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

Bra-vo!

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. It's dangerous, demoralizing, and a beatdown every single shift.

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.

"Soooo...how 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 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 just...got 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.

Thursday, May 31, 2018

Precepting, Part 1

I've posted before about precepting, but have had the most interesting opportunity and result over the past few months. This post will be part one of a two, maybe three parter. Let's talk about it!

A new grad in my department was recently given the shit end of the stick for her orientation. On a 16 week orientation, she had TWELVE different preceptors. Twelve. Many of her shifts were spent in triage, where her preceptor was assigned for the day. Other times she was in the fast track/clinic area. Many of her preceptors weren't actually preceptors - they were just staff nurses there who only found out she was with them when they showed up for work that day.

There are some new nurses who are inherent badasses and can overcome such trials, but not everyone is able to do so. This new grad was not one of those badasses. She was sweet and nice and bubbly and also scatterbrained and dangerous as hell because she seemed to lack time management and the recognition of sick patients. She came off her orientation and had one week on her own, and it went...poorly.

This new grad was called into manglements* office, where she was met by the Boss, Big Boss, HR, and new grad program director. "We think you're not safe to be on your own, and you need to fix this," they said.

Well, no shit. You set up a new grad to fail, and then blame her when she fails? The job of orientation is to teach a new grad rhythm, good practices, consistency, skills, and time management. When you're with a different preceptor every week, it's impossible to grow overall - you become a task person, because the new preceptor doesn't know you and can't let you take the lead. It takes weeks to months for a new grad to find their own pace and way of doing things. They need the consistency of the preceptor to be their backup and make sure they don't kill anyone while figuring their own shit out. They need a preceptor who can actually teach, not just someone to direct them to various tasks.

It's horribly unfair to skip all of these critical steps and then act shocked when the new nurse isn't safe on their own.

***

Precepting sucks. It's twice as much work, because you're teaching a new nurse how not to kill people, and you're managing a full load of patients while trying not to drown but also let the new grad do everything. You've got to find the time to actually teach, yet you have to keep your patients happy and press ganey bullshit certified.

You have to find the right way to call out your orientee when they do something wrong, but do it in a way that is constructive, not punitive. You have to encourage them, but also be aware that real patient's lives are in their hands. You have to let them fly, but not out of your sight. You have to let them make mistakes, but not ones too big. It's hard.

***

Next up: how to fix a failed orientee!




*manglement was a term I first saw used by a nurse blogger, and for the life of me I can't remember who to credit it to. Nurse K, maybe?


Saturday, March 31, 2018

Insults

I've been insulted with the most colorful of language at work through the years, and it seems that patients are somehow globally involved in a network of one-upsmanship where I think I've heard the most creative insult possible and then somehow even that gets topped.

With that in mind, I really appreciate my patient the other night bringing it back to basics.

I got called a bitch, albeit indirectly, as she was talking to someone via speakerphone the entire time I was attempting to do a workup on this early twenties frequent flyer. When I immediately dropped all my supplies on the bedside table and removed my gloves in preparation to leave, she then addresses me directly with an "I don't like your attitude, bitch."

I shrugged and left the room, with a bye wave on my way out. I took back all the pain medication I  had with me, too, which royally pissed her off. I guess she thought I was going to give her norco after verbal abuse? The logic seems suspect to me, but at any rate she was helpfully escorted off the property about an hour later after attempting to pull the "I can talk shit to your face and make threatening gestures but still expect everything done for me" bit on two different nurses.

Gotta say though, after all the years of increasingly elaborate insults, it's quite refreshing to get back to my roots as a simple, straightforward bitch.

Tuesday, March 27, 2018

Pinkeye

I recently offered to take an admitted patient upstairs for a coworker of mine, and oh my god it was the best decision I've ever made at this hospital.

My coworker asked me to help roll this patient, who was a zillion years old, so he could put a new bandage on the pressure sore on her buttcheek prior to her leaving the department. I turned this tiny old lady onto her side, and he bent over to get a better angle at bandage placement. And then it happened: the greatest moment ever witnessed.

You know those air puff machines at the ophthalmologist? The ones that shoot a jet of air directly onto your eyeball in the name of science? Imagine that exact thing happening except instead of a fancy expensive machine blowing a gentle puff of air, it's a century old colon forcing out a stale fart hard enough to ruffle his hair.

I nearly peed my pants from laughing hysterically and had to leave the room where somehow the entire ER staff was in the hallway and wondering why I was falling apart. In retelling the story, I'm making myself laugh even harder and could barely function for more than two seconds without the whole vicious laugh cycle starting over. My coworker finally comes out of the room, and had to deal with concerned staff members asking him all night how his eyes were doing and if he needed a script to help with pinkeye. I spent the rest of the shift in perpetual laughter, and had to go wipe off all my eye makeup because I had cry-laughed it down my face.

Oh, man. I think this might actually be the funniest moment from my near-decade of nursing. I can't even keep my shit together just writing this post, and I'm so glad the universe decided to do me a solid and let me have this little joy.

Sunday, March 25, 2018

Sass

Oh man sassy old ladies are the BEST. We had this broad last night who got tripped up by her dog and took the express route to the tile floor. Fortunately she was the rare very old lady who was magically not on blood thinners, totally alert and oriented, and also hilarious.

While the doctor was suturing her gaping eyebrow laceration back together, she hit on many topics:

"I'm so glad you're sewing me up so my brains don't ooze out of that. I've only got a few years left to hold on to them anyway, can't be careless now!"

"You don't have a ring on. Can you sew your phone number into that for me?"

"If I slip you a twenty, can you maybe just tighten up that thread a bit and make me look young and surprised?"

"Just imagine the bloody mess the other lady was when I was done with her!"


Thursday, March 15, 2018

Annual "I haven't blogged in months, but I'm still alive!" post

Oh hai guys! Lookit that, it's been yet another multi-month stretch where I haven't blogged. Sorry about that. Every year, I somehow get surprised by the fact that over the dark cold months of November-February I withdraw into myself (and my couch) and then suddenly rediscover joy and socialization and friends once the sun comes out and warms everything up for more than two consecutive days. It's like haven't gone through this before...except I have, every year, for the past fifteen years. One day, I'll buy one of those happy lights or just take a vacation to Mexico in January.

ANYWAY. Blog. Here we go!

***

I had a patient a while back who died.

She was one of those patients who, by all rights, should have died before she got to the hospital. I triaged her in from the ambulance after she had a sudden syncopal episode while driving and thought, since she was also diaphoretic and complaining of chest pain, that she was having a massive heart attack.  I was wrong - I got an EKG on her before doing literally anything else, but it was normal. So I proceeded to get her undressed, on the monitor, get vitals, and start a line. I did all this within five minutes. Her pressure was in the 80's, and all of a sudden she told me her lower back had just started to hurt.

Fuuuuuuuuck. After announcing to the ER MDs that I thought she might have a ruptured AAA, one of them went into the room and promptly confirmed my suspicion via bedside sono.

I did everything right for this lady - from ER arrival to OR arrival was around 80 minutes. It would have been sooner, but the cardiovascular team was already operating and had to close before they could take my patient. We were short staffed, and somehow by myself I still managed to get this elderly patient undressed and triaged, on the monitor, obtain an EKG, start two big IVs, send down all the labs including a type and cross (which at our facility is a step that takes an extra minute or two), get a doctor in quickly, find the sono machine, order blood products, keep this sweet and totally oriented patient and her family from panicking, move her to the critical care side of the ER, give report to vascular when they did arrive, keep the patient alive, AND chart all that shit. I did a fanfuckingtastic job, all by myself. This was one of those situations where everything went perfectly, and I felt like a complete badass for correctly diagnosing a critically ill patient and giving her the best possible shot at making it though alive.

She died the minute they moved her onto the operating table.

It was emotionally devastating, and I was fortunate enough to find the family and spend some time with them to express my sadness and cry with them. I've thought about this patient for months, but always was comforted by the fact I really did give her an amazing chance at surviving - and that the family saw how much work I did to help her.

***

I found out this week that the patient's case was reviewed by the hospital for a possible delay in care, and I'm furious. It just goes to show that even when everything is stacked against me and I still manage my patient perfectly, instead of a congratulations for a job well done I get told it's still not enough.

Monday, November 27, 2017

Knees

You know what's really gross? What I could go without seeing again? The inside of someones knee. That's real disturbing, especially when it's attached to a leg that is flailing about but also sadly lacking in skin or kneecap or ligament and is also flinging blood everyone. I thought the only time the femoral condyles should be visible were during a sterile and well planned knee replacement surgery, but I guess 23:00 in the ER trauma room is a great time too.

PSA: Don't get piss drunk and do a lot of drugs, then drive >100 mph on the freeway and get ejected from your car where you'll skid facedown across all four lanes. You'll leave your knee on the road, as well as most of your face and toes.


Wednesday, November 22, 2017

X

I think the only thing that surprises me anymore about ER ridiculousness is that I'm still surprised by it. Like, seriously. I've been doing this for NINE years! HOW am I still shocked that people are so ridiculous?

Case in point, last week:

Young Dude, with a mild viral illness: I don't have anything for fever. Can I get a prescription for tylenol so I don't have to pay for it?

Me: No, tylenol doesn't require a prescription. If you get the store brand acetaminophen, it's like two or three dollars a bottle.

YD: How the fuck do you know if I can pay for that or not?

Me: Uh, you have an iPhone X in your hand?

YD: Fuck you, lady, I'm outta here. If I get a fever again, I'll just come back here for more tylenol.

End scene.

Tuesday, September 12, 2017

Improvement

So remember that time I was orienting back up in the trauma area, and was feeling super bummed because I felt like I had forgotten a lot of old skills and was generally being a shitty nurse?

I finished my orientation, got a couple of solo shifts done, and I'm happy to report that it's coming back. There haven't been any really hectic dumpster fires yet, but so far so good. I signed up to take a critical care refresher course in a couple of weeks as well, so that's good too.

Thanks to you guys for the support and encouragement from a few posts back. It's a good feeling to know that I don't, as initially feared, fail as a nurse.

Wednesday, August 16, 2017

Announcements

Last night I walked into the docs area to let him know that the gyn exam was all set up. Instead of being a normal human being and saying, "hey doc, the gyn exam is all set up," I just walked in and bellowed "ARE. YOU. READY...TO PELLLLLVVVVVIIICCCCCC???????" and walked back out. 

I don't know what's wrong with me.