ED in Cincinnati

Even on my vacation I get to hang out in the emergency department. My mom broke her arm midway into our vacation. I was in Cincinnati for my cousin’s high school graduation. We had a lovely time. The big surprise was the presence of my sister. Yep, Heather came from Lima (Peru) to spend the week. It was great seeing the look of surprise on my Mom’s face when she saw my sister. I had been clued in a few days before our departure since I had some things my sister wanted. I was wondering how to get them to her. She asked if I could keep a secret and when I said I could, she suggested I bring the items to Cincinnati. I had no idea just how difficult it would be to keep the secret. I did not intend to tell it, but it nearly slipped out a few times. The look on Mom’s face was worth the effort of keeping the secret.

The graduation was nice. My cousin was valedictorian and gave a speech with his co-valedictorians. He did a fine job. Now there are no more high school graduations and only two more under-graduate ceremonies left. There is always the possibility of weddings for a few of us…

So, the night before the first cousins were to begin departing we cranked up the traditional family game of spoons. We can get pretty wild. There is a mandatory fingernail and ring check. If your nails are too long or your ring setting too large, you may be required to fix the hazard before entering the game for the health and safety of the other players. About three or four rounds in, my dad came down the stairs and requested I follow him back up. I was not sure if I had been singled out as the rowdiest and thus earned a lecture or if my nursing expertise was needed.

It was the latter. It seems that my mom had slipped while getting ready for bed and taken a hard fall to the wall. Long story short, we made a trip to the local emergency department where it the suspected broken arm was confirmed. She has a break at the top of her right humerus.

Birthday v. 41.3

My co-workers

Well, another year has gone by and I really do not feel any older. I was actually working this year, both on the morning and the evening of my birthday. It really was not a bad way to celebrate. I was surrounded by friends doing a job that I really love and although it was busy, it was not a bad night. No one died.

My first celebration was two days before my birthday since that was the only time the whole family could get together. Mom and Adrian cooked my favorite meal and my favorite carrot cake. My brother and his family came over. It was a fun evening.

On the morning of my birthday, I had a dinner packed by my mom the day before. Can you imagine a 40 something having their lunch packed by their mom? It was the delicious leftovers from the night before. I would let her pack a lunch for me whenever she wants to! I had salmon with pineapple salsa, spinach, asparagus, sautéed red, yellow, and orange bell peppers, sweet potato fries and salad. I left the carrot cake at home for another time. I did not want to be in too much of a food coma.

My co-workers are great. They organized a little dinner and cake event for the evening of my birthday. We had sub sandwiches, chips, fresh strawberries, chips, cake and ice-cream. The charge nurse is the person in charge of making the unit run smoothly. On my birthday, our charge was the organizer of the food and such. She was concerned that I thought they forgot, so she let me know that there was something planned, and we would get to it as soon as we could, but not to expect it before midnight. So, technically, my birthday was not celebrated on my birthday.

I don’t think I will make a habit of working on my birthday, but it would be okay if it happens every now and then.

SCIWORA, or what I have learned

I was working back in the observation unit (OBS) in the emergency department. The OBS unit is where patients go who are too sick to send home but not quite sick enough to admit. Usually, they are patients who need a bit of “wait and see” before deciding which way they will go. Will they get better and go home or will they fail to improve and be admitted. I am not all that fond of OBS for a few reasons. First, it is a bit lonely back there. Generally speaking, there is one nurse and up to five patients in the small, self contained unit. Secondly, since you are somewhat isolated from the rest of the department, you do not have a readily accessible back up when things go awry. I have had a few patients get transferred straight to the ICU after a stay in OBS. We had a chid the other night that was in OBS, then transferred to a “big” room (the trauma rooms), intubated, and sent to the ICU. Pretty scary stuff!

So, when I was back in OBS a few weeks ago, I had an 18 month old boy who had been a restrained passenger in a motor vehicle accident with two adult fatalities. My first concern was that there were no family members present to watch and comfort the child. Not only was he alone after the trauma of the evening, but he was Spanish speaking and my Spanish is somewhat limited. I really felt bad for the little guy.

We were trying to obtain a urine specimen from the kiddo using a urine bag. When I checked the bag to see if he had produced anything, I noticed he had an erection. This did not concern me too much, but I did make a mental note, as it is not a terribly common finding. I checked the bag again about an hour later and noticed that the erection had not resolved. This was definitely out of the ordinary, so I told the doctor. Her suggestion was to watch it for another hour and check back. I then documented my observations and the fact that I had notified the doctor. When I went to check, I noticed that the patient did not appear to be moving his legs. Not wanting to cause undue alarm, I went to the doctor and told her my concerns. She came and checked his reflexes noting movement of his toes after stroking his foot. She felt that he was fine, so I did not document my concern.

Meanwhile, the erection continued, so we had to catheterize the patient to obtain the urine specimen and relieve his bladder pressure. The patient’s dad had arrived. I was so happy to see him that I had a hard time controlling my emotions. I was so relieved that this child now had a familiar face and voice after what must have been a most perplexing and stressful night. Since it was the end of my shift, I went home.

When I returned the next night, I heard that my patient was in the ICU. He had a spinal cord injury known as a “SCIWORA”, or spinal chord injury without radiographic abnormality. You can imagine how hard I was kicking myself for not being surer of my observation. At the very least, I should have documented my concern and the fact that I notified the doctor. The patient’s condition would not have changed with earlier notification, but that does not really help me feel any better about it. I do not know the long term outcome for this patient. There is some hope that he will regain movement, but only time will tell.

The lesson learned for me? Document, document, document! When in doubt, document. I was so afraid of writing what I saw for fear of making too much out of nothing. I was afraid that someone reading the note would “freak out” over what was obviously not a problem. After all, the doctor had evaluated the patient and felt there was no problem. Now I know to trust what I see. If it concerns me enough to notify the doctor, I need to document it as well as the fact that the doctor was notified.

The Dundler Mifflin String Quartet

My Cousin, AJ, is the cellist

Back Office Testing

I am not sure how it works in other areas of nursing, but in the emergency department, we run several back office tests like rapid strep, urinalysis (UA) and pregnancy tests. I have had a few UA’s which were positive for urinary tract infections, but otherwise, all of my back office tests have been negative until yesterday.

Last night I had a positive pregnancy test. I really wasn’t expecting it to be positive. The patient was a 12 year old girl with hip pain. Usually, a pregnancy test on a teenage girl is just a formality. You don’t really expect it, but you have to rule it out. Maybe a positive test on an older teen, but a 12 year old? I had to confirm that I was seeing what I was seeing. Were there really two lines? Maybe I should repeat it. Apparently the family had the same thought. We collected another sample, and indeed, it was positive again.

It was difficult to gauge the family’s reaction. They seemed happy enough, but there was just the slightest under current of tension. As the nurse in the situation, I had a difficult line to tread. It was obvious I knew the score, but I needed to remain unbiased and neutral in my reaction and interaction. I tried to strike a balance. I did not want to get too serious, but yet a joking manner did not seem appropriate. I tried to engage the patient in light conversation while gathering the needed information. Trying to let her know that I was on her side and not judging.

I guess this case was just a much more dramatic presentation of what I strive for as a nurse with every patient. My patients need to know that I am on their side and that I do not judge the situation they find themselves in. My job is to care for my patients. Not just physically. Yes, I apply bandages, but I would hope that I also apply emotional bandages. I believe healing involves more than the physical. By expressing my concern for all of my patients and their families, maybe I am sowing the seeds of healing.

Should you visit me? Or "What is an emergency?"

What is an emergency? It seems that there are many people out there who don’t know the answer to this question. Can the patient breathe? Are they bleeding? Is there a bone broken? Are they awake and alert? These are the questions we attempt to answer in triage. Remember your ABC’s? In all first aid and CPR classes, the first thing they teach you is ABC, or Airway, Breathing, and Circulation. Additionally, we have added D for “Da brain”. Chances are, if all your ABC’s are in order and functioning, you do not need to go to the emergency department.

Let’s start with A and B since they go together. Is the patient moving air? If so, they are good! Even if they are coughing or have a stuffy nose, chances are they are going to be fine without any intervention. If they are breathing really fast and seem to be working hard at getting air in, they might need to be seen. One way to tell they are working hard is to look at the belly and neck. If the muscles in these areas are getting a workout, that is not so good. By all means, come see me in the ED.

How about C? Amazingly, children rarely have trouble with their heart. How about the other circulation issue, bleeding? How long, deep and where is the cut? If it is small, not on the face, not deep, and can be easily cleaned out, you are good! If not, come see me…

Da brain. Is the child lethargic? What the heck does a lethargic child look like? Can they answer questions appropriate to their developmental level? Think about how you feel when you are sick. Don’t want to eat? Want to sleep all day? When a kid is sick, they can feel the same way! Kids can get dehydrated much quicker than big people, so here are some easy ways to determine the hydration status: tears, diapers or trips to the bathroom, and moist mouth. If they have these things, they are probably ok. If not, come see me…

Do not come visit when your child has a nightmare. Do not come see me when they have a cold. Does their tummy hurt? Go to the doctor in the morning. The emergency department is not the best place to hang out when you are bored in the middle of the night. The other night, we had a family who brought their child for a cold and then, after waiting an hour, the parent asked, “Why did I come to the emergency department any way?” It was all I could do to refrain from replying, “I don’t know. Why did you come to the emergency department?”

Another issue; why do parents end up in the ED without the supplies needed for the general care and feeding of their child? I do understand that in an actual emergency, there is often no time to grab these items. However, when a family is coming for less urgent care, why do they leave this stuff home? If you were going to the mall, would you expect the shop keeper to supply a diaper, wipes and cream for changing the baby? It will likely be a long wait, maybe some books and or small comfort toys would help the cranky child who is usually asleep at this hour and now is in desperate need of a nap. I had a father the other night who demanded immediately after being placed in the room, “I need a diaper, baby wipes, and cream and a bottle with formula.” This was for an older child with special needs who required a diaper size which we do not usually stock in the ED. Fortunately; there were some in the store room.

To sum this up, if there is an issue that truly needs immediate care, come see me. If not, consider staying home and calling you doctor in the morning. Generally speaking, the doctor is less expensive and the wait will be shorter. If you do decide to come see me, bring whatever supplies you might need as the wait times can be quite long at this time of the year. When in doubt as to staying home or coming to the ED, call your pediatrician or a nurse advice line. Children’s has just such a resource which can be found online at http://www.thechildrenshospital.org/wellness/at_home/index.aspx, or by calling 720-777-6543.

The training wheels are off!

Look Ma! No training wheels. I (and all of my patients) survived my first week off of orientation. I was in the observation (OBS) unit the first night. The OBS unit is intended to house patients who need to be observed for a few hours (less than 24) to make sure they are indeed getting better and ready to go home. With the high level of occupancy in the hospital at this time, the OBS unit often ends up being a holding pen for patients waiting to go upstairs to a regular room. I had several patients (about four at a time), some went upstairs, some went home, and a few stayed the night. It was busy, but not too bad. The biggest problem with OBS is that you feel a bit like you have been sent to outer Siberia. It is a bit cold and lonely.

The next two nights were out in the main ED with a regular hallway. Taking a hallway means you have 4 rooms, and you care for the patients who rotate through. You see a wide variety of patients and conditions, although you see mostly respiratory patients at this time of the year. I did get two items accomplished.

My first day on a hallway saw my first infiltration. My patient was a five year old with no muscle tone. Her veins were difficult. I was quite pleased with myself when I got the IV on the first try. It seemed like a good one with excellent blood return and it flushed easily as well. The patient needed fluid bolus, so I hooked it up. After the first bolus, she needed another. I checked the IV site, which looked good, and started the second bolus. Near the end of the second bolus, the doctor asked for another bolus and more lab tests. Being the ever dutiful nurse, I unwrapped the IV site, hoping to draw blood from the line already in place. Imagine my surprise when I noticed that my patient’s arm was bout twice the diameter it had been prior to my intervention! Amazingly, because of the lack of muscle tone, the arm was still soft and not painful to the patient. The estimate was about 100 ml of fluid in the tissue surrounding the IV site. For those of you who have never experienced this, just know that any extra fluid in the tissues usually caused a hard swollen area which is usually painful. So, I had to remove the IV and start another. The patient’s mom was very understanding, telling me what a good job I was doing and how glad she was to have me for a nurse. I suppose this should have made me feel good, but I was really wishing she would get a little upset, because her kindness was making me feel even worse…

The other item I got out of the way happened on my second day on a hallway. I was helping another nurse hold a patient for a nasal wash. In this procedure, saline drops are placed into each nostril, and then a suction tube is inserted into the nose to the back of the throat and mucous is collected. We often refer to this as a “booger-ectomy”. You might imagine that the kids do not care for this procedure, and can put up a bit of a fight. So, as the “helper nurse” I was in charge of holding the hands and head still. This is usually done in the “touch-down” position, with the hands above the head near the ears. All was going well, the patient was old enough to cooperate a bit, and then she gave a good cough. The cough is actually not an uncommon occurrence, but this one was quite moist, and a bit of it managed to hook around my glasses and land directly on my eye-ball. I had on gloves and a mask, but no further eye protection. My glasses should have been enough… And to make matters more interesting, the patient was positive for strep throat and influenza B! Fortunately, I had antibiotic eye-drops in my locker for my last round of pink-eye.

So, lessons learned:
- Wear eye protection, even if you have glasses.
- Check, check, and triple check all IV sites
- Don’t get too sure of yourself
- I can ride without the training-wheels!