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Real ER Nurses Don’t Cry

I wrote this post in mid-March…one year from the date that I first started my stint in the ER as a nursing student. I never published it…I’m not sure why, but here it is now. I am feeling so much better and it is really nice to read this post, just two months later…

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I am no longer a student nurse, no longer an orientee. It is unofficially my 1 year anniversary in this ultra-urban level 1 trauma center ER, yet it is actually only my 2nd month off orientation (which was a six-month endeavor), and now here I am, rolling along, sort of wobbly, like a kid on a bike without training wheels for the first time. It’s funny how impatient I am for confidence. I expected after 8 months of being a RN, I would feel better…not fearless per se, but better than this. I like the ER, but I don’t love it. I always take a very deep breath before going in and brace myself for the assault that I know (most nights) is inevitable. I know now that I wasn’t built for the ER long-term. I’m not a huge fan of blood and guts (though I’m pretty proud to say that I have nearly perfected my mask of nonchalance) and I consider it a great night in the ER if we don’t get any terrible traumas or cardiac arrests. Funny, because most ER nurses get their kicks from a “good” trauma. I just pretend to understand that.

I’ve noticed that my moods have been more mercurial these days. Part of this I attribute to the recent passing of my wonderful grandfather. But I also suspect that my newfound capriciousness and random bouts of teary-eyes may stem from sadness and intensities that I haven’t found time or energy to deal with from the ER. Again, why am I not blogging? That always helped me before! But then again, I am a morning person…living on the night shift. I’ve noticed that I have also been cooking less (I crave cereal ALL the time), knitting less, and even exercising less. I really need to fix this lifestyle…it’s gotta be possible to live a normal life on the Night Shift!

One thing I like about nights, though, is that sometimes…sometimes, I get the kind of quality time with my patients that I got in the nursing home. It never felt like there was enough time on the Day shift to ever spend that kind of quality time with a single patient. But on some nights, the really good ones, there are nearly empty hours. I only have 3-4 patient that are “mine” and I really get to take my time.


On one such night, I was working a patient up for chest pain. He knew the drill, he had been to the ER plenty of times for much of the same. An older gentleman, he was a little gruff and curt with his words in the beginning. He was polite, sure, but not exactly a fount of engaging conversation. However, as the night wore on, and more patients were discharged, I had the opportunity to check on him various times. He was asymptomatic and in the wee hours of the morning, our banter developed. Shortly after his second set of labs came back, it was discovered that his potassium was quite elevated. This is the moment most nurses dread for their bed-bound patients. I include myself in “most nurses.” This is the moment of the Kayexalate. And to be quite honest, most patients aren’t exactly jumping up and down for it, either.

The elixir of Kayexalate is an ominous-looking thing, and its looks reflect its purpose. It comes in a small plastic bottle, and pours into one of our styrofoam cups like a long viscous concoction, slightly lighter brown than Hershey’s Chocolate Syrup, but of the same consistency. Most patients get two bottles for a dose, which comes out to be more than a 2-swallow shot. Nurses hate it because it makes their patient have MANY bowel movements, and patients hate it because it tastes bad (or so I’ve heard) and, well, the same other reason — MANY poops.

So, when I introduced the elixir to my new friend, I didn’t exactly expect a warm reception. But there he was, grinning, saying, “Ah yes, I was wondering when I would get this.” Surprised, I asked whether he had tasted it before. “Oh, yes,” he assured me, “My potassium is ALWAYS high. And I just love this cocktail,” he said, grinning some more. Surprised, I proffered the styrofoam cup, and he took it, immediately raising it to his lips for a sip. Yes, a sip! Not a chug and grimace, or the other many expected responses, but instead a small sip with a smile as if it were a fine scotch. “Ah, cinnamon,” he said. And then another sip, “And a touch of vanilla,” another sip, “and dare I say apple pie?” By this point I’m not just smiling back at him, I am actually laughing. Clearly, he is playing with me. But it is such a welcome change from the usual replies. This man reminds me of my residents at the Assisted Living Home. He is graceful in his aging, he is not remotely angry to be awake and drinking Kayexalate at 3am with a nurse in the ER. In fact, he is making it a fun experience for everyone. And this is what my patient taught me. As much as I can, I want to treat this experience in the ER as a chance to make the night better, lighter, less serious, or just more comfortable for my patients and myself.

 

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A longer silence

I have been marinating on my Pediatric experience (known as Peds in med-speak). Since we’re not left with much time for personal reflection in this ridiculously accelerated program, I haven’t really known what to write about it…a longer marination than is normally necessary for a spring chicken.

I guess the geriatric population was easier for me. It’s not always easy to see someone grow older, weaker and sicker, but I find it much more “right” and natural than seeing a kid in pain. Hopefully the elderly have lived long, fruitful and productive lives and feel full to bursting with rich experiences. While I know this is not always the case (and I know this is going to sound a bit uncouth/crude) at least they had their chance, right? What chance does a 5-year-old with leukemia get to truly live, run and play? What about the 14-year old boy knows more about his brain tumor and T cell count than about the English, Math, or Social Studies that his peers are studying in high school – which he hasn’t even been able to attend even once due to his illness. How can I even begin to relate or fathom the unfairness? I can’t yet, and I know I can’t. They tell us that we have to empathize yet at the same time somehow manage to avoid sympathy, but let me tell you, that is a mighty hard thing to do when a scrawny, bald chipmunk-cheeked teen boy with impossibly long eyelashes is trying to choke back tears while telling you how scared he is of his disease, but ironically even more scared to go back to high school where he will be “looked at funny” by his fellow classmates. How do I respond to that? Or when I watch him nervously vibrate his wasted leg while speaking with the attending doctors about his disease progression, and what exactly they mean by “plan B” if the chemo and doesn’t work this time, just like it didn’t last time, or how the surgery didn’t the time before that. Instead of protecting him, which I can’t do, I do the only thing I can do which is treat him like a normal boy, and work on a puzzle with him, hoping that for a single second maybe he will forget where he is and what he is dealing with.

Doing my rotation on a hematology oncology floor of a children’s hospital is difficult in many ways. Every morning I steel myself for the onslaught of emotions, and sometimes I do it too well, and then I just feel numb. But that isn’t right either and I obviously haven’t found the perfect balance. When I am numb, I am ineffective. Like when you have a numb cheek from Novocaine, you chew funny, you feel awkward, and something’s just not right. That’s how I feel on the Hem-Onc floor and I know it’s not quite right either even if I am not running out of every room sobbing which clearly would be even worse!

On Thursday, I had the amazing opportunity to do a day-long rotation in the Pediatric ER. Ironically enough, however, the first patient of the day was a teeny weeny 3-year-old with leukemia presenting with a fever and elevated heart rate. The poor little girl knew what was coming, she had been there enough times to know the torture that was about to ensue as we poked her with needles, drew labs from her central line, and hooked her up to an EKG. The entire time she whimpered and cried, but remained incredibly compliant. As her miniature chest heaved with sobs, she held up her shirt for us to access her Broviac with a bigger needle than has ever been stuck in me! When asked which finger she wanted her pulse oximeter monitor to be placed on (completely painless) she still cried but held up her trembling right index finger for us to wrap it on. The entire time, Mom was curled around her poor little baby, comforting and soothing and wiping her tears. Dad was standing by, murmuring soothing words to his little girl. The older brother was also there, sitting quietly in the corner, obviously accustomed to these events. My emotions totally got to me here, I hadn’t felt prepared to deal with a leukemia patient on my day in the ED. I swallowed the lump in my throat and blinked quickly a few times. But in a weird way, it felt right. I was seeing treatment from a different angle, and in this case it was reassuring. The nurses were incredible – even in an emergent setting, they were calm as can be. They reassured their patients with their demeanor and caring touch. They moved efficiently. In a matter of minutes, this little girl was assessed, and labs were sent off. We moved on to the next patient of the day…and then the next…I saw so many different things and I saw the beauty of how well triage, nurses, support staff and attendings can all work together to care for people in distress. It was amazing and I learned more in a day than I feel like I do in a month of didactics. I know both are necessary for my learning, but this was also food for my soul.

 
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Posted by on September 11, 2010 in Healing Spoonful, Hospital

 

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