Saturday, November 2, 2019

Eyes, part 2

Hey everybody! Remember that time I said I had witnessed the grossest thing ever in my ten years of nursing? Yeah well I beat that last night. Not trying to brag on myself or anything but I'm pretty proud of the fact that I didn't vomit directly onto the patient when I saw this. Or, more appropriately, heard this.

Let me set the scene.

Typical middle aged generally unhealthy guy who thinks "I can definitely do that activity even though it requires getting on a roof and I've been north of 270 lbs for at least twenty years" comes in to the ER. He's got a litany of injuries, including an eye injury causing proptosis and a non-reactive pupil. It's either lose the vision or do a relatively uncommon procedure to temporarily relieve the pressure.

We called in the OMFS guy, who very excitedly came in to do a canthotomy. Only a few of the people in the ER had seen this actually done before so when we sedated the guy everyone gathered around to watch. OMFS gave us the anatomy lecture, pulled the corner of the eyelid out, then just poked a pair of sterile scissors in and cut. He then told us that to really relieve the pressure, the tendon needs to be released from the skull. It honestly wasn't that bad, until one of the ER docs asked how he knew he was in the right spot and how he didn't go too far.

And you know what he did? POKED THE SCISSORS IN EVEN MORE. He goes "oh, it's just eye socket here, you can't really hit anything important. You just listen for this - " AND SCRAPED THE SCISSORS ON THE SKULL - "and then scrape everything off the bone." If you've ever heard the sound of someone scraping scissor points along a skull, it's not a good sound. It gave me goosebumps and heebie jeebies and extreme nausea. It's not a natural sound. It's...awful.

The canthotomy itself wasn't even that bad, compared to the aftermath of the only other one I've seen. Apparently when the doctor is competent and it's done right it's not even really a thing. It just looked like a little laceration by the eye. Oh, but I know. I know that sound, and it's forever in my brain now. Bleegh.


I will say that I would have been debilitatingly grossed out by this whole eye thing except that the next patient to come in was even worse and while looking for identification in his pants pocket I accidentally dropped a piece of his leg bone on the floor. Femur? Tibia? I don't know, but it wasn't where it was supposed to be and there were lots of openings it could have come from. Really puts things into perspective, honestly.

Friday, July 26, 2019

Fresh Feelings, 2.0

I thought I should update you guys on the guy from the last post, because it's not often that I have feelings and I want to get the full effect here.

The other night I found out the post-arrest guy was on one of the inpatient floors. Not the ICU, but med surg. Med surg! He had been downgraded through the hospital ranks, so when I realized I was admitting another patient to the same floor I offered to transport them myself so I could check in on him. I rounded the hallway corner and came face to face with the patient's wife - she immediately recognized me, and asked me to come in to say hi. When I dropped the other patient off, I walked into post-arrest guys room - and he was sitting up! In bed! Awake! Without oxygen! And talking!

I said "I don't expect you remember me, but I'm the one who started chest compressions on you." He immediately burst into tears and asked if he could give me a hug. Let me tell you, he was not the only one crying.

We had the most wonderful conversation, and as he kept repeating, "we're talking to each other! I'm here because of the work everyone did for me!"

You guys. Sometimes we really do make a difference. It's a fantastic feeling, for everyone involved. I love my job.

Saturday, July 13, 2019

Fresh feelings

Part of being a nurse for ten (10!) years is that the mundane, ridiculous stuff no longer warrants a blog post. I have seen a lot, been called a lot of names, and witnessed such a wide variety of foreign bodies in rectums that I no longer rush home to write about all these events. The shit that I used to write about four times a week is still happening, but there's only so many times I can reword the same feelings into fresh posts.

But this week, I experienced a patient that truly made me want to come home and write about it. So here I am!


The highest potassium I had ever seen before, up until this week, was 8.3 - I thought that would be a record to stand for a long while. But a few days ago we pulled a patient out of a car who was pulseless, gray, and apneic. I jumped onto compressions and we got started with the usual code process.

When the labs came back a few minutes later, the potassium was 8.9...EIGHT POINT NINE. You didn't read that wrong.

We gave more calcium, bicarb, insulin, and dextrose that I've ever given to someone before. After 45 minutes and the third round of CPR with subsequent ROSC, a coworker called out to the doctor that the patient had opened his eyes. I thought that surely she was imagining things but when I went over to the patient and asked him to squeeze my hand he promptly followed that command.

I went up to visit him in the ICU the next day. He's awake and though still critically ill, intubated, and on pressors is following all commands.

As any of you ER people know, this is the rarest of occasions. We don't usually get wins like this. Normally the okay people stay okay, the really sick ones we often prevent from getting sicker, and the dead ones stay dead. There's only been a few times in my career where I can look back and say definitively that I and my coworkers took a dead person and made them alive again. This week it happened, and I am still so happy I was a part of his care.


If there's anyone out there still reading this blog, thank you for caring about what I have to say!

Tuesday, March 12, 2019


We all know that the Hill I Shall Die Upon when it comes to nursing is the sad and confusing story of why people all across the nation can't seem to understand that the order of operations for ER dress code is CLOTHING OFF, GOWN ON. Why, for the love of all that is holy, is this so fucking difficult?! WHY?!

Anyway, I have another boulder to lay in the foundation of this hatred.

Last night a woman comes in for vaginal bleeding. The ER doc very thoroughly explains that she's going to do a pelvic exam and why it's needed, and then steps out. I stay a minute longer to set up the bed/pads/speculum and to explain that she needs to take EVERYTHING off from the waist down and that I would be chaperoning said pelvic exam. I handed her a gown and put a few blankets on the bed.

After vacating the room for a couple of minutes, the doc and I walk back into the room. The woman is sitting there, gown on, under the covers. She says she's ready for the exam. I lay the bed back and pull up the blanket, and for fuck's sake she still has her pants and shoes on.

The patient then says "wait, I have to take everything off?" Can't I keep my pants on?"

FFS, people.

Tuesday, February 19, 2019

Discharge instructions

Me: Okay sir, you're all set for discharge. The doctor came in to talk with you and give you results - what did she tell you?

Patient: First of all, I can't believe you told her I did meth. I told you because you asked, but I didn't think you'd tell her.

Me: Well, you came in for anxiety and insomnia. Your tests were all normal, but the meth is FOR SURE a cause of your symptoms. It's a pretty important thing for us to know.

Patient: Yeah, but I've been doing meth for years and it's never given me any problems before! It can't be the meth. It's gotta be something else!

Tuesday, February 5, 2019


One of the best feelings in nursing is knowing that your coworkers have your back. That best feeling gets even better when said coworker is someone in management. Take, for example, the shitty day I had yesterday. Of all my patients, only one was discharged...and it was a discharge home to Jesus. The rest went to the ICU.

During the management of my eventual home-to-Jesus patient, a significant trauma rolled in the doors which split the available nursing resources as many of them went to assist that patient. Another nurse was in with my sick septic pop pop a few doors down, and when my sick respiratory problem on BiPAP patient started having more difficulty breathing, there just wasn't anyone left to help. It's hard to prioritize care sometimes, but doing CPR means I'm assisting the literal sickest patient in the department and I couldn't step away.

Help arrived in the form of the most BAMF house supervisor ever. She poked her head into the CPR room, asked who the nurse for BiPAP patient was, and then says "is this your patient too? Cool, don't worry about the other one, I got it."

And then she stayed in that room for 90 minutes! She straight up assumed care, paged the admitting MD, medicated the patient, reassured the family, and facilitated a discussion on plan of care. She. Was. The. BEST.

When I finally got my critical patient out of the ER, she accepted no praise whatsoever. Her words were just "well, you were busy!"

It's been a bit of a shitshow at the hospital recently, but man it is so amazing to know there are some people that will grab a shovel and jump into the trench with you instead of sitting in a office and judging from afar.

Saturday, January 12, 2019


Instant tears. The ones that spring up, uncontrollably, with no warning. Tears that are triggered by the deepest of emotions. Have you ever felt those tears?

Taking care of little old grannies in the ER for vomiting or weakness is a daily routine for me. Start an IV, get an in-and-out cath urine, gently rehydrate, and repeat everything you say at least twice because a hearing aid battery is inevitably not working well. I feel for these patients for so many reasons. The stretchers are uncomfortable. I deny them water at first because they might have a small bowel obstruction. We're out of sandwich trays. The blankets are never warm enough. It's four in the morning and their children went home for the night, and now they're all alone in the room in a strange place. Each little incident wears on them.

I do this so often that while it wears on me too, it's just a routine.

Until it isn't.

It ceased to be a routine the moment I turned her arm over to place an IV and saw a row of old, faded numbers tattooed there. I froze. I couldn't think of anything to say or do. After a long, uncomfortable pause, I dumbly looked up at her and asked "are those...?" Her daughter nodded, and the tears were instant. I managed to apologize for losing it, and after a few minutes was able to compose myself enough to place the IV. The patient was sweetly oblivious to the entire interaction.

At the end of the ER visit, I apologized again to the woman's daughter. "It's okay," she said. "If she were feeling better, she'd tell you about it all."

Auschwitz saw an estimated 1.3 million people during the years its camps were in use. Around 1.1 million of those people were murdered or died in other horrible ways. Of those 200,000 survivors, even fewer are alive today. I am so incredibly humbled to have met and cared for just one of them.

There are moments in life that irrevocably change you, and this was one.

Thursday, January 10, 2019

TEN years?!

This week marks the 10th anniversary of starting my first nursing job ever. Ten long, short years ago. I remember how nervous I was to take care of patients, even though I hadn't yet passed my NCLEX and thus was still considered a new nurse graduate not even allowed to chart or administer medications.

It's been a wild ride. I worked my way up from terrified brand new nurse, to mostly competent baby nurse, to proficient trauma/critical care nurse, to occasional charge nurse, and then decided to leave my confidence level in the dust to start travel nursing. I spent nearly five years doing that, where I met friends all around the county, worked in varying levels-of-shitshow hospitals, learned to adapt out of my comfort zone, and then met and married some dude I met halfway across the US. I'm now back to full time nursing at a single hospital. I bought a house and generally live a pretty cushy life full of caffeine, friends and family, and instagramming about my cats. I get cursed out pretty regularly at work but that's to be expected because I do work ER after all. I precept new grads occasionally, and have had the opportunity to change some of those new grads for the better. I mostly have my shit together at work, although sometimes the day does wear me down and defeat me.

I don't know if I can do ER forever, although I swore up and down when I started that I absolutely would. The changing environment of emergency medicine is probably the biggest obstacle, but the lack of respect from hospital administration, my aching feet after 3 long consecutive shifts, and need to challenge myself are also factors.

I do love my job though. I love the ER, and honestly can't see myself doing anything else for the forseeable future. I'm good at this job, and when I need a change or to challenge myself I take on a new grad orientee, or learn a new skill, or ask to be trained into a new role. When or if I do get tired of all this - perhaps hospice nursing? I think I'd enjoy that. We see so many people yanked out of this life violently, tearfully, unwillingly, that I imagine it would be a welcome change to be with people who know their time has come. I don't think I'm mature enough for that job just yet though, but maybe in a few more years.

It's also been a fun ride with this blog. I started it over eleven years ago! ELEVEN! I haven't even had my all time #1 comfy sweatpants for that long. Shit, I've had this blog for double the time I've known my husband - even weirder is that this thing is how I met him in the first place. Life is funny sometimes.

Here's to another ten years of nursing and blogging about it, although I ain't even gonna lie and say I'll post more frequently. Y'all know better than that. Cheers!

Tuesday, December 4, 2018

A post about that time I felt extremely uncomfortable due to a physician's comments towards me

There's no cutesy blog post title here, because this is a serious topic and I'm still fighting mad about it.

A coworker and I were starting heparin the other day, as the vascular physician was at the bedside talking to the family. For background, I'm 33 and have been a nurse for 10 years. My coworker is in her mid twenties, and is new (it was TNG from a few posts back). The physician is male and I'd guess to be in his forties or fifties. The patient was somewhere between 20-35, and more importantly WITH HIS WIFE.

TNG and I walked into the patient's room with the heparin drip. As we walk in, the doctor notes that we have the med and says, "good, my nurses here are about to start that heparin we talked about." First of all asshole, I'm not your nurse. I'm an employee of the hospital and I work for the Emergency Department. Not you, not your practice, and also I'm a grown ass woman who isn't a possession. But whatever, I let it slide because it's busy and I'm not about to make this awkward in front of a patient.

Dude MD can't shut his mouth there, though. His very next sentence is this: "If these girls didn't have that medication, I'd say they're just coming in here to flirt with you." I look up, glare at him, and flash my wedding ring towards all present.

But wait, IT GETS WORSE. He goes back to discussing the plan with the patient and his wife, who look very weirded out at this moment. I'm thinking we're in the clear and I can get out of the room without further comment, but no. After we finish verifying med dose and rate and hit start on the pump, he says "oh good, these hot girls, I mean nurses, got everything started."


I turned around, and just said "NO. You are NOT doing this." And I walked out.

If I had stayed in the room, I would have punched him right in the dick. I wish I had said something more specific about the blatant sexual harassment, but if I had opened my mouth again it probably wound have gotten me called to HR.

After TNG and I left the room we told coworkers in the immediate vicinity. I'm not sure if I need to escalate this further because I really don't feel like getting involved with management, but I'm debating the merits of getting a neutral male coworker of mine to be a witness if I decide to say something to the physician. It's not acceptable under any circumstances, but especially not in my place of professional business.

I dunno, I just can't believe something this blatant happened to me. I'm used to the stupid shit that patients say, but this is on a whole new level.

Please advise, internet blog readers.

Sunday, November 11, 2018

Pelvic adventures

I had the most adorable new resident corner me in the supply room the other day to ask me the most humiliating of questions - could I chaperone a pelvic exam for him, and also by the way could I walk him through how to do a pelvic exam while we're at it?

Apparently the ER doc sent him out into the wild, and the resident admitted that he's only ever done the exam on two real people before, but "it's been a while." I have to say, this is legitimately the first time I've ever had a doctor flat out admit that they don't know how to doctor yet. While I did enjoy giving him a bit of a hard time it was actually super encouraging to see a resident admit they don't know something, seek out a nurse who does know, and ask for their instructions and recommendations. I showed him all the supplies we would need, the order of swabs for STD testing, how to use our particular speculums, and what to tell the patient during the exam. He followed instructions perfectly and did a great job.

Too often we'll see a resident who has literally just graduated speak down to a nurse with 5, 10, 30 years of experience and dismiss anything we say or do because "you're just a nurse." Not this dude. He swallowed his pride, and came out as a better practitioner because of it.

He doesn't really need to know that I've actually never done a pelvic exam....watching hundreds of them is totally the same the real thing, right?

Wednesday, October 24, 2018


Work has been a real bummer recently - courtesy of Manglement (TM pending to Jo at Head Nurse), we've been chronically short staffed, in the middle of a mass exodus of experienced staff, and mass hiring of brand new nurses. Some nights, entire sections are staffed with nurses who have less than a year on the job. Don't get me wrong here - I love new nurses. Shit, I was one once upon a time. They're fresh from learning the newest research, excited to start working, and it's thrilling to watch them come into their own and become highly competent people. A good hospital ER balances the influx of new grads with a bevy of experienced ones, and makes sure to have enough support staff to keep the department running while they learn. Our place does not, and the short staffing means it's demoralizing and a beatdown many, many nights.

I reached a new low the other day when it came to barely having enough resources due to low/new staffing, but at least I get this blog post out of it!

My otherwise stable trauma patient needed a chest tube for a hemo/pneumothorax, and the doc finally was able to get into the room to place the tube. I had multiple other critical patients, so wasn't going be in the room for much of the procedure. A tech was there to help, but she was going to be opening the chest tube tray, taping tubes down, and generally functioning as a circulator nurse. There was no one to hold the patient's giant boobies out of the sterile field, though.

The doc, myself, and the tech stood in the room for a minute to try and figure out what to do. The patient was generally a badass with everything, and was like "do what you guys need to, I'll be fine." I looked at the chest tube set up. I looked at the patient's boobies. I looked at the doctor. I looked at the boobies again.

" awkward will it be if I tape your boob to the siderail? Are you cool with that?" I asked the patient. She laughed and then was asked if I was serious. I was.

I sure did get a roll of cloth tape and secure her tit all the way over to the contralateral side rail. I felt like a fucking MacGuyver. I'm sure the OR does this kind of shit all the time, but it was a first for me. I got a round of high fives from the doc, tech, and even the patient, and then I ran out of the room to go make sure my other patients were all still alive.

If low staffing weren't an issue, all of these patients would have been taken care of and no one's boobies would have been taped to any sort of ER item. I guess this is our department life now?

Thursday, June 28, 2018

Who in their right mind would do this?

By "this," I mean put my coworker/family member/BFF and I together in the trauma bays the other day. She's a psych shit magnet. I'm a hot-mess-then-crash shit magnet. With our powers combined, it was a disaster of a day.

When change of shift rolled around, I swear I heard at least nine people go "oh my god, they put you two up here together? Dafuq were they thinking?!"

Good to know our reputation is holding strong...

Tuesday, June 12, 2018

Precepting, Part 4

Thank you guys for the feedback on the previous few posts. I appreciate hearing the reactions to my teaching style, and based on your responses it seems I should stick with what works!

I'm so very happy that The New Grad is doing better. She is a completely different person than the one I inherited - she's much more confident, she gets her work done, and most importantly she is able to manage critical patients.

We had one shift near the end of her reorientation where I got to witness it all click together. For HIPAA reasons, I can't even share the basics of the trauma we took care of, but suffice to say it was real bad. I took over charting since it was a giant cluster and didn't have time to teach, but I made her the primary taskmaster (I know, I know...after all my talk of how she needed to direct and not task...) because I wanted her to be right in the mix of blood and trauma surgeons and chaos and also because we're all probably going to be called into court over this sad case.

TNG it. I don't know exactly what went through her head, but she absolutely nailed everything she did. She put in a clutch IV. She dropped an OG tube and foley, right in the mix of RT's taping up an ET tube and XR getting their shots. She verified and helped give emergent blood. She grabbed the monitor and extra IV pole to get the patient to the OR. I didn't direct her to do any of these things - she just did them. She listened to the verbal orders from physicians, identified needs for the patient, verbalized her actions so I could chart them, and managed to function in a trauma room that was packed with staff. It was beautiful.

We got the chance to debrief afterwards, and when I asked her what changed she just sort of shrugged and said she kept reassessing and doing what was most important at that moment. I could have cried.

She was on her own just a couple shifts later, and it's been going tremendously well. Just the other day, she relayed to me the most recent shitshow she took care of: while giving blood to a severely anemic patient, another patient of hers coded. It was an out-of-the-blue code, where they went from fine and talking to CPR. She did everything right - her charting leading up to the code was impeccable, and showed that she had been in the room multiple times, had the patient on the monitor, and reassessed him frequently. When the code was in progress, she documented everything well, called out for things she needed people to do, kept track of times for code medications, and made time afterwards to console the family. Our director singled her out later for the outstanding work and documentation she did. When I asked TNG how she felt afterwards, she said she was freaking out inside but just kept doing what she needed to do - and let's be real, that's all critical care ER nursing really is at first, isn't it?

I am truly honored to have made a difference in her career. I've precepted before and felt that I did a decent job but turning around what seemed to be an unsalvageable situation makes me realize that I'm actually pretty good at this. Much of the credit has to go to TNG though - she's the one who kept at it, listened, learned, and pulled through.

I'm so, so proud of her.

Thanks for listening, y'all.

Saturday, June 9, 2018

Precepting, Part 3

Let's continue hearing all about the ways The New Grad (TNG) turned herself around, yeah? Okay!


I mentioned how TNG had pretty atrocious charting when I first got her, and this was my one big personal hurdle for her. I'm an over-charter, but it's saved my ass on many occasions. If a patient gets up to use the bathroom on their own, I document that they were able to do so. If someone has a brief bout of crushing chest pain, I do the ekg but also write a little narrative leading up to that. As my preceptor years ago taught me, "you should be able to know the story of any patient in this department just from reading the chart."

TNG pretty much charted an assessment and vitals, and that was it. I fixed this by having her follow the hourly rounding model pretty strictly. If she went into the room, the first thing I had her do was open the chart. Whatever she did in the room, she had to document before she left (unless things were emergent, of course). When TNG first started, she tended to talk to the patient for waaaaay too long, then try and go back out to the desk and chart everything. She'd inevitably get called away to something else, and things never got charted. Forcing her to chart in the room helped her to multi task, as she had to talk to them and also chart. It helped the patients feel better because they gave an answer and they could see that it was going into the record. I also had her free text many things, and all in the same note. This helps her have a running narrative of what's happening with the patient, and any interventions she took. When she goes to call report later, or talk to a doc over the phone, everything is in one spot.

Charting in the room also prompted her to go outside the basic focused exam - if she's gonna chart that other systems are WDL, it helps to actually be looking at the patient to verify that instead of clicking through in a hurry later. I also had her look at the same few things every single time she opened the chart - vitals, last documentation, and new orders. It was redundant a lot of the time, especially if the patient was simple, but it got her in the habit of always scanning the same places in the chart to highlight what she needed to do.

Opening the chart frequently also helped TNG do everything all at once - she'd look at the orders, and get everything done at once - IV, labs, fluid started, meds. The fewer times you have the leave the room for stuff, the more time you spend in the room with the patient. This rolls into another huge issue she had - delegation.

I too struggle with delegation sometimes. I've always felt that if I can do something, it's rude to find someone else and ask them to do it instead. Usually this works for me, but occasionally I guilt myself into doing everything and then all of a sudden I'm in the weeds. So I worked with her to delegate small tasks, and let her focus on the big picture. Need someone to drop blood off at the lab? She'd call me to do it. Does that patient in room 73 need a pillow? It can wait, or you can snag someone sitting at the desk to do it. When a patient who needed multiple tasks came in, she'd bring help in with her if it was available. This allowed her to meet her budgeted time for a patient, get the necessary charting done, spend more time on critical thinking and less time on simple tasks, and also made the patient happy because shit got done quickly.

The last big thing I can think of for my precepting strategies is something so obviously necessary, but sadly one that many preceptors don't do: share your own failures. I told her dozens of stories of me screwing up - of making a medication error, of forgetting to do something for a patient, of me missing an obvious diagnosis. I told her of all the times I cried on the way home from work my first year. I told her how overwhelmed I was, and of how I questioned if I was meant to be a nurse. I told her how I still have those feelings sometimes, and that the day those feelings go away completely is the day you truly become dangerous. She needed to know that her feelings of inadequacy in this job are not new - every single new graduate out there has them, and if an experienced nurse pretends they never felt it too they will make those feelings even worse. Also, what a shitty way to exert power over someone, right?

It's hard for new grads. They're in a job where all of a sudden they can accidentally kill somebody, and that's terrifying. The amount of information needed to be a competent nurse is HUGE. It's not something you graduate nursing school with and all of a sudden have your shit together. It takes time. A lot of time. The most you can do is continue to learn - keep an open mind, learn new tasks every day, read on your days off, listen to experienced nurses, ask questions of the physicians, always find out the "why" behind actions. Most importantly, know when to ask for help - because this job is tough, and the ER is a team who shouldn't let you fail.

If management had done her right during the first round of orientation, all of this wouldn't have been news to her.


Part 4, up next to close out this little series. Please let me know if this helped anyone out there!

Sunday, June 3, 2018

Precepting, Part 2

Where were we? Oh yes, I remember - setting a new grad up for failure, and then acting all butthurt when they fail.

Here's where I come in. Management pulls me aside and tells me that the department has a new grad who wasn't good enough, and they want to give her another six weeks of orientation before deciding to send her packing. Would I be so kind as to be her preceptor? Also, she'd start with me tomorrow!

I agreed, and the following day the new grad (TNG) showed up, and it was like a punch in the face.

She was...not good at nursing. I say that not to be mean, but as an honest assessment of her ability to be a good nurse. TNG lacked any sort of time management, or the ability to prioritize tasks. When a sick patient showed up, she recognized that they were sick but was completely frozen on the next steps. Her charting was atrocious. She was a monumentally flawed new grad, and she was now my problem.


It's not much of a spoiler alert to say that she wildly improved and is now on her own and doing fabulously. So instead of giving you all a blow by blow of her six weeks with me, I figured I'd lay out my precepting methods in case it might help someone else orient a new grad. Because I've gotta say - this might be my finest work ever, and I'm proud of being able to turn her around and even prouder of her for doing it.


We started her out with one patient, so she didn't have to work on prioritizing or time management between patients. She could do her triage and focused assessment, then all tasks needed. I found out that TNG was great at tasking. She was kickass at IVs, and good about putting patients on the monitor, getting them undressed, and talking to them. She had a great personality which made patients like her, which definitely helps. But oh man, the critical thinking was not there.

So I came up with a game, which was very non-creatively called Sick/Not Sick. When a new patient came in, she had one minute to lay eyes on the patient and tell me if they were sick or not sick, and why. Early on, it was a struggle to get her to identify why they were sick - not everyone has poor vitals, or textbook complaints. The ability to ID sick is more of a gut feeling, but by forcing her to identify why that gut feeling was present or not I was eventually able to make her think about all the differentials. Once we had differentials and potentially critical problems, I'd make her give me all the expected interventions for those problems. Over the six weeks, she went from being hesitant to pull basic differentials and interventions, to being able to reel off a list of multiple problems and anticipating how to fix each one.

TNG also struggled with time management. I worked to fix this by using a per-hour time frame since we use hourly rounding as a metric, and then budgeting time as needed. We get four patients at our facility - thus, each patient gets 15 minutes of your time per hour. If you have a sick patient who requires 30 minutes of time, your remaining three patients each get ten minutes.

I also forced TNG to keep her encounters brief (within reason - I never made her cut short necessary or kind interactions if the patient needed it), since in the world of ER nursing you never know what will come through your doors. If you need an IV started, don't delay it. Get it done now, round on your patient, and free up your time for the next thing. If there isn't a next thing, then you get to spend bonus time with a patient. But if there is a next thing, or a new ambulance patient who is a hot mess, then your work is done already and you're not in the weeds with simple tasks.

We also worked on prioritizing tasks. If you have a patient that needs something simple and another patient who is going to require a lot of your time, do the simple task first. Both patients will have their work done in the same overall amount of time, but the simple task patient will be happier quicker. In this same vein, she began to recognize that if you have a critical patient who needs all your time, the other patients will have to wait.

I gave TNG homework - specifically, this: the Emergency Severity Index resource guide. It takes a long time to become a proficient enough nurse to work out in triage, but this is a vital guide since every nurse has to triage their own ambulances, and also recognize when someone has been under-triaged and to make the necessary upgrades. Chapters 2-4 are the part I made her really study. This flowchart also goes back to her sick/not sick assessment:

Through all of this, I wanted to let TNG make mistakes. When you screw something up, it sticks into memory far better than someone else telling you how to do something. So, I let her screw things up - as long as the patient wasn't harmed or inconvenienced, of course. If she called report and forgot to tell the floor nurse something, I let her scramble to figure it out when they asked. When she was supposed to recheck a temp on a febrile patient but didn't, I let the doctor come find her to ask why vitals weren't updated (I had already rechecked it, for those wondering). If she was about to make a bigger mistake, I'd let her nearly make it then stop her from doing so - and pull her aside for teaching. I found that over time she became more aware of her actions, so that the mistakes she was making early on became nearly non-existent.


This is becoming quite a ridiculously long post, isn't it? I have a few more strategies I wanted to mention, but in the interest of keeping this post shorter I'll add the rest onto the Part 3 post.