The pain scale.

Here I am contemplating at least, my last few shifts as an ER nurse.

Of course, all of this could fall through and I could have years and years of ER nursing ahead of me.  Hey, there are worse things.  But, if this is to be my last stint of ER duty, even for a while, I want to get a few things down and thought I would share.  For those of you here only for adventures and pretty pictures, come back soon.  They will return. 

Now...sit down with any ER nurse and ask them about the pain scale.  At the very least you will get a groan and an eye roll.  Some, like myself, will go off on a passionate rant about the misuse and abuse of the standard 1-10 pain scale.  This sounds like it isn't a big deal, but it might be more so than you think.

Let me tell you why.

First off, when you come in complaining of pain, we take you seriously.  You took the time out of your busy day to come all the way down to the ER and probably waited a pretty good amount of time in the waiting room to boot.  Obviously this is more than just a minor boo boo.  (Except when it isn't, but that is another rant.) I get that you are trying to convey to me the serious and urgent nature of your pain.  Again, you are here, that tells me something.  Telling me you have level 10 pain because your ankle hurts, or even your stomach hurts, doesn't do that.  The first thing that does, is prevent that pain from ever getting worse.

You see, the scale only goes to 10.  Yes, even if you insist your pain is 25.  So, when your migraine gets worse, or your back starts hurting from lying on the junky ER stretcher mattress for a couple of hours, there is no way to document that.  The computer will only allow an entry up to 10. 

Your pain got worse?  No it didn't.  10.

One guy I worked with, definitely of the ranting variety, would ask people who rated their pain a 10, "So, if I set you on fire right now, you wouldn't notice?"

It gets irritating.

Especially when you arrive and are texting your friend about OMG you are at the hospital and eating the bag of chips from the vending machine in the lobby while you tell me your belly pain is a 10 out of 10.  Look, if you won't take this seriously, why should I?  I have a guy next door with 6 out of 10 chest pain for the past hour.  Who do you think is getting my time?

But, the real reason is different.

The real reason is that I have seen people in level 10 pain.  Most ER personnel have and it can be quite the profound experience.  You see someone who is gravely hurt and fading in and out of consciousness.  Every moment they manage to stay awake they are crying and begging for medications maybe you can't give them because their blood pressure is too low from all the blood they lost.  Frequently, the pain overwhelms them and they fall into animal screams before they lose consciousness again. 

So, what was your pain level again?  Let me give you a clue, if you can tell me it is a 10, it isn't.

Please, respect the pain scale.  It can be useful if used properly.

For a good example of what I am talking about, look here:  Pain Scale

The ER kicked my butt.

I doesn't happen often. 

Yesterday, the ER won. 

I am good at my job.  Much of that arises from a time when I wasn't very good at my job.  Not being very good at your job when someone's life or health depends on your proficiency is a very stressful situation.  That stress leads you to work hard on getting better or it burns you out.  I worked hard and got better and my stress level at work decreased to an acceptable level. 

But. 

And that is the nature of the emergency room.  You never know what is going to happen. 

Yesterday started off well enough.  I was busy, but nothing too bad.  Then a DKA arrived.  For those who don't know, these are somewhat personal for me.  These are possibly life threatening emergencies and they deserve as much of your attention as you can spare if you are the nurse.  While I was getting that all settled in, my sepsis arrived.  Systemic infection that can be life threatening.  Good times.  Dehydrated to the point that I couldn't find an IV site.  Luckily, my co-worker came to my aid with an ultrasound, just in time for them to tell me about the STEMI that was arriving into my other room.  Everything else stops for the STEMI.  This is an evolving heart attack.  Time is tissue.  We had a lot of work to do to get this guy to the cath lab within the window.  Again, without a couple of co-workers, this could have gone badly.  Even with all the help, I was starting to get a bit overwhelmed. 

We get the STEMI out and up.  I walk back over to my sepsis, to try to get back up to speed with where I was and what needed to done.  They tell me there is now a code stroke coming into the room where the STEMI just left.  It isn't even clean yet.  Oh yeah, I have another room with another patient I haven't even mentioned. 

This is the point where I realized something has to give. 

Mind you, this happened on a good day, in a good hospital.  At the morning meeting they informed us that we were 'upstaffed' today.  And even though we had an extra nurse, my charge wasn't going to send anyone home  just in case. 

So, working in my favor was an extra ED nurse, a charge nurse that was good at recognizing and fixing problems as they crop up, and a pretty well run hospital.  Without any one of these things, this could have been a lot worse.  It reminded me of other places and other times when I was not so fortunate.  Sometimes these things happen when you are down a nurse, with a green charge in a place that cares more about saving money.  I've been there too. 

I'm tired.  I need a break from all of this.  Is it weird that I am looking for a more sane work environment in a prison?  Probably.

I am pretty sure though, that I won't have to do urinary catheters on 2 year old kids and CPR on 90 year old people.  I guess I will see. 

Yesterday, everything worked out thanks largely to my coworkers.  We got everything settled and I even got sent of to lunch.  Then I returned to the new patient that wouldn't stop pooping on himself.  Some days.

And on this day I broke a little.  As I have before.  When I got home my family put me back together again, like they do.  I will go back again later in the week and try again. 

It's time for a change.

I'm ready.

Every once in a while

I don't talk much about work here.  Heck, I don't talk much about work anywhere but at work usually because people just don't understand.  There are things you see and do working in an emergency room that just don't translate well to 'normal' people.  Or, well... anyone else really.  Don't get me started.

I know this blog space is usually filled with long exposure pictures of waterfalls, kids, passing street signs and other things not appropriate for long exposure photography, but it is a blog about a travel nurse and family.  Every once in a while nursing will creep in.

We in the ER do some pretty heinous stuff on a regular basis.  I have scraped archeological  layers of feces of people that haven't unbuttoned their pants in a month. Think about that for a second.  I have been yelled at, spit on, cursed at (OK, that one can get amusing at times).  I have seen more blood, guts, death and sorrow than I care to recall to anyone who can't share the experience.  Honestly, most shifts I am happy if nobody died and I didn't get fired.  I don't always meet my goals. 

Every once in a while though, circumstances coalesce into an opportunity to personally help someone.  I help people all the time as part of a team.  I do my part and start IV's, assess and monitor patients, give medications and so on.  I help people often that way.  But to do so personally, that isn't so frequent. 

This time it happened.  It was a pretty routine situation.  The person, and their family who accompanies them, comes in and tells of a chronic problem that is worsening.  They have been dealing with it for a long time and no one has been able to explain to them why this thing is happening.  It is somewhat obvious to me what is likely going on, but some problems are sensitive.  Some problems carry with them a stigma and a judgement from the patient and the public that prevents you from just walking in and going, "Yeah, you probably have X, but it isn't an emergency." I could tell from the history and what they reported their doctor telling them that even the primary doctor was tiptoeing around the diagnosis. 

Normally I am so busy that all I can do is rush in, draw the blood, administer the medication and do my normal routine stuff and get out.  I would love to sit down and talk to you long enough to figure out how you communicate so I can try to figure out the best way to convince you of what you are dealing with and what you need to do, but that would take 30 minutes and I barely have 5 because I have three other patients, one kid who can't breathe, one who has a kidney stone and a 90 year old who has been throwing up all day and is losing their blood pressure. Normally.

This time it was slow.  I had some time.  Instead of sitting on my butt at the nursing station or getting a bite to eat or any of the other things I could have done, I decided to go into the room and talk.  It took a while, but I think I explained something important.  Something about how a small decision made in reaction to something that happened long ago can snowball into something later.  How even dysfunction can become normal when you do it long enough.  There is no judgement.  There is only a lack of understanding.  I feel, whether it is true or not I will never know, but I feel like I explained something to this patient and their family that will make a real positive difference in their lives. 

That feels good. 

I don't know if I would say it makes up for the crap, abuse and sadness that often accompanies this job, but it helps. 

Another weekend at work...

Another pediatric code.  Dang, this is way too regular.  I have equaled my career total of pediatric codes in the past two weeks.

This one was a little different though, we never had a chance.  The only reason it even came into our ER was because a child was involved.  That makes it a bit easier to take, I think.  To fight is to become emotionally invested.  Just going through the motions on the outside chance something startling happens doesn't require much emotion.  Just a numb sadness.  Or perhaps, as Papa likes to say, my sensory strunods have been numbnetized.

After it was called I went back out to my other three patients.  One has a heart rate of 30-35, one is a large man freaked out on PCP and one has a toothache.  Yeah.

Can you guess which one was more demanding?

I've noticed a correlation.  If it is a true emergency, nobody cares how long it takes.  Nobody cares.  Just please do whatever you have to do to make it right.  It is the non-emergency that is demanding things hurry up.  Why is this taking so long?  Can't you see that I am in pain?  10/10 pain!

And as ridiculous as that seems when compared to the other patients, you can't let that get to you.  You have to try to remember that their pain is the most important thing in the world to them, or they likely wouldn't be here.

It's hard though, sometimes.  I don't care if you brought your mom.  I don't care if ibuprofen doesn't work for you.  I am devoting more time to you than a patient that has a legitimate risk of dying...tonight.

And if I don't smile, and don't show enough concern, they fill out a survey and I get in trouble.

Don't worry.  I smiled, I effectively demonstrated my compassion while expressing as effectively as I could why they weren't getting admitted and sedated for their toothache. 

It is amazing to me how much can happen in one 12 hour random ER shift. I have thought about writing one, but I don't think people would believe it who weren't ER nurses.

You know that feeling you get on a Friday after a busy work week?  Hell yeah!  I made it!  I get that after every shift.  I am always a little surprised I and at least most of my patients survived and nobody got fired.

So, I'm taking a couple days off.  Maybe I'll post up about how I fixed my toilet next.  Give everybody a break and talk about a different type of crap.

Head colds

I hate head colds.  You know what I'm talking about.  Your nose runs like a faucet with a slow leak.  Your head feels like someone is blowing a balloon up inside your face.  None of your thoughts seem to be clear and you have that nagging, tingling itch in the back of your sinuses that is driving you insane.

That is not an excuse to go to the ER.  Unless of course, you work in the ER.  Then it is not an excuse NOT to go to the ER.  Staffing for a shift is usually pretty tight anyway.  If one person calls in it usually means everyone else has to take an extra patient or two and when patient to nurse numbers go up, outcomes are pretty well correlated to go down.  We all know this.  So just try calling in to work with anything that doesn't involve needing to go to the ER, some other ER because you wouldn't willingly show up at your own (I fear they might create new and inventive ways to use catheters).  Sinusitis?  Bronchitis?  Ha.  We train to not get sick from contacting sick people.  The reverse is true as well.  Besides, as a traveler, I don't get PTO.  Don't work, don't eat. 

Usually you just slog around the nursing station like the zombie you are until you need to go into a patient room and then marshal all your energy so you can appear like a normal human while you work with the patient.  Wash your hands, wash your hands, wash your hands.  Then, as soon as you leave the room, you re-zombie and trudge about your business. 

Then they bring me a code stroke.

This is a patient that has developed symptoms of a stroke recently.  Like, within the last hour.  You see, if you have signs of a stroke, it is a race.  There is a medicine we can give you if you are having a certain type of stroke, but we can only give it to you if we can start it within around 4 hours of the onset of symptoms.  Later than that and the risk outweighs the reward.  The drug tPA essentially dissolves all blood clots and prevents new ones from forming for a period of time.  This can be detrimental to you, so the decision to use it is not taken lightly.

By the time the patient is in the room, they have been in the ED for 40 minutes or so, getting triaged and then taken to CT to rule out a bleeding stroke.  They want the medicine administered within 60 minutes of arrival.  The guy at triage has tried three times to get a line on the patient and failed, they are a hard stick.

So, there are 20 minutes to get two IV's started, administer a stroke scale, get the medication from pharmacy  and about a hundred other things.  Do you think anyone cares about that head cold?  Nope.

I got two lines in two sticks, we beat our target times and got the medicine in...with help from the stellar crew here.  Then I had to stay in the room with the patient for the next hour to make sure nothing more drastic than bleeding from those three missed IV's earlier happened.

So, I'm happy to have a couple of days off.  Head colds suck.

He looked like someone I care about.

Not exactly alike, but enough.

His heart wasn't working very well tonight, not at all.  Not enough for consciousness when I met him...at least I hope.

He wasn't my patient.  They needed some help and I gave it.  I was the first to notice the heart rhythm change into something not compatible with life.  After the shock I jumped on for CPR.  I give excellent CPR.  No bragging, just a fact.  I take pride in that.  If you go down and I am around you will have a chance.  I was this man's heart, off and on, for two hours.  CPR is tiring.  But, when I did compressions, his heart would come back and gave us time to keep fighting, keep searching for a cause and a cure.  My new team mates commented on my 'life saving hands.'

All for naught.  We made sure he didn't die on Valentine's Day.

I hate the sounds people make when they realize their loved one is gone.  Screams, wails and choked sobs, they all suck.

But you have to shrug it off.  You have to move on.  Your other patients need warm blankets or pain meds or something.  So, you press on.  You let it go.  It's amazing, but you really do.

So forgive your nurse if they aren't always cheery.  If we seem like we don't care, it isn't because we don't want to.  Sometimes we just can't.