time to fly the nest

It may be time to leave my first nursing job. I have been here five years, they trained me as a new grad in the ER and I have loved it. I learned the skills and art of ER nursing from some excellent mentors. I know I chose the right profession, I love the mystery of figuring out what is wrong with a patient, hearing their stories. I love the challenge of dealing with difficult situations and patients. I especially love the excitement of stabilizing a really sick patient and the teamwork that happens when it gets crazy.

I have since taken on a second job at an urban trauma center and have stepped up my game to take care of critical trauma patients. This hospital is a teaching institution with an awesome staff of doctors and nurses. It is a pleasure to work with them and I have learned so much in a short time just by the sheer exposure to many types of patients. To do this I am working many shifts, days at one job and nights at the other job. I was always afraid of working nights but it turns out I LIKE it. Night shift fits my body clock, I have never been a morning person and have always stayed up late. I find now that I am dragging on the days I work day shift.

I need to let go of the day job, the one that took a chance on me as a brand spanking new grad, the one that trained me to be a nurse. The manager that hired me is gone now, replaced with a manager that treats us like warm bodies to fill the schedule. I know it is time to go, but I am finding it hard to leave. The department is at an all time low right now, morale is low, per diem nurses are leaving for other jobs. The only ones that are staying are the ones that are vesting in the retirement.  I have only been here for 5 years though, and only 2 of those as a benefitted position, I’ll be dead before I vest in any retirement since I came to this profession late.

Welcome back

I have not posted for almost 4 years! What happened? Life happened and it still goes on.  I am still an ER nurse, still working in my local county hospital ER, but I picked up a second job at a large urban level 1 trauma center.  It has been a goal to work in a trauma center and be in the middle of the chaos and excitement. I started there 18 months ago and am now fully trained to take care of whatever patient comes in the door. I love, Love, LOVE my job.  I work with great staff of nurses and docs, including med students, interns and residents. I learn from just standing in their midst, although we rarely just stand around. This ER is busy, I work night shift there and it gets crazy with crashes, falls, gunshots and stabbings; not to leave out the regulars, drunks and psych cases. Never boring.  My other job now feels like a walk in the park.

As for the other job, I have moved from being the new grad to teaching the new grads. I am now precepting my fourth new nurse. I really like teaching. Although we don’t get compensated at this facility for it, I feel like I get to train someone to be the kind of coworker I want to work with. I work very hard to encourage them and foster a helpful collaborative attitude.

I have a few new goals, first to pass the CEN. The certification exam for Emergency Nursing.  I also want to get beck to regular blogging. I find that writing helps me sort out my thinking and my emotions. I am usually exhausted when I come home from work, then by the time I have recovered, I have forgotten details about what I want to blog about or I am headed right back in to another shift. Any suggestion from you readers about how to be better at this?

Until next time…

Compressions compressions compressions

The new recommendations are out for CPR from the American Heart Association. They advise compressions only, 100 per minute. It is more important to perfuse than ventilate. My new favorite blogger, Life in the Fast lane has posted a nice summary. Or check out the AHA directly. And always be ready.

no longer a new grad

So hey, yesterday marked my 1 year anniversary of being hired in the ER, my first job out of nursing school.  Does this means I am no longer a new grad?  I am not sure.  The learning curve has been steep this past year, with lots of scary moments when I felt like patients lives were truly in my hands. I have survived that first year and have emerged with more confidence at being able to handle any patient that comes through the door. Now I can get IV’s in most patients, even the long time drug abusers that have no veins left. I can rely on my gut feeling about a patient’s condition enough to confidently bug the doctor to take another look. My biggest thrill is to have an experienced nurse ask me for my thoughts on a patient or try for an IV that they have missed.

The other day I had a stroke patient that met the criteria for tPA. I was shaking in my Danskos as I pushed the loading dose into her IV and turned on the pump for the tPA drip. She didn’t bleed, and began to show slight neuro improvement. It wasn’t the miraculous recovery we all hoped for, but we didn’t cause harm.

Do no harm. I have managed this year not to make any of my patients conditions worse, mostly I am able to help them and send them on their way feeling better than when they came in.  I never realized how much teaching goes on in the nursing role and I am getting much more comfortable at it.

I still feel new at the job, but much more confident now. Many things come naturally now that felt awkward a year ago, and I don’t have to look up infusion rates on every single antibiotic anymore, I know them.

I will continue raise my eyebrows at what patients decide to insert into various orifices.

nursing is my fitness program

There have been some studies that show that standing up while working is better for you than sitting at your desk all day. Duh!  “Your chair is your enemy” says New York Times Opinion writer, Olivia Judson I chuckled as I read this after I spent nearly 2 1/2 years as a student studying in a chair, on the couch, or lounging in bed when I wasn’t sitting in a classroom!  I  have never had a desk job,  so I can’t speak from experience about what it is like to sit in a cubicle and work at a computer day in and day out.  I used to do lab work which involved lots of standing at the lab bench. Then I had my own photography business in my home while I was raising my kids. Didn’t sit around much with that either, if I wasn’t chasing one of my own kids, I was chasing one of my clients, or traipsing around in the parks looking for good portrait spots.

Then I went back to school and had to spend hours reading and studying.  I wish I had had one of these treadmill desks then!  Today I read a piece from Macworld, Stand While You Work, and it inspired me to write this post.  The author talks about how he converted his desk to a standing work station and the other adjustments he had to make to take care of his feet.

I jokingly say that nursing is my fitness program  because as an ER nurse I rarely sit down.  In part it may be because I am new at it and not as efficient as the veterans, but I am constantly walking, running, pushing or pulling heavy things, reaching, bending down, balancing, and squeezing myself into positions while working with a patient. I actually like this part of nursing, I have never been one to go to the gym, many health clubs have made their money off of me because I will sign up with the best of intentions and then after a few weeks or months stop going.  I get bored easily and frankly exercising is not my idea of a good time.  But the physical activity required of me to do my job makes up for it.  When I get home I am physically as well as mentally tired.  This picture isn’t in my ER, but it depicts a typical scene in mine.  The beds are always full and patients line the hallways, and those hallway patients are often commenting on how busy we look, they are not usually the ones that complain that we are not getting to them quickly, they see what we do…. for 12 hours straight.  I have to say that in the six months (I can’t believe I have been there six months now!) I have been working, my body feels good. I am active, I am using muscles that have been dormant too long, and I am dropping pounds (not at a huge rate, but enough).  I live close enough to the hospital that I often walk to work and some days the walk home seems to take forever because I am so tired, but it does me good.  I see far too many patients with health problems stemming from a sedentary lifestyle and poor food (and drug) choices, that I am grateful to have a job that works for me this way.

Now, my couch is inviting me to put my feet up and relax on my day off. A body does need rest too.

Change of Shift

A year ago I was still in nursing school and in total awe of all the nurse bloggers I was reading when I should have been studying. Now not only am I working my dream job, I am hosting Change of Shift! It is such an honor to be counted among the ranks of all those nurse bloggers I am still so in awe of.  I hope you all enjoy reading this edition.

We’re starting off with Mother Jones and her commentary on Change of Shift: The Art of Giving Report.  It really is an art, especially at the end of a 12 hour shift to be able to pull enough brain cells together to make coherent picture of our patients to hand off to the next nurse.  Mother Jones talks about “dumping.” It is bad form to do this, REALLY bad form.

Another thing that is REALLY bad form is introducing infections in the hospital. Tess submits her friend, Lynn’s post with some very wise advice “Don’t disconnect IV administration Sets”. Well, DUH! but how many times have we done this very thing to get our patient changed, or even let them go to the bathroom! Great reminder Lynn, we all know this is bad, but our rush to get stuff done often finds us using this shortcut.

Rehab RN reminds us that the words that are routine for us, are life-changing for our patients. We must remember to listen through their ears sometimes and be compassionate as they wait for their Prognosis. Thank you for this glimpse into the waiting.

While I am short on experience, I am long on compassion and that is what keeps me going. That and the faith that I am having an impact on my patients now that I am In the swing of things as mamatrauma in my dream job in the ER.  I hope I can keep that going as the years go on….

…..and on.  We think our current way of thinking will never change and we tell ourselves “I will never fill in the blank“, we are so sure.  Kim over at Emergiblog talks about her experience with this in her post Five Years On… All I can say is never say never, I always end up eating my words.  Kim mentions that it was getting into blogging that inspired her, we are so glad you did ’cause your blogging inspires us as well!

Some may say that social media has no place in medicine but Not Nurse Ratched entertains us with her story about a patient and Facebook. NNR never fails to entertain me, she is funny and full of useful information for all us nursing geeks. Check out her post Facebook in the ER and you’ll have a good head shaking chuckle.

Are you considering a change? Thinking about travel nursing? David Morrison at Travel Nursing Blogs has some things for you to think about as you choose which assignment to take. Read  Ask a Travel Nurse: What should I look for in a first travel nursing assignment? before you sign on the dotted line.

Speaking of advice, Dr. Dean has financial advice for Nurse Millionaires. Well, I am not one of those yet, but at least now I am getting paid to work instead of paying tuition to be allowed on the unit!  Read about how to protect yourself from identity theft in Scam, Spam, Phishing/Thank you Ma’m:How Millionaire Nurses Protect Themselves.  Looking for a career change that will use your nursing skills? Look at what Victoria Powell has to say about Nurse Life care Planning as a field. It just may be your thing.

When it comes to the blogosphere there are lists galore. It is heaven for those in search of information. I bring you lists of interest to health professionals. First, because we are enamored with how the body works from the Nurse Nut, 50 Incredibly weird facts about the Human Body. Amazing and bizarre, check it out.  At the risk of stirring up debate, here is Miranda’s list of 25 Little known facts about the National Health System in Britain. Lots of facts I didn’t know, 30% of their workforce is nurses and they are one of the largest employers in the world! That’s a lot of nurses. Pretend you are in the check out line in the grocery store and read about The 10 Scariest Celebrity Malpractice cases. The sad part is this is just the tip of the iceberg in medical errors. The fact that they happened to celebrities doesn’t make it worse but it does get people’s attention.  And finally for those of you who tweet,  25 Twitter Accounts every Nurse Practitioner Should Follow according to Linda at E-MED News.

Thanks for reading. I hope you have enjoyed this edition of Change of Shift as much as I have enjoyed pulling it together. If you want to submit for the next edition, it is being hosted at Nursing Student Chronicles. Send your submissions to laney1210@gmail.com  or by using the carnival submission form. Past and future hosts can be found on the blog carnival index page.

In the swing of things

I just finished working 5 shifts in a row and am beginning to feel like a real ER nurse now. I still think I need a sign that says “new nurse” on my forehead though.  Now that I have been in the department for all these months, and because I am older, the docs forget and think I am one of the nurses with 30yrs experience!  They expect me to be familiar with many more diagnoses and more efficient in getting things done for my patients.  It is nice however, that they now come to me about the patients instead of my preceptor. I am starting to develop relationships with them and gain their trust to be their eyes and ears with the patients.  I am beginning to trust my own instincts  a little more too. I had a 1 yr old patient this week that was pretty sick, he just LOOKED sick from the moment I laid eyes on him and it turned out to be true, his WBC count was way elevated and he was dehydrated. He wouldn’t drink anything and he just had this glassy eyed look about him.  We ended up transferring him to Children’s Hospital.

There was another patient I had last week that was confused and altered from alcohol encephalopathy. She was completely disassociated from reality and fearful. Her skin had a yellow cast to it, her sclera were definitely yellow. She was tremulous too and at one point seemed like she was having a seizure but did not lose bladder or bowel control and kept talking through it. The doctor wanted to just pump her up with ativan, he thought she was going through alcohol withdrawal.  I talked to her sister who had been caring for her, and was convinced that she was  not drinking.  She didn’t smell like it ( I can recognize that smell now) or act like it.  Her blood alcohol level came back undetectable and her ammonia level was elevated.  What she really needed was thiamine and lactulose. We gave her a banana bag without the thiamine, but pushed the thiamine first to get it into her system quickly.  We gave her a lactulose enema because she had been vomiting and could not take oral meds.  Then I had to drop and NG tube to suction out her stomach because she started to vomit blood. Because of her confusion, everything scared her, and she kept trying to pull her IV out and get out of the bed. We ended up having to use soft restraints to keep her tubes in and eventually admitted her to ICU.

I rarely get to know how my patients do after they are admitted to the floor from the ED. I often wonder what happens to them and how many of them make it home. I think at the end of everyone’s medical record there should be a “what happened later” section like in the movies when they tell you “so and so grew up to be a teacher and someone else ended up being a cop and tracking down drug dealers because of his experience from being one.  I wonder if my patients go home and back to their old habits after their health scare or do they make even just a few changes like eating less salt or becoming sober, or becoming consistent with always using a barrier birth control method if they are going to have many partners.  But, alas, I don’t get to know, I can only hope and have faith.

turned loose in the ER

It has been a long time coming.  Way back in January of 2007  when I took my first prerequisite classes to start my nursing career, it seemed like I would never get to this point. Ever since then it has been an intense ride through nursing school, and then through the new grad program.  Finally after 16 weeks of working in the ER with another nurse watching my every move, I am being turned loose. I’ll be working my first solo shift next Wednesday, so try to stay safe and out of the ER.

I am excited and nervous at the same time. For the most part I feel confident. I know I am a good nurse even though I am still pretty green. I am thorough with assessments, clear in my charting, and getting more efficient at getting everything done for my patients. I have figured out how to get the attention of the lab, radiology, CT and ultrasound. I have learned a bit more about the docs so I can predict what I can get started for my patients before they ask. I listen well to my patients, and they are always grateful that I am nice to them. They comment so much on my being kind and compassionate that it makes me suspicious that this is not the norm.  I think however that the truth is that I have not worked long enough to build that protective shell around my heart, I am still wearing it on my sleeve.  The nervous part comes when I get a patient that is really sick and I know the timing of my care is critical. I am not so fast yet, I still look up lots of meds before I give them, I double check dilutions and infusion rates and compatabilities just to be sure that what is in my head is actually right. I worry about getting IV access started quickly enough and those sickest patients have the worst veins!  I worry about not recognizing just how sick a patient is, especially a kid because I haven’t seen enough of them.  And my biggest worry is that I will make a medication error that will cause a patient harm, I guess no amount of experience will ease that worry.

So far I have surprised myself at what doesn’t gross me out. Patients puke, poop, and scream. Bleed, smell bad, and curse. So far none of it has made me want to run. Usually there is a glimmer of a scared individual that melts my heart and makes me want to help them feel better. Each case is a challenge to try to figure out what is making them sick and how can we help. And there is endless opportunity to educate people about their health. Many have heard it all before, and really need encouragement to take steps towards health. Call me crazy, but I get off on encouraging people and giving them hope.

So if you come into my ER you can expect to be listened to, cared for with kindness, have your stuff explained to you and be encouraged to live a healthier lifestyle. Watch out, new ER nurse turned loose.

I hit my stride….then stumbled

I know this is going to be the way it will be for me for a while.  I’ll have hours or maybe even days where I feel like the nurse I dream of being. I am compassionate and accurate with my care of my patients, their stay in the ER is as short as it can be while providing them the services they need, and I am thorough and current in my charting as well as helpful and cheerful as I go about my work.  I had one of those days this week.

I started working with a new preceptor this week on the 11am to 11pm shift. First of all this shift fits my body clock much better. I get up at the reasonable hour of 8 or 8:30, I get a nice breakfast and a few chores done before work. And I am alert through the entire day especially after dinner which is my most productive time of day.  My nurse kept feeding me patients so that I always had four, but let me work pretty much on my own to care for them.  I was able to keep up, I had hardworking CNAs that shift that didn’t disappear when I needed help with something, the unit clerk  was in a good mood.  The day went smoothly and at one point I thought to myself, “I kinda feel like a real nurse with some confidence, I can do this! and I love my job!”

Then came the day that I stumbled so often that I realize I need knee pads and thicker skin.  I started the day with 3 patients; one that had been boarding in the ER already for 16 hours. He came in for a cough/COPD exacerbation and his chest xray had shown suspicious spots, (he had had previous lung CA) and possibly pneumonia. The ER doc  admitted him but there were no beds so he was boarded with us until one was available. That day we had 8  admitted patients waiting for rooms. He was started on IV antibiotics, and needed a CT scan.  His floor orders were numerous and he was grouchy. He demanded so much of my attention for so much of the day that I had a hard time focusing on my other patients. He wanted to go home, but did not want to leave AMA. I listened and talked to him, I got the admitting resident to come talk to him several times, the ER docs came by and talked to him and he remained uncooperative. He refused to sign consent to get his records from another facility. When his room was finally ready a little after 3pm, I called report but he refused to go to the floor.

All through this I ended up being delayed getting things done for my other patients. We were quite busy that day, I had a steady stream of other patients too including a 5150 hold patient beginning alcohol withdrawal. I constantly had the ER docs coming to me to ask me why I hadn’t done this or that yet. Sometimes they were legit, sometimes I was waiting on pharmacy or lab or someone else.  I was kept needing to do two or three things at once and probably making the wrong choice about which came first. And of course the CNA’s were always vanishing.

Then I had the resident who had added on to the floor orders for my boarded patient earlier in the day reprimand me for not ordering a scan she had written an order for. I was totally confused and I felt all the self confidence drain from me as I stood there listening to her right there in the middle of the ER.  My preceptor was gone from the floor she had a meeting for an hour and then went to the staff meeting (that I missed) so when she got back I talked to her about all that had been going on.  I  hadn’t realized that while our ER docs put the orders in for scans themselves, the docs for the rest of the hospital do not, she was expecting me to put that scan in the computer.  I had gone through and taken care of all the rest of the orders, medications, O2 parameters, trying to get consent for records (which he refused) etc.. I caused a delay of this diagnostic. The funny thing was, that I had been calling CT all afternoon to get him in and they never mentioned that they didn’t have the order, they just kept telling me they were backed up and they would call, or they didn’t pick up the phone at all. The patient was also arguing with the docs all afternoon about not wanting to stay and have the scan at our facility, he wanted to go somewhere else.  In the end with his family’s  help we convinced him to get the scan and stay for one more dose of antibiotics, then he left AMA.

I was drained. There were so many times during his care that in hindsight I could have handled better. As well as handling the rest of my patient load while I had such a demanding patient. I see my mistakes, and I will be more attentive to those particular things in the future, but I can’t help thinking about how many more mistakes I have to make. I am so afraid of causing someone harm rather than inconvenience or delay in their care. And I just don’t like the feeling of not being on top of my game. In the meantime, I’m standing back up, brushing off my bum, putting on a confident smile and showing up.

still low on the learning curve

I have always been quick to learn, especially when I am really interested in something. I read everything I can find, I talk to people and ask questions, and I study stuff until I conquer it.  I don’t know if it is the enormity of this field or the fact that I am into my sixth decade that makes me feel so inadequate. I am just not used to feeling so slow minded. Particularly at my age, I have lots and lots of experience in lots and lots of areas, just not nursing.  This worries me, since I only have about a month left of my orientation before I am on my own. I just don’t want to cause any harm to my patients.  I can’t see that one more month is going to give me any more confidence than I have now.

Some days I come home and ruminate over the mistakes I have made and wonder if I’ll ever get it together.  Mind you, I haven’t caused any harm to a patient, just delayed their stay in the ER or made the MD frustrated.  I do things like set up for a pelvic and forget to get the vag light out of the Omnicell, or assist with an LP and not have extra saline flushes in my pocket, or not notice a discharge up for my patient and stop to ask the MD what their plan is for the patient.  It would do my spirit better to think about the things that I have done that made my patient’s experience better, like listen to their story and reassure their fears, like bugging the doc to take their pain seriously and give them some medication, like spending time with them at discharge answering every last question they have.

This job is challenging, hard, frustrating and most rewarding. I just hope I didn’t start too late in my life to make it all the way up the learning curve.