Archive for April, 2009

a breather

{ April 22, 2009 @ 7:45 pm } · { Uncategorized }
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back to work today – not a normal day but just taking critical patients. there were only two all day, unfortunately (from a learning standpoint). but it was still really helpful to be able to really focus and get a sense of what i need to be thinking about with these patients that need a lot more care. i felt that so much more was coming together. so now, the next thing is to be able to take care of those heavy cases and at the same time deal with all kinds of other problems. but i think having some time and space to absorb this information has also helped get my head back in a better place. and now that my confidence is coming back, it’s just time to work on getting up to speed. and pharmacology, my old nemesis, is also back. i forgot that one of the main things nurses do in the hospital is give medicine. lots and lots of medicine. and in the ED, lots and lots of crazy hardcore medicines.

both of the patients we had today were there for significant brain hemorrhages. both have virtually no chance of recovery. the two situations were entirely different, but both had family or friends present. i had some conflicting thoughts and emotions around their presence – part of me was so focused on doing the nursing care that needed to be done that i found it difficult to fully engage with the emotional experience of the families. another part of me that was feeling good about the day as a learning experience and feeling relieved and successful about the job also felt that in a way i was profiting from their losses and distress. kind of a strange feeling. i guess that if i hadn’t been just focusing on the critical patients, i might have felt that i was just taking care of them. and i think that with one of the families, it actually made a difference to them that i was there more frequently and paying more attention than i could have otherwise. and one thing that my previous work taught me was to be fairly comfortable talking about issues around end of life and choices about care.

i’m looking forward to the time that i will be able to do all the tasks that i have to do with less effort and concentration (though not with less caution!) so that i can also be more available for emotional support and decision making for and about a person who has suddenly become sick or injured.

meltdown!!?

{ April 21, 2009 @ 12:13 pm } · { Uncategorized }
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the past 2 weeks have been… challenging, to say the least. i made this change largely because i wanted something new and different – it’s turned out to be giving me a completely different sense of myself as a learner. most past experiences of learning a new job or role have been pretty independent – i’ve gotten used to just being dropped off into whatever situation, and i manage to catch on. and in the meantime, whatever supervision i have tends to be fairly far removed, so the process turns out the be largely self-regulating.

this time around, i’ve had the constant presence and support of my preceptor, but also have been under constant scrutiny. i’ve appreciated the attention and input, but have found myself responding in surprising ways… and not particularly helpful ones. i don’t tend to think of myself as an overly anxious person, but that side has really come out over the past few weeks – somehow i’ve gotten myself into a cycle of constant self-critique, which takes me from recognizing that i’m making mistakes to feeling worried about making mistakes to making even more (and ever stupider) mistakes. sometimes i have a hard time zeroing (that word just doesn’t look right…) in on the most important thing and end up spending my time and energy doing things that shouldn’t be the top priority for the given person/situation. which, obviously, is the exact opposite of what i need to be doing.

so … time to take  a big breath and try to regroup. had a talk with my manager and preceptor this morning – they were both understanding and supportive. we’ve made some scheduling changes so i’ll be at work more frequently but for shorter periods of time, and i’m going to get a couple of extra weeks in orientation. i’m going to do a little studying to catch up on some medication info that i’m not quite on top of yet…. and try to relax. hm… that sort of sounds like a mandate for a massage…

another first

{ April 10, 2009 @ 10:36 am } · { Uncategorized }
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back to work yesterday. kept  busy with a couple of emergent patients. one, an older man who came by ambulance from a nursing home with respiratory distress, turned around nicely – was opening his eyes and looking much more comfortable (according to his family much more like his norm) by the time we sent him to a regular medical floor. it’s kind of amazing to see that process when it happens – when someone comes in really sick and gets better by the time he leaves. the other one was a middle aged man who was sent by a clinic where he was having an outpatient treatment. he’d had a sudden change in his mental status. he was pretty out of it by the time he got to us, and deteriorated over the several hours that i was taking care of him. i watched his neurological status change almost before my eyes – from being confused and disoriented to being very lethargic and only responding to pain/discomfort. i found myself feeling worried and helpless as i watched him decline, even while the diagnostic process was going on – CT scan, blood work, etc. – just wondering what it actually was that he needed and whether we would be able to get it done in time to help him.

initially he was quite aggressive, probably because of the fact that he wasn’t understanding what was going on, and because what was going on was decidedly uncomfortable. his condition was such that we needed to do a number of invasive procedures over the course of the time he was there – from taking a rectal temperature to putting in a foley catheter and a nasogastric tube. we started with the IV – one of the techs had to hold him down while i put it in and drew blood. then – i don’t even remember what it was that we were doing, maybe something as benign as repositioning him, but all of a sudden, he lurched up in bed and landed a heavy punch to my chest. i wouldn’t have liked to have been on the receiving end of his full force had he been less debilitated.

i’ve often had to fend off swats and scratches and general resistance, but never something as direct (or as powerful). the funny thing was that although i was surprised, i almost didn’t register it – i remember thinking, am i hurt? i don’t think so. and then just going back to whatever it was we were trying to do. the resident next to me asked if i was ok and i said yes and that was it. i was almost surprised that she asked somehow.

except for fights with my siblings when we were kids, and the odd spanking from my parents, i’ve never been hit. i know that nurses (along with other health workers) frequently face violence in the clinical setting (some of which is not a byproduct of confusing/mental changes) and i don’t think it’s particularly uncommon in the ED. it’s something i haven’t spent much time thinking about. do i feel vulnerable? not really. but i think that’s because my tendency is to assume that people are not going to attack me, not necessarily because that’s an accurate assumption. perhaps i need to tune up my alertness to danger. not what i expected to get out of this new undertaking! but not a bad thing.

busy busy busy

{ April 6, 2009 @ 1:20 pm } · { Uncategorized }
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worked all weekend… spent my time back and forth from work to home, with barely enough time to sleep and eat. it was good to be there for three days in a row, though. i have the next 3 days off, which is great on the one hand, because i have a big exam to study for (it is of the employment-contingent-upon variety!) but on the other hand, i felt like i learned so much over the past 3 days and i’m afraid of getting behind by the time i go back on thursday. had my first evaluation with my manager and preceptor – they thought i was doing fine in terms of my knowledge base, which was one of the things i was most concerned about in this transition. the main thing they think i’m behind on is speed and time management, which was something i didn’t expect to have so much of a problem with. ultimately, i still don’t think i’ll have a problem with it – i’m sure i have the capacity for it – but i can see that i’m definitely not there yet. sometimes things feel like they’re going along smoothly, and sometimes i feel like i’ve been turned into the dumbest person on the planet when i forget or miss something that should be really obvious. and time flies so quickly once we start getting busy, and then all of a sudden i find myself behind and catching up for hours.

but i like being there, and i want to succeed…. it’s just a matter of working through the process. i don’t mind putting myself in unfamiliar situations, but i also feel a lot of discomfort in that pre-competence space…. which i think is part of why i tend to learn quickly, so i can get out of it!! i’m trying to figure out how to get up to speed, and also how to take advantage of the opportunity to work with my preceptor during orientation and learn from her. she is just so knowledgeable and great at what she does.

the truth about the ER is that there’s no rhyme or reason to the pace of things – you can have one patient at the beginning of the shift and then have 5 more walk in during the next hour and be completely swamped. i notice patients’ reactions too – those who come in with less acute problems, if they happen to be there while there’s nothing more acute going on, may end up being very happy with the care and attention they receive. but if that person with the scraped knee walks in, and ten minutes later we all get called into the trauma room, we may not be back for an hour, and even when we are out, there is probably someone else waiting with something more important that needs to be addressed first. so, while we’re trying to keep someone from dying right that minute, someone who has a minor problem that may not even actually need medical care is stewing about how terrible all the nurses and doctors are and how he is not getting the attention he deserves. almost every day i have a patient tell me i am a good nurse and almost every day someone else tells me how bad a nurse i am. (right now, to be honest, i am a lot more concerned about what my manager and preceptor think!! although obviously, i try to take the best care possible of everyone.) and almost every day someone complains about how long the treatment is taking, even if it’s not being abnormally delayed, and someone wants us to hurry up because of needing to get to another appointment or take care of some commitment. i think a lot of it goes back to the acuity of patients’ medical problems and how that compares to what else is going on at the same time. but i also think that somehow the idea of the emergency room connotes instant gratification – which is far from reality!! some people think we’re mcdonald’s, where they can ask for exactly what they want and get it right away – cheap/easy/tasty – but in reality we are a lot more like a soup kitchen, where they get whatever we have available, with extreme variation in speed and quantity. and then we ask them for their co-pay.