Confessions of a registered nurse (Confessions of a student nurse)

Some people earn instant respect by the credentials after their name. Others earn it by the school they went to, the awards they have won, or the position they hold at their job.  In pediatric nursing, these achievements mean absolutely nothing. A few weeks ago I had a fifth grade boy as a patient. He had a wound on his leg that I needed to examine, but he was terrified that I was going to hurt him. When I would come near him he would move to the other side of the bed. I needed to earn his trust or I was going to get nowhere. “How far can you get in Guitar Hero?” I challenged him. “I can almost beat it on medium,” he bragged. “That’s cool, I can beat everything but Jordan,” I casually said. His eyes got large and his mouth dropped open as he froze and looked over at me. “You can almost beat Guitar Hero on medium!?” he asked.  I smiled and replied, “No. I CAN beat it on medium. I just can’t beat Jordan on expert.” As we continued to discuss Guitar Hero, I assessed his wound and changed the dressing without even an “ouch”. 

Ok. Blood culture, urine culture, lytes, CBC, rapid RSV for room 3. Has the baby in 2 peed yet? I still need to do his urine dip, and why won't his line flush? He still needs his Rocephin, has it been thirty minutes yet? I'll call the pharmacist again after I take care of 3. The doctor is in room 1, so hopefully I have a few minutes before I have orders. But that baby is really retracting and her oxygen sats are 94%, so I should take care of her before I worry about the baby in 2. Crap. Why is the mother for 3 standing in the hall waving me over? Ok, blood culture, urine culture, lytes, blanket, Gatorade, CBC, rapid RSV for 3. I'll get my supplies together, what size IV should I use? 24 gage will probably work. Is the doctor writing orders on 1 now? Deep suctioning, rapid RSV for 1. But I still haven't even started the workup on 3. Whose alarm is beeping? 1's sats are now 92%, I'm not comfortable with that. Why aren't there any neonatal nasal cannulas in this room? I'll get the bag and mask ready just in case. Are her lips blue? No, just my panicked imagination. 86%, is this machine reading right? I’ll wake her up and see if that helps. I wish I could find a tech to help with the workup in 3, I should be done with that by now. Is there something in my shoe? I keep feeling a sharp stabbing pain in my foot. But I can’t sit down yet. I have to take care of this baby now. It’s been fifty minutes since 2’s vital signs. I’ll be with 1 and 3 for at least twenty minutes, so I have to get 2’s vitals first, but he’s stable, should I just wait for his Rocephin and be late on his vitals? Oh yeah, I still have to call the pharmacist.....

This is what my brain goes through in just a few minutes at work. Winter in a pediatric ER is like this nonstop. By the time I get home, I don’t want to think about patients or hospitals or anything work-related. Unfortunately, as soon as I fall asleep, I am suddenly overwhelmed with patients again. I wake up panicked because I’m late on vitals and giving meds. I remind myself that I am not at work for another four hours, then close my eyes and return to my demanding patients yet again. When my alarm goes off around 5, my brain feels ready for a break, not to begin another twelve hour shift. Am I overwhelmed? All the time. Am I on the verge of a breakdown? That’s a possibility. Do I love what I do? Absolutely.

"Possible seizure at school," the EMS said to me as he wheeled his patient into my room. The patient had never been diagnosed with seizures, but this was his fifth similar episode. At school, the boy suddenly became quiet and sat there, staring straight ahead. He would not speak to anyone or move, even when directed to do so. An altered level of consciousness like this could signal many scary situations- seizures, brain tumor, blood sugar problems, drug toxicity, etc. What was wrong with my patient? The resident ordered all of the appropriate and expensive tests, and the neurologist was at the patient's bedside quickly. She was not sure what the problem was, but planned on admitting the patient after the MRI was complete. The boy's mother was begging him to respond to her, but he sat there quietly. When I was in the room doing an assessment and checking his pupils, I noticed that he had tears in his eyes and that his lower lip was quivering. I asked his mother if I could speak with her son for a minute, and brought her to a chair outside the room. I sat down next to him and said, "When I was in school, the kids made fun of me because I was so short. I came home in tears all of the time. I hated going to school." This made him start to sob. "The kids all say my mom is crazy," he replied to me. "That must really hurt," I said. This made him cry harder, which made me want to cry. "You can't tell your mom why you are upset, because this would hurt her feelings too," I asked him. He nodded his head. I asked him what he did when the kids upset him but he couldn't tell his mom. "This," he replied. I talked with him for a few more minutes, and then went to tell the resident that he was able to speak. She quickly went into the room and came out a few minutes later. He wouldn't say a word to her. I went in with the doctor and explained to the boy that I knew it was difficult, but that the doctor really needed to hear him talk. I asked him what his favorite subject was. "Math," he answered.   I left the room to take care of my other patients and when I checked back a bit later, he was no longer being admitted. They performed a CT scan just to make sure things were ok, and arranged for him to follow up with a psychologist. When he was leaving with his mom, he walked up to me and gave me a huge hug. Finally, I felt like I could handle this ER job. I was making a difference. What have I been stressing about? As I stood there filling out the rest of his paperwork, smiling to myself, the housekeeper rushed in to clean the room. I looked behind me and saw another EMS guy coming towards me with a young boy. Can't I get a minute to recuperate!?! He started giving me report before the room was even clean- dog bite to the lower leg. No big deal, probably just a few stitches, I thought. They brought him in the room and as they passed me, I noticed the word "Flight" on the back of their jackets. "He was flown in?!" I asked, panicked. "Yes, it was a pit bull," the man responded. Thankfully, an attending doctor walked by as the EMS said this, and the attending followed me into the room. He took the bandage off the leg and immediately instructed me to find the other attending and bring him STAT. I looked up and immediately regretted it. There was barely anything left of his calf, and I could clearly see his exposed muscles. I found the other attending and overhead paged my preceptor immediately. Before she was there, both doctors were giving me orders - Morphine, IV fluid, sterile saline, portable x-ray, antibiotics, etc.  I froze. Morphine and what else? What am I doing here? Did I really just see that boy’s calf muscle?! Was that his bone? I want to be a receptionist again.....

Every patient who comes to the ER is triaged when they first arrive. When triaging a patient, a complicated formula is used to determine what "level" to make that patient. Here is my own version of our levels:
Level 5 - should have gone to a pediatrician's office- send down hall to First Care
Level 4 - same as level 5, but higher priority than level 5
Level 3 - stable for now, keep close eye on
Level 2 - kind of stable, requires a lot of work, could go downhill any minute, send to Katie's room
Level 1 - trauma, life or death situation

I don't know why, but for my last few shifts, all of my patient's have been level 2's. The first few days I handled things without too much difficulty, but on Wednesday, I was put in the Asthma room. The Asthma Room is a little taste of Hell. It is a small room with seven reclining chairs lined up against the wall. There is one nurse responsible for all seven patients, and unless there is a trauma in the back, there is a respiratory therapist there as well. That's right- a seven to one patient to nurse ratio for children having TROUBLE BREATHING! For those of you who are not medically inclined, a patient's airway is the most important factor in keeping patients' alive, and children are known to go from respiratory distress to cardiac arrest in just minutes. Any one of my seven patients could quit breathing. When I am in the asthma room, I feel like I am holding my breath the entire time. Just keeping up on the hourly vital signs for seven patients keeps me busy- but then there are meds and admission papers and nursing notes and PARENTS to deal with. When I find out at the beginning of the shift that I am in the Asthma room, I say a little prayer asking God to give me the strength not to cry until I get to my car at the end of the day. Wednesday I barely made it to my car before the tears started flowing. I forced myself to return to work on Thursday, and was given a normal room assignment. Thankful that I wasn't in the Asthma room, I thought I was going to have a good day. I was wrong. My first patient was supposed to be a direct admit to the floor, but they didn't have any rooms available, so I had her for six hours. She was on a ventilator and was having difficulty breathing. Then they brought me a "Level 3" who ended up being admitted to the ICU, except there were no ICU beds available, so he stayed in my room. My next wonderful surprise was an autistic child having seizures, two of which he demonstrated for me in his room. When he started seizing, all I wanted to do was leave and never look back. How can I handle these three patients at the same time? I barely made it through the day without losing my mind. I guess I was hoping that they would save the severe patients for the more experienced nurses, but that is not how things are going to work. So here I am now, nervous about going to work, but somehow loving it at the same time. I know that I will get through it and am thankful that I have found a few experienced nurses that I can turn to for help. For now, I am keeping my fingers crossed that I start getting a few more Level 3’s my way, but that I will be able to handle the Level 2’s I am somehow destined to get. At least the level 2's make for good stories, as soon as I get the energy to write them....

The young couple entered the ER early in the evening with their brand new baby girl. She was beautiful and her parents could not keep their eyes off of her. They thought she had some kind of a virus- she had not been eating and had not had a wet diaper in over a day. They were nervous as all new parents are, but knew that we could fix their perfect baby and have her back to her happy self in no time. After the nurse and the respiratory therapist examined the girl, they decided that something was wrong and alerted the doctor. There was an immediate rush of people into the small ER room, and all the parents could do was stand back and watch. The baby was brought to the trauma room and within minutes the top cardiologists were at the baby's bedside. Pretty soon, a tube was down their girl's throat to help her breathe and they were headed towards the elevator to go up to the ICU. Their daughter would be having open heart surgery within hours. Watching them follow their daughter towards the elevator was heartbreaking- they were almost moving in slow motion. Their gazes were blank stares. This could not be happening. In the elevator, they were up close to their baby and able to see all of the medical devices she was attached to. The mother reached out her trembling hand to touch her baby, but pulled back, too afraid. After gentle reassurances from the medical team in the elevator, she again reached out her hand and had barely touched her daughter when the elevator door opened and the rush to save her daughter's life resumed. As everyone poured out of the elevator, the shocked parents stood there for a moment, the mother sobbing, the father fighting back tears. Hours ago they thought their daughter would be put on antibiotics. Now doctors were preparing her for open heart surgery. I don't remember the girl's name, and I can't remember what she looked like, but I know that I will never forget the expression on that mother's face, and how helpless I felt because I could not do anything to make her feel better.

During one of my internship classes, we were told, "At some point, you are going to have a patient who is not breathing, and you will have to do CPR." This statement definitely caught my attention, but I was comforted by the knowledge that all I would have to do is yell, "HELP!" and five nurses would come running to my aid. You are never alone as an ER nurse because all of your coworkers are right there to jump in when needed. Unless you are alone in the ambulance bay, that is.
Last night my patient's mother requested that I bring her daughter out to meet her in the ambulance bay with the car. We do not normally do this, but since I was not busy, I agreed. I wheeled the patient to the back door and waited inside. After a few minutes I heard car tires screeching and the car horn blaring, not letting up. Wow, she's in a hurry! I started wheeling my patient down the wheelchair ramp when I heard a woman scream, "He's dead!"   Uh, excuse me? Who's dead? This is not where you are supposed to drop patients off. I looked up and saw the source of the scream, a woman standing by her car in the middle of the ambulance bay (pretty much resembles a dark alley). I looked at the car and didn't see any passengers, so I assumed that the "dead" person was a young child. My training kicked in and I knew what to do: run to the car, grab the patient and run him to the trauma room. I put my patient's wheelchair in park and ran up to the car (I know, probably not the safest move). I opened the door to save the child's life and was shocked to see an adult man slumped over in the front seat. He was blue and not breathing. This is when my entire body froze and all I could hear was my heart beating. I had no idea what to do. He was too big for me to move by myself, there was no one in screaming distance, and the driver of the car was too panicked to do anything. All she could say is that he had overdosed on heroin, and she had no idea how long he hadn't been breathing. Thankfully, my patient's mother showed up and I yelled to her to take her daughter away. She quickly obeyed. That's when I took off running inside for help. I didn't know what else to do- my first code and there was no "code blue" button to push. My gut told me to never abandon a patient but my brain told me I couldn't handle this on my own. Thankfully the trauma team responded to my plea and came running to the bay area where they pulled him out of the car and onto the street. Even though we are a pediatric ER they were able to bring him to the trauma room and save his life. My preceptor Susan, after lecturing me about never going to the ambulance bay alone, told me that I should be proud about how I handled the situation. To be honest, I'm most proud of the fact that I somehow avoided peeing my pants! Hopefully, my next code will take place in the comfort of a well-lit, warm, code-blue-button-nearby, ER room.

Some patients and their families think that nurses are waitresses in scrubs. They think that their request for a blanket should be their nurse's number one priority, because she couldn't possibly have any other patients with real problems, right? I had one of these patients the other day. The worst part was that she should not have even been in the ER, she should have gone to a walk-in clinic or her primary care doctor. But she showed up at the ER and was brought to my room, so I got to wait on her. Every few minutes the mother would signal me from the door. They needed a blanket, so I went and got a blanket. As I handed her the blanket, she said that they also needed towels. Why couldn't she have told me that before!? She wanted me to call the doctor at least every half hour to ask her questions. I can't bug the doctor while she is in with a trauma to ask how long until my stable patient is discharged! I don't know why I could not communicate this information to the patient's mother, but somewhere along the line we were not connecting. After the girl told me that she was in extreme pain, I got the doctor to write an order for IV pain meds. When I tried to flush the IV, the line was blown. I informed the girl that I would have to start a new IV or give the medicine as a shot, and she suddenly no longer had pain! She didn't have pain for at least two hours, until the doctor started talking about discharging her. While fetching yet another blanket for my patient, I noticed that another patient was being brought back to my other room, so I glanced at her chart. It said, "laceration to foot." The girl was wheeled into the room and she smiled and waved at me as she passed by. I relaxed a little bit, thinking that this would be an easy case. I went in the room and started my assessment of her. She had a make-shift bandage over her foot, so I put my gloves on and lifted it off. I could not believe what I saw- her foot was cut so badly that you could see the tendon to her toe. While I was examining her foot, her parents lifted the sheet up to block her view. I quickly understood why. These were some smart parents. I asked the girl to rate her pain for me. She said it was a two out of five. Had she had the chance to see how badly she was hurt, I'm sure it would have been a seven out of five! I just couldn't get over how different my two patients were- the one with nothing wrong with her was screaming "NURSE!!" every time I walked by the room, and even screamed at the top of her lungs when I took her temperature across her forehead. The patient with a cut down to the tendon was polite and never even complained. When going from the heavenly patient to the, uh, opposite of heavenly patient, I wanted to tell her how bad the girl next door was making her look. But I like where I work, and I don't want to lose my job yet, so I served her with a smile my entire shift. I was shocked and hurt when they stiffed me on the tip though..... Maybe that third cup of coffee was too cold?