Ending on a Sad Note

There were a lot of different experiences I could talk about from my last day in the  ED, but the one that really stuck with me was my last patient of the day. The 20-year-old female came into the ED complaining of vaginal bleeding and extreme pain. She had gone to another ED a few days before where she had been told she was miscarrying, given pain meds and sent on her way. Now she was out of pain meds and wanted more. Nobody was really taking her seriously, since they had all had patients who faked pregnancy/miscarriage to get pain meds (how AWFUL is that, by the way???), but I wasn’t sure.

This was NOT my first patient that came into the ED with abnormal vaginal bleeding – but the first one who came in saying she had had a miscarriage. Our PA didn’t even believe that she had ever been pregnant, so she ordered a urine pregnancy test.

I walked into the patient’s room and told her we needed a urine sample. The look of anguish that washed over her face was heartbreaking, and I told her that I would help her as much as I could. Since she came into the minor trauma area in a wheelchair, I took her by wheelchair to the bathroom, and helped her obtain the sample. The urine sample was full of blood and tissue. So much for a clean catch. As we were setting up for a pelvic exam, the PA took her medical history and I found out that this was this girl’s sixth pregnancy, and I tried not to judge. I was happy that her partner was there with her and sorry she was in such pain. I helped her get to the bottom of the bed, expecting a normal pelvic exam. However, the exam was in no-way normal, and caused her a large amount of pain...

The MD swept into the room, took one look and told the girl (who was still whimpering) that she was still actively miscarrying, and called for more IV push morphine (I had already given her some 5 minutes earlier). When I came back from getting the morphine, it was just the girl and her partner in the room. I told her what I was doing, and that it was going to help with all the pain. Then I told her that unfortunately it was the end of my shift, and that I had to go. She responded with tears. I told her that now that they had figured out what was wrong, it was going to get better, and that I was sorry she was hurting. I reassured her that another nurse and NA were on duty, and that the MD and PA treating her were there for another 2 hours. She wasn't being abandoned. She calmed down and I walked out of the ED.

It was a difficult, emotional experience to end my preceptorship on, but I felt like we actually were helping someone - and that was positive and fulfilling.

Not Quite the Flu.

The ED is a completely different animal than any other place in the hospital. In more ways than one, it's just like the restaurant where I work - sit them down, ask what they want (what's wrong), get them what you can (push meds, get blood or urine), send in the manager (the MD, PA or NP) and send them on their way. Turn those tables (rooms)! 

Instead of doing a head-to-toe assessment where I use my stethoscope, penlight and fingers, I get to have a 3-minute question and answer session, with minor follow up if there is a specific ailment (like listen to bowel sounds if the abdomen hurts, etc.). As the days in the ED went on, I think I became complacent in my assessment - one of the things that I wanted to get better at during my time in the ED.

We had one patient that came in complaining of flu-like symptoms. The Physician's Assistant thought it was probably the flu, but ordered a chest x-ray to cover her butt. When the results came back, we were both were shocked - Pneumonia. At least she had listened to his lungs and determined that his right lower lobe was diminished. I, on the other hand, only asked him how long his signs and symptoms had been going on, and if had been taking anything for them. Sigh.
 

Later on I started the same patient's IV. He didn't like needles, so I told him to look at the wall while I put in the IV. Good thing I did, because I didn't pull the tourniquet off his arm and couldn't get the saline lock on fast enough ... so he bled everywhere ... like to the point that I had to move my white pants and shoes out of the way so the blood could drip on the floor. I was seriously freaked out by this incident, but both my nurse preceptor and the PA told me not to worry, and that I was still learning. I still felt bad though. Thank God the patient didn't look over toward me! Sheesh.

Eventually I get better at all this...right?

Another ED Experience...

We had another patient who came in to the ED complaining of nausea and vomiting, with a sharp pain in her lower right abdomen. My preceptor started the IV, gave the patient morphine IV push and then started a bag of normal saline. When I came back 15 minutes later to check on the patient, I noticed that she had red streaks running up her arm, and her veins were puffy. I stopped the IV and placed a cool compress on her arm, and then went for my preceptor.

All we had given the patient so far was morphine, and I could see the veins leading away from her IV site were red and puffy, so I knew it was probably a local reaction to the medication. I asked her again if she had any allergies, and she said no. I stopped the IV pump and got a washcloth from the cabinet, wet it and placed it on her arm. I told her that she was probably having a small reaction to the morphine that we pushed (which is why her arm wasn't hurting now that the saline was running), and that I went to go get my nurse.

I told my preceptor about the situation, and what I had done so far. She went into the room and took a look, and pretty much told the patient what I had - that this was probably a local reaction to the morphine, and that this reaction was common. To make sure we were right, she asked the doctor to come in and take a look at the patient. Begrudgingly he took a minute and went to look at the patient's arm. He agreed it was a reaction to the medication, and prescribed Benadryl IV push.
 

This situation kinda freaked me out - I mean, who has seen red streaks running up someone's arm?? It looked like blood poisoning or something. It all worked out, but I couldn't help but think about what would have happened it it wasn't a local reaction, but a systemic one. Her airway would have closed off or her breathing could have slowed. Since she wasn't hooked up to a monitor...how long would it have taken for me to come back and check on her? That thought chills me...

Adventures in Nursing

During our senior semester, we do a preceptorship in a specific unit at the hospital. Kind of like an internship, we spend 56 hours with a nurse, working their shifts with them, and becoming more and more independent. I chose to do my preceptorship in the Emergency Department (ED), and it has been a fantastic experience. I wanted to share a few of my experiences there - hopefully you'll find them as crazy as I did!

My second day in the ED, my nurse and I had a patient who was complaining or continuous nausea, vomiting and diarrhea. In order to replenish her fluids quickly, the doctor ordered a liter of normal saline to run wide open…which meant she needed an IV started. Since I had never successfully started an IV on a patient, she sent me in with the IV supplies by myself – and told me to return to her if I thought I couldn’t do it.

This was my second attempt at an IV start in the ED – at the first one I was aiming correctly, but was afraid to hurt the patient and didn’t push far enough into the skin. Thankfully the weekend prior to the clinical day included a visit with my mom, who had promised to be a pincushion for me as I practiced IV sticks (she is a saint). AND I got the stick on the first try – so I had slightly more confidence than I had before the weekend.

As I went into the room by myself and examined the patient’s arms, I talked to her about if she had ever given blood and asked her which arm they used. She pointed to her left, but I had just seen a large vein in her inner arm. I asked her if that vein always stuck out like that and she assured me it did. This was like a giant bull’s-eye on her arm. She seemed really calm – I’m not sure if it was from her nausea or her natural state – but I was grateful, because I was a wreck. I tried my best not to show how nervous I was, especially that my hands were shaking! I had a hard time starting the IV without getting blood everywhere, but I did my best to recover and start the bag of saline. Once the IV was started and a medication was pushed, my preceptor came to check on me. She asked me if I got blood, and thinking that she meant the blood flash when starting an IV, I said, “YES!!!!” Actually she meant if I had pulled blood for the lab. Oops. I had been so nervous about the IV that I hadn’t read that she needed a full workup on the order sheet.

All's well that ends well, right?