantly telling me how sick she was – as if I could forget. She told me again and again that the regular doses of pain and anti-nausea medication that I was giving her had done nothing at all and she would rate her pain as ten out of ten, and later twelve out of ten. When I paid attention to her it was almost worse than when I ignored her. I hate to say it, but I realized that I had to be firm and set limits with her so that I could safely care for my other patients as well. It was a hard lesson, but very necessary. And when she was finally medically cleared (with yet another CT scan, that she demanded) she still wasn’t ready to leave. Multiple physicians tried to use reason, and I did my best as well, but we could not get through to her.

Then suddenly, while I was in the midst of drawing up medications for another patient, an old man appeared at my side. He said he was her father. He looked nearly as tired as me. But with a sweet smile, he asked me if she was medically cleared, and if so, could he take her home? Unanticipated, a huge sigh whooshed out of me. I told him that yes, she had been cleared. Another sad little smile and he said, “If she is clear, then I can take her off your hands.” This small stocky man with the unruly grey Einstein-esque hair and disheveled appearance–sweater pulled taut over a slight paunch–was my knight in shining armor. And after a full day of caring for this patient with no relief or remission of symptoms, arguing with her about her diagnosis (or lack thereof) and just generally sweating over her care, she meekly followed her father out the door. That easy? For me, it was. That was one day for me. One hard day and then I get to wash my hands of it. But guess who doesn’t get to do that? Her kind mother who called earlier in the day to inquire about her status and her sweet father who came to escort her home and ultimately ended the circular game of discharging someone against his/her will, sick or not. Mother and father will never wash their hands of their daughter’s illness and neither will this woman herself, who is clearly sick in a way that the medications in our Pyxis simply cannot treat. I left very sad, and frustrated. Our system isn’t very good at dealing with the mentally ill. In fact, I would even go so far as to say that the system failed this patient, despite our well-intentioned efforts, and that makes it fundamentally flawed. Clearly, I don’t know the whole story. I only saw a small piece of the puzzle. But, I know something different should have occurred to stop the cycle of her using the ER like a revolving door. Should she have received a psych consult even though every complaint she had was physical in nature? The clues of prior visits point to yes, although clearly this is not a means to a permanent end since prior psych consults have not yielded answers or an end to the behavior. And should she have been assessed for an addiction? Perhaps. It is hard to say without knowing more of the story than her singular ER visit.

What I do know is that the very next day, while putting a chart away at the charge nurse’s desk, a little piece of me shriveled up inside when I heard her voice behind me saying, “Oh, Rachel…I’m back. This time I am really sick!” There she was, brought in by EMS…AGAIN…on a stretcher. She told me that she was still feeling terrible, and that “they” had called her back because they had seen something on her CT scan when re-reading it. I have to admit, I held my breath and crossed my fingers that our team wouldn’t be assigned to her care. And it wasn’t. But the Communications nurse later told me that the look on my face was priceless when the patient called out my name, she said she cracked up, and only for that reason was the patient not assigned to our team again Only in blog-land can I admit how grateful I was. After another 12 hours of her in the ER, with so many other patients, I may have quit my job on the spot. Obviously, I need to learn to better outlets to control my frustrations, because not every patient is pleasant or kind. I am working on learning not to let my crazy patients make me crazy as well because then i really can’t help them!

And now, a recipe for peace. Tea and these cookies, combined with a little yoga on the side help me stay externally peaceful in the ER.

simple lemony cookies

Ingredients (I doubled this recipe and kept one log in the freezer for later use at a future tea party date!) From: VodKitchen
  • 9 Tbsp. butter
  • 1/2 cup fine sugar
  • 1 large egg
  • Barely less than 1 cup all-purpose flour
  • 1/4 cup quick cooking oatmeal
  • 1/4 tsp. baking powder
  • 1/2 tsp. salt
  • 2 lemons for zest
Preparation
  1. Put your softened butter into a food processor with the rest of the ingredients (save the lemon zest) and process until smooth.
  2. Finely grate your lemon zest. Stir the zest into the cookie dough and mix together well. Spoon on to a piece of plastic wrap and roll into a sausage shape with a roughly 2 1/2-inch diameter. Chill the dough in the freezer for 30 minutes.
  3. Preheat the oven to 375°. Get your chilled dough out and cut it into 1/4-inch thick slices. Place these on two cookie sheets, making sure you leave a good bit of space between the slices because they’ll spread while cooking. Place the cookie sheets in the middle of your preheated oven and bake for about 10 minutes, until the edges of the cookies are golden brown. Let them cool down slightly before transferring to a wire rack to let cool completely.

Also great made with orange zest instead of lemon, and served with tea, coffee, or hot cocoa!

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Comparing myself to overcooked pasta…

Every night leaving work, it’s like the energizer bunny coming to screeching halt after a nonstop day of go-go-go.. On autopilot, I resist collapsing like one big gelatinous noodle. In some recess of my brain I know that my bed is better than train tunnel for sleeping. Thus far, I have always won against my limbs, thank god. Not that I am actually complaining. This is exactly what I wished for: bedside nursing, interacting with people as much as possible, constant learning, and never sitting at a desk in a cubicle. I got all of those things. So far, no matter how tired, frustrated or emotionally drained I am at the end of a hard day in the ER, I am still excited to go back (after a solid night of rest). I can’t say how long this honeymoon phase of our relationship will last (me and the ER, that is) but I am really hoping it’s a not a fleeting feeling.

As a new nurse, I am always running, my brain whirring, trying to anticipate the next step. In the beginning, I had plenty of time to learn my patients and know them fairly well (at least well for a brief ER interaction) but now as I grow more adept with my few patients, I have been taking on more patients, and more. It’s hard to know them as well now, often, just staying on top of their medical case is the best I can manage. Sometimes I yearn to spend more time with just a few patients…respond to all their “real” needs as well as the self-professed “real” needs, instead of triaging their professed needs myself. (For example, bleeding wound=real need. Fix it: clean, gauze, tape, presto-donezo. While, “I’m starving, I haven’t eaten in 18 hours, get me some food now,” is not a real need…I am sorry but it’s not, when the guy in the next bed is bleeding.) I want to respond to all needs equally, which is simply impossible in the ER. I have to make snap decisions, which clearly doesn’t please everyone. The flip side of wishing that I only had a few patients, is that obviously there are some patients that you would much prefer never even crossed the threshold… Luckily, there haven’t been many of those.

Sometimes it’s impossible to miss a special moment though. Yesterday, I had an elderly patient with a laundry list of geriatric problems — Alzheimer’s, Parkinson’s, new onset seizures, the works. Oh yeah, and probable pneumonia on admission. The wife (who looked much better, I might add, and at least 10 well-preserved years younger) claimed that her husband, on a better day (pre-pneumonia, I imagine) walked around the house a little bit, and even spoke occasionally. Pretty incredible to believe from what I saw lying on the stretcher. Nonverbal, limbs contracted inwards, shivering and weakened by illness, he was a full workup waiting to happen. He was in my care all day, while being screened into the ICU and then waiting for a bed to become available. While we drew labs, waited for results, started broad-spectrum antibiotics and gentle fluids, and periodically changed his sweat-soaked sheets, I watched the wife interact with her feeble and febrile husband. He never spoke, but she spoke to him and seemed very certain of what he needed at any given moment. She, dressed in a smart red suit with perfectly arranged hair, sat at his bedside for hours upon hours. And this is no private room either. The ER is full of incessant beeps, whistles and alarms, combined with a cacophony of human-emitted noise – complaints, moans, the works. It can’t be pleasant for a patient or a family member (not that I particularly care for it, either). Yet, she calmly and gracefully sat by his side and thanked us for all the care we provided, not once blaming us for the slow pace of diagnosis and admission to the ICU. At regular intervals when I checked on him, she would be stroking his forehead whispering gently to him, or rearranging his pillows and blankets, or spoon-feeding him miniature bites of applesauce. It nearly brought tears to my eyes, such tender and private interactions that I witnessed as my patient’s nurse. These are the moments that I live for and that I strive to reproduce as a nurse for my patients that have no one at bedside. If this patient had been all alone, I might not have known a single thing about him other than the details of his illness. But with his wife at bedside, I learned that he had someone who loved him dearly, and he probably loved just as tremendously in return. Learning these little tidbits reminds me that my patient is also a person, with a story all his own beyond the hospital stretcher. On a busy day, there isn’t often time to find out the stories of every individual, but it’s important to remember that they all have one.

 
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Posted by on October 13, 2011 in Emergency Room, Healing Spoonful

 

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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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