nursing woes

     WOW, I just had the hardest week so far in my orientation to the ER. Worked my 3 days in a row. Now, up on the floors, I hated working 3 days in a row. Sometimes its cool to get your days done and have up to an entire week off before working again, but working 3 days in a row week after week got old real fast. In the ER it seemed to be not that bad working 3 in a row. Of course I'm talking about 12 hours shifts so it can get tiring mentally and physically depending on your patients. Now when I was on the floors I was working graveyards and that in itself could be taxing but the biggest problem is when working on the floors if you get stuck with shitty (figuratively and literally) patients. You're almost certainly stuck with them for the rest of your shifts that week when working them in a row. Of course you can complain about your patient group and get assigned another or give a  patient up but thats just not how i roll. AND, if you do give up your patients, you'll almost certainly get an even shittier group. What can i say, i believe in karma.
     So, about my week from hell. My first day for the week nothing stands out as really difficult or overwhelming, but I had just come back from about 6 days off or so. That is kinda hard to bounce back from as you're still in lazy mode. Now my second shift for the week was the shift from hell. I'd say i'm pretty good at handling stress. I've had hard shifts on the floor but at our hospital what makes our med-surg floors hard is that its a little more back breaking than other facilities would probably be. How do I know? Not because i've worked at other hospitals but because even our own hospital wasn't that demanding initially when i started working there. Say what you will about CNA's (nurses aids), I'm not the type that puts all my work on them, I like to consider myself as self sufficient. I was a CNA myself for a couple years. The thing is, having an aid there, even just to answer a call light and tell a patient i'll be there, or to take my vital signs, once during the shift makes such a difference to me as it helps me put more into the charting i'm supposed to be doing. Which is a big part of nursing as "if its not charted, it wasn't done". I agree but I think nurses begin to spend more time with the computer than the actual patient and thats a whole other blog on its own.
     Lets talk about my second shift before i get sidetracked again. For the sake of privacy, I wont delve into specifics, and some people may not have the stomach for what goes on in the ER. Heres the thing, I had two patients, one came in completely altered and didn't even know their own birthday the other we'll just say, is losing a lot of blood. The first one, after doing a workup and getting her stabilized. She is so much better and supposed to go to a med-surg floor. No problem, when i sent patients up to the floor, I do what I can and try not to leave too much left over work for them to do upstairs but at the same time I'm not going to do EVERYTHING. If its something i feel is somewhat critical like fluid boluses, antibiotics, or especially stat orders. Then yeah, i'll most definitely do them, but i'm not gonna concern myself with stool softeners or even some home medications. If a patient comes in with a blood pressure through the roof with a systolic of almost 200's and its down to 140's. I'll let the floor give the scheduled home med for that. I mean, half the time we dont even have those meds in the ER. Now, what I am adamant about is the patients safety. If i feel a patient isn't appropriate for the floor i'm sending them too then i'll do my best to get them upgraded. Lets take my confused patient for example. Doing so much better, actually talking, alert and oriented to everything. Complete 180, had some complaints of pain but this was a normal chronic thing. This person is supposed to go to a regular med-surg floor. The problem is that the blood pressures originally hovering around 90's/50's is now starting to dip and stay well into the 80's/40's and periodically getting lower than that. Of course she's not symptomatic, but in my humble opinion this is a patient that should be on at least a telemetry floor. Long story short, and i do mean long story, I got her upgraded to a stepdown unit which is basically between ICU and a telemetry floor. ICU nurses usually take 1-2 patients and telemetry nurses take 4 patients. So in IMC which is our stepdown, the nurses take up to 3 patients. Much more monitoring going on there. From beginning to end, we were having trouble with starting that patients IV's. The Paramedic wasn't able to start one. We started one, went bad, started another, went bad. Of course the first one i tried I didn't even get so she was poked at least 4 times. Last IV went bad just before I had to send her to the floor. Damnit sending the patient up without an IV sounded good right about now. Well its not in me to do that to them so I tried another and it worked great at least for the time being. And during this time my other patient bleeding profusely was there needed attention too.
     My bleeding patient, originally was supposed to get stabilized and sent home, which in my opinion wasn't the right decision. It really wasn't and in the end we got to admit him but not right away because that would have been too easy. This patient was supposed to be going to a med-surg floor and then in the end got upgraded all the way to an ICU floor. Yeah, pretty critical patient, as if all the bleeding wasnt enough, and all the tried and failed IV starts didn't top it off. To top it off we had 1-2 other patients at the same time who thankfully were not as critical.
      Now at this point in my preceptorship, the anecdote should just be about MY patients and not OUR. For the most part they are only MY patients but on this particular day my preceptor had approached me at the end of the shift and said she just couldnt let me drown any longer. I definitely was drowning though. I mean I could probably manage on my own but the whole IV thing simply had me on my wits end. It was like at one point I was stuck doing nothing and couldn't move forward. I knew I had to buckle down and just try one but it was seriously like, "who should I start with, the patient with nonexistant veins, or the patient with veins has already blown 5-6 times?" and this was in the middle of all the shittiness going on. Well, like I said my preceptor approached me saying she couldn't let me drown any longer, and at the same time told me that those patients were definitely hard and that is a situation where she most certainly would have HAD to ask for help because that was just too much for one person.

transitioning from floor nurse to ER nurse

       Im about 7 weeks into the ED or ER whatever you want to refer to it as... Emergency, whatever. It has been an accumulation of feelings thus far. Exciting is probably at the culmination of them all but dont doubt for a second there hasnt been nervousness, fear and and anxiety in there. People say I'm doing well, all I have to say to that is... "Im a good actor".. and really, thats what you need in nursing, some of you new grads will learn this. I've been a nurse for 5 years, so my acting is on point. First off, there will always be procedures you haven't done in a long time, that goes for every nurse. Your patients though, they don't want to know that. Heck there will be procedures you haven't done since school and you may have previously only done it on a mannequin. As long as you can walk in, get the job done without showing you're scared out your mind, no one will be the wiser. That said, I have a good collection of skills in my skillset from being a floor nurse, but I haven't done EVERYTHING, like starting IV's or even sticking babies.
   
     I made it very clear when precepting under another nurse for my ED orientation. I can take medical-surgical patients all day long. Telemetry patients (patients on a heart monitor), well, they're basically med-surg patients on a heart monitor a lot of times, and I can take care of them competently and be able to ask a question or two about heart rhythms if I need to. Pediatrics, well they can be any kind of patient of course its just that they're.... pediatrics, so here we start to delve further out of my comfort zone because peds can change status quickly from good to bad and handling their medications is a lot more delicate when it comes to doseages. Not to mention babies have tiny veins and parents that dont want you hurting their babies which can make procedures a bit uncomfortable. Then theres kids, depending on age, they can almost be handled like adults, young ones can be very inquisitive, and from what I hear, VERY STRONG, like HULK strength almost. Try starting an IV on the hulk while he's thrashing around. Ok, then theres unit patients, like ICU/CCU (intensive care, critical care units). This is completely out of the realm of my comfort zone and off into a far away galaxy. Nurses on these floors usually take 1-2 of these patients and have them the entire shift as opposed to say taking 5 patients on a med-surg floor for your entire shift. These patients usually are in bad shape, and have like 456,000 IV drips all hanging at the same time keeping the patient somewhat stable. First off they're telemetry patients, on a million IV medications that I'm not familiar with. I could be the Johnny Depp of nurses and still show my true colors of fear panic and anxiety. So as an ED nurse, we take all these patients stabilize them somewhat and then send them to the appropriate floors. Don't get me wrong, I'm willing to learn, jump in and do what needs to be done but I wont be 100% comfortable.

     So lets step back a little. About a week ago, I had a 45day old infant, came in with a fever and we need blood. Whatever, I'm all over this.. I can feel some veins, but its a tiny baby, so im kind of on the fence now because I feel a vein but you know, I'm not too sure. We got the smallest needle possible. We also, had a light we could shine through the babies hands and see all the tiny veins. Awesome, wait they look even too small for the tiny needle we have. So we go back to the antecubital (basically the elbow area but on the inside part of your arm that bends) nice.. i can totally feel the vein especially after my preceptor pointed it out to me. Does the parent know its my first time? No... but I have started a million and 5 IV's on adults before so this wasn't too bad. What made it weird was my preceptor was explaining everything to me, how babies have tiny veins, how they're hard to find when dehydrated, etc etc. What made it completely ok was that the parent in the room was responding with "ohh, ok, i see, oh ok". LOL he thought we were explaining it to him.. well in a way we were. BUT lil did he know, it was being explained to me too. So we have to hold the baby's arm down pretty well and poke the lil girl get flashback and im golden. See, when you start an IV or draw blood, you first wrap a tourniquet around the arm, the pressure in the vein kind of increases, you can feel the vein with your finger and when you poke through the vein, sometimes there'll be this sort of pop, you get blood in the chamber of the needle or IV or what have you and you know you're in. That "flashback" of blood goes with a sort of feeling of accomplishment especially with patients who are supposedly a "hard stick". This being my  first time sticking a baby, that flashback was such a huge sigh of relief. Of course the baby wasn't too dehydrated which would have made it hard but for a first timer, it was great because 1. now i can with confidence say "oh yeah i've done this before" and 2. I somewhat know what im doing as opposed to previously had ZERO experience. This put me almost on cloud 9.

     Lets step forward to a 2 year old I had about a week ago, after the baby. Little boy, super inquisitive,  been vomitting for a few days. Dehydrated, needed fluids, not a baby, but kind of on the other end of the spectrum. We go in, of course he's scared, even cries and yells out saying he wants to see the needle. I did my best to sort of console him or explain things thoroughly and gain his trust of course. Tourniquet on his arm.. and guess what, i cannot feel a damn thing! his other arm has a lil green spot where he has some sort of vessel but I've learned you can't really rely on those, and I can't even see where its going , if its straight or curves or whatever. Nothing in his hands, nothing in the antecubital. I'll be frank, I was kind of scared shitless. My preceptor feels around and says she feels one in his antecubital and points it out and so i feel for it and my immediate thought in my mind goes something like, "oh ok i feel it wait what?". I felt a lil something, and then I didn't and wondered if i even felt anything. Now I have no problem trying but this poor kid, I dont know, I feel bad for him, i HATED needles as a kid. My preceptor says to me "here hold his arm" and im thinking "ohh ok god i hope she tries and doesn't make me do it". Honestly thats probably the first time i've felt the need to step back and ask someone else to do it for me. Its like she read my mind. So we tell this brave lil kid not to move when he gets poked because we dont want to have to do it again. She sticks him, advances, pulls back a lil advances a different way, pulls back a bit and advances a slightly different angle and gets flashback.. HALLELUJAH! And the kid didn't move an inch. Seriously he was a brave lil dude i didn't just tell him that for nothing. I get his fluids going and my preceptor and I talk about it. She says she had a hard time finding the vein and he was pretty dehydrated coz his vein was barely palpable and had no buoyancy, which it didn't, thats exactly describes what i was thinking in retrospect when i was feeling his vein. So i didn't do that one, which im glad i didn't, but it was still a learning experience. I have no shame in that one honestly, because had i had that patient on my own, that is one i wouldve had someone else do for me.
 
    There are different degrees of difficulty with patients when it comes to IV's and other procedures. You kind of have to pick what your comfortable with and either try, or not try. Sometimes you'll fail and sometimes you'll succeed. Eventually your comfort level will get higher and higher. BUT, you have to at least try, I know floor nurses who never try and guess what, its safe to assume they suck. I dont think im all that bad at IV's. Some people come to me to start theirs but believe me it wasn't always like that. I would try and fail and have someone else try and today I  still go to other people to start my IV's if i can't get them but it just happens a lot less often these days. So dont be afraid to try at least once and on the other end of the spectrum, dont be afraid to step back when you need to and ask for help. Nurses are great resources for help and advice. Not everyone knows everything, and when you feel you know everything, thats the day you need to quit because THAT is just scary.

who am i?

Hello, I'm a rather complicated individual who enjoys a healthy lifestyle while succumbing to many guilty pleasures. More hobbies than my time allows. I was an RN on an orthopedic floor (broken bones, and back surgeries), which also took oncology (cancer) patients. I did this for close to 5 years. Due to the supposed economy's effects on healthcare. I had to choose a new path within nursing and made the switch and became an RN in the Emergency Department. On my days off, I love to sleep, which has been a favorite past time since I've been working the graveyard shift for the past 6-7 years or so. Other than that, I like to ride motorcycles, and previously was in love with the gym and fitness but have found a new challenge in Brazilian Jiu Jitsu (bjj). So, this blog will be a collection of random thoughts mostly, stories of my new journey through bjj. Also anecdotes and thoughts from life of an Emergency Department (ER or ED) RN in order to help myself reflect on different things I experience while trying to minimize how jaded i get. Don't be surprised if you read a few things about motorcycles and guns. Come take a ride with me...