Category Archives: Nursing

Stories from a Nurse’s perspective.

Advice to the new Emergency doctor from the old Emergency nurse

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Welcome to the emergency department! I hope you love it as much as I do!
As a first placement you are going in at the deep end. If this is a subsequent placement then you still have a lot of changes to embrace in this challenging new environment.

Our most recent intake of fifteen brand new doctors has prompted this blog. It has had a noticeable impact on the department. They are all lovely young men and women and I really feel for them as they deal with all the new experiences in the emergency department environment. So I wanted to share some tips and insights that might help make the transition easier for anyone in this position.

My advice comes from twenty (something) years of nursing experience, and seven years of emergency nursing, but I still remember what it was like to be new. Which is something no one should ever forget because one day you will be the senior person and being able to remember how it feels will make you a better mentor and leader in the future. I wanted to gain a broader perspective than my own for this blog, so I asked for some input from my colleagues, and while the incidents and stories they relayed to me varied, the themes remained the same. I think that most of the issues and clashes arise from dealing with personalities and human nature. Unfortunately from both sides, medical and nursing. And a huge focus of the feedback I got related to blood collection and cannula insertion.

So here it is,

First quick one before you start. Yes, in the Emergency Department you have to work weekend’s and night shift. Knowing this will save the person doing your rosters from thinking you are stupid.

Clean up your own mess. That includes in the tea room.

Please don’t be offended if someone ask’s you to clean up your own mess.

Dispose of your own sharps.

If a nurse helps you find equipment and sets up for a procedure, for example the plaster trolley, please clean it up and put it back yourself. At least saying “hey, where does this go?” Shows you are happy to do it, you will be directed where to put it or (because you asked and showed an intent to do it) the nurse may take it for you. Leaving it in the corridors outside the cubicle and walking away will get you one pissed off nurse and he/she will tell their friends.

A good life long piece of advice, no one person knows everything.

If a nurse is telling you something about a patient, it is for a reason, please listen, it is probably important.

There is only one gift from god, and they already work here.

Carry lube in your pocket.

Bring a little pocket/purse sized snack, that doesn’t need the fridge, you may not get a break. Sugar is happiness. Nurses like happy doctors.

Be friendly, introduce your self, be approachable.

Now to the cannula issues, in the department I work in most of the nurses are able to take bloods and insert cannulas (most will have done more than you’ve had hot breakfasts) but ultimately it is the responsibility of the doctor to obtain the blood and iv access.

If the nurse has inserted the cannula and taken blood then they had time to. If not they were too busy and you need to do it. Chances are you need the practice, more than the nurse does.

On some shifts there may be a relief staff member that may not be competent to do cannulation so a good approach is, if the cannula is in, try to say thank you to the nurse (This one thank you will probably ensure all your cannulas for the rest of the shift will be done before you even see the pt.) And if the cannula is not yet in, do it whilst getting the pt’s story. Best not to just leave the blood slip there, try to find the nurse and see if they have time to do it.

You are qualified to put in a cannula and therefore qualified to take one out. You actually have time to remove it and apply pressure for a minute whilst giving a discharge letter and instructions to the patient.

This is a great practice, for both the patient and the department. Because when the patient tells the nurse ten minutes later that they can leave and then the nurse spends ten minutes trying to find you to confirm the patient can actually leave (and that they have their letter and possible script), before removing the IV, the next patient could be in the cubicle being worked up.

So there you have it, all simple things to keep in mind while you become familiar with your new role.

Do you have any positive tip’s or advice of your own? I would love to hear your thoughts or suggestions. Feel free to leave a comment below.

Stay safe, be happy.

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My Patient Advocacy Story.

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20130319-193138.jpgBeing an advocate on behalf of our patients is one of the most rewarding and sometimes challenging roles nurses perform. I recently had an experience where I needed to go out of my comfort zone to advocate and provide a safe environment for my patient. After the shift I wrote about the experience, as this is my new self-styled “therapy”. I have just re-read my account of that evening and I was immediately transported back into the busy bustle of the trauma room that evening. I remember the patient, his cries of pain, his gratitude for the morphine, his concern for his injuries, and all the little details that built my suspicion of further injuries. I cannot put all the details into my blog for professional reasons but keep in mind as you read that it was a highly stressful fast paced situation in which I knew the patients care was going in the wrong direction. And the Doctor wasn’t listening to my concerns. I knew that for the safety of my patient I had to speak up.
The patient had fallen from a motorbike at high-speed. A mechanism which is highly suspicious for sustaining injuries. This patient had walked into the Emergency Department. This is a little unusual but not unheard of. He had an obvious injury which we call a distracting injury. It was a busy night in the trauma/resuscitation area with all our resus rooms full. Trauma patients have multiple staff providing multiple procedures simultaneously, there is actually a process to this type of trauma care but on this occasion I was not happy with this process and I believed some of the routines for this patient had been skipped or rather decisions were being made not to have certain procedures performed. I repeatedly attempted to discuss with the doctor some of the decisions that were being made, however this was to no avail. My level of concern was so high, that I felt it was necessary to take things further and ask the Consultant to review the patient. This step effectively went over the head of the treating doctor in the trauma room. The review by the Consultant took some time because we were very busy that night. In the meantime due to the concerns I had regarding possible spinal injuries, I remained at the head of the patient manually maintaining the alignment of his spine and ensuring he was not moved until the Consultant had addressed my concerns.  After his review of the patient, the Consultant agreed with my concerns and ordered the patient to under go the appropriate scans. When I returned for my shift the next day I discovered that this patient had extensive injuries from his accident, including spinal fractures, which had been my main concern.
My recount of this situation has been the short version of the long story and has really just summarised the events of the evening. It was an extremely stressful and upsetting situation, I can only think of two others that rank up with it for me.  Unfortunately the doctor involved never spoke to me again, however there are positives which I have taken away from it and valuable personal lessons learnt about assertion, advocacy and backing your judgement.
In every action we undertake and every decision we make, the safety of our patients should be our number one priority. A good question is to ask yourself when advocating on behalf of a patient is, “What treatment would I want to be happening if this were my husband, child or parent”.
Following this incident I had great support from my nursing colleagues and from the medical consultants involved. I work in a department that has a fantastic team culture and a big thanks to you all. In the end, having checks and balances and being able to question and agree or disagree with one another’s decisions provides a place where the patient has the highest level of care resulting in the best outcome possible. I will never forget this experience and will use it to grow and develop my practice and assertion skills, especially when dealing with patient advocacy.
Do you have a story you can share about a time you advocated for a patient? I would love to hear it!
Stay safe, be happy!

ICE Drug Bust.Good News for Emergency Departments.

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Police have seized 585 kilograms of ICE in a Sydney drug bust. Most people probably hear the news and not give it much thought once the news reader moves onto the next story. But the reality is, even if you are not touched directly by drug abuse on a daily basis, it will have a huge impact on the whole of our community, socially and financially. Ultimately this drug would have been destined for distribution to the rest of Australia and I for one think it should have a big impact on the number of aggressive and psychotic patients that present to our Emergency Department for the next few months, hopefully longer.

ICE is the purest form of crystal meth. It is extremely addictive. And it is one of the causes of the presentation of aggressive patients to our Emergency Department. Patients who have ingested ICE are usually sleep deprived, some not having slept for days. They are out of control, paranoid, hallucinating, itching or picking at their skin, aggressive, malnourished, have high blood pressure, an increased heart rate, dizziness, headache, possibly fever from infection due to non-sterile injecting habits and may have also injured themselves as a result of aggression or the inability to make reasonable decisions for themselves.

Patients with these symptoms are usually brought into the department by the police. Often against their will, but in this condition we have a duty of care to reasonably detain them for their own safety and for the safety of others in the community. As you can imagine this creates a highly volatile situation. However it is a very common presentation in our department and we have very good and well rehearsed strategies, policies and procedures in place to ensure the smooth running of these situations. We have excellent resources which range from the police, our security staff, registered nurses, mental health nurses and experienced senior doctors. We also have a designated place for this type of patient to go to initially. Consideration is given to the presenting patient’s safety, the safety of other patients in the department and the safety of all staff involved in the situation.

If the patient is unable to be verbally de-escalated or refuses oral medication as part of this strategy then the medical management of this situation is a chemical sedation process (medication) either intravenously or intramuscularly, to relieve the patient from  some of the symptoms and to create a safe environment for all others. We can then proceed to treat the physical condition of the patient. The patient will at this time be asleep.

The patient then spends many, many hours in the Emergency Department and when all the medical issues are resolved and the patient is awake and alert and not requiring admission for a medical reason they then receive a mental health assessment. ICE use affects a persons mental health by causing psychosis, which involves delusions, hallucinations and distorted perceptions of reality. Which if prolonged can lead to a diagnosis of schizophrenia. ICE use worsens existing mental health problems and affects the users ability to work and maintain an adequate financial situation. It affects relationships and families and can lead to homelessness in a downward spiralling cycle of circumstances.

So you can see why it is such a great thing that  585 kilograms of ICE has been prevented from reaching the streets and will never make it into the hands of the sons, daughters, mothers and fathers of our society. Beside the four hundred million dollar street value cost attributed to this seizure it will save our communities hundreds of thousands of dollars in costs related to law enforcement, ambulance services, medical care, mental health program’s, family breakdown, crime’s committed to pay for the habit and probably a lot of other things that I cannot even begin to imagine.

This is not meant to be a definitive treatment plan or a tool for educational purposes.

The majority of people don’t need to deal with this type of thing on a daily basis at work and probably don’t realise the impact of this on the individuals who do. Do you have an example of an experience with someone on Ice or another drug? I would love to hear about it.

Stay safe, be happy,

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SMACC are you going?

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Social-Media-IconsThe 2013 SMACC (Social Media and Critical Care) conference will be held in Sydney from the 11th to the 13th of March. It is the coming together of emergency medicine, critical care and social media. You can check out all the details at smacc.net.au. It is the future. Whether you like it or not. I am a new convert to social media and up until a few years ago avoided all forms of technology based endeavours. My husband handled the home stuff, and my kids helped me out with the TV remote (and I hate to admit it but sometimes still do). However now I make sure they take the time to show me things instead of doing it for me, much to their frustration as it would definitely be quicker for them to just do it for me, but these days I insist.

My foray into the world of blogging, (which started with me reading them on a regular basis) has been a tentative step and one that I have relished as time goes on. There are things I’m planning on doing with my blog in the future and I am interested in new possibilities that arise almost daily, but I find I just need to take my time and work through them, with or without help, but ultimately doing it myself is the only way to learn.

As a student nurse in a hospital training setting 22 years ago we were spoon fed during our lectures, we did not use personal computers and had no on-line resources. I did know how to use a library though. I have always learnt best in a practical setting and by writing stuff out, reading information from a screen doesn’t seem to work for me when required to retain the knowledge. And by the way our lectures went from 8am to 4.30pm monday to friday for the entire “block” which was anywhere from 3 to 6 week stints. Of course during university study later I had a crash course in using a computer for assignments and online research. At the time I was studying I was pregnant with my first child and spent 16 weeks vomiting and extremely unwell and after deferring for 12 months I returned to study with a baby/toddler. During the last semester of my study I gave birth to my second child and attended lectures with him in tow (I was amazed at the anti-discriminating nature of university). So needless to say, I was a little distracted and my heart not completely into mastering the technology required at that stage of my life.

I am sure there must be lots of nurses with similar circumstances. Perhaps of the same age? So for all you whippersnappers out there, who were born into a world where you can’t imagine life without Facebook and wonder how my generation ever kept in touch with our friends, if you see my struggle, be patient, I am trying and so are many others from similar backgrounds. There are others of the same generation who are streets ahead in the technology department and the world of social media, I admire them and I am also so jealous. But for the moment I will just be proud of what I have achieved so far.

I now need to log in and do all this years mandatory competencies in the new online format whilst I’m on holidays. I will not have the opportunity to take the time I need at work and be disruption free. It will take a little while to get my head around it all the first time. And maybe the second time as I will have forgotten how to do it by next year. There is no off-line time given for this at work unfortunately.

So don’t forget to check out smack.net.au and if you’re not already into it, read a few more blogs, follow the ones that interest you, have a look at some online education. Don’t know where to start? Google. Search something that interests you, read and watch, refresh by reading up on something you came across at work today. You will eventually find sites that suit you and you can like and favourite them. What is the one thing you haven’t had the chance to see or do yet? Google it!

I would love to hear about your favourite online resources. I have slowly been increasing the people and journals that I follow on twitter, each one leading to discovering more and more interesting sites. I am connecting with similar people through Linked in and I have a few medical apps, the latest one called “Upshot” which I’m still sussing out at the moment. I have about eight podcasts that I listen to regularly, my favourites are probably the EMCRIT and EMRAP podcasts. If you haven’t already then you should check them out. My favourite nursing blog is currently Impactednurse.com. So please share your favourites in the comment section below, or plug your own!

Stay safe, be happy,

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Where is the off switch?

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brain-cogs1Have you ever had that moment when you do something only to realise that it probably wasn’t well thought through. At the time and in the moment you were focused on getting something done, only to realise down the track it probably wasn’t done in the smartest way. I had one of those moments recently.

It happened with a patient that had just had six minutes of cardiopulmonary resuscitation (CPR) and was intubated (Had a tube into their airway and a machine breathing for them) after taking an overdose, so needless to say it was in a highly stressful situation. At the time “the resus” didn’t seem like such a big deal, but on reflection not too many people do this sort of thing on a regular basis at work, and yeah it actually was very a stressful situation. The event I am talking about was minor, easily resolved and not even an issue EXCEPT that I felt like such an idiot.  I knew at the time, that a bigger problem for me would be the amount of time I would spend berating myself about it and going over and over it in my mind.

I thought about it for the rest of the shift. I thought about it walking to my car, driving home, whilst I was NOT going to sleep. It was the first thing I thought about the next morning, whilst having my shower, making breakfast, etc etc, you get my point.

I cannot help it. I go over and over stuff like this in my head. And it sucks. I’m wondering if others do this? I’m wondering how to stop it, because it takes more than just telling yourself to stop it. All my logic tells me it was no big deal, could have been worse, nobody died. Then I have a crisis of confidence and I think “I shouldn’t be doing this job and I should get a job where I have no responsibility.”  Deep down I know this isn’t necessary or true and that I’d be bored stupid. And that I’m actually pretty good at what I do but none of this helps at the time.

I know there are personality types out there who would be reading this and thinking, what is she talking about, get over it and yourself. But what I would like to do is find a happy medium. Care enough to take the time to reflect on the action or incident, learn from the experience and move on. Stop the churning. I know I’m one extreme but I think the other extreme would be just as bad. I would hate to be dangerous because I believed I could do no wrong.
I debated actually posting this blog. I’m a bit embarrassed about admitting this in such a forum, as it’s probably not something you would openly discuss amongst work colleagues, but I think there must be people out there who go through the same doubts as I do after something like this. I am finding out through feedback about my blog that there are always people who can relate to the things I write about, so I have decided to go ahead and post this because if you too are a someone who goes over and over situations like this, you are not alone. Or maybe it is just me, alone?
So now I have written about it and I am hoping this helps. Writing this blog is my own therapy as you know, get it out of my head and onto the “page”. I would really like to hear your thoughts. Are you a churner? What do you do that helps you switch off the cogs turning in your brain? I would love to hear some strategies!
Stay Safe, be happy.
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Burnout. Part Two. Me again.

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I guess looking back on my pre holiday blog things were starting to get to me and probably had been for a while. So I decided to do a bit of reading and research into burnout. We tend to throw this term around quite a bit and I have discovered it can be more severe than our common use for the word when we just use it to describe how we are feeling on a bad day.

The definition of burnout is long term exhaustion and diminished interest. It can have an adverse affect on all aspects of our lives and relationships, not only our work life. Symptoms of burnout can be,
feeling physically drained,
emotional exhaustion,
lowered immunity,
pesermistic outlook and
increased time off work.
If this sounds like you then there are few things you can do.
The first thing is to
recognise your situation, which can be hard to do when you are bogged down in it.
Try to take some time out, away from the situation.
Slow down and take a break, cut back on your commitments and activities.
Give yourself time to rest, reflect and heal.
Get support from your family and friends,
share your feelings and relieve some of your burden.
Re evaluate your goals and priorities, think about your hopes and dreams.
What is important to you?
This could be a time to rediscover what really makes you happy and to set course accordingly. Find the chicken soup for your soul.
I have returned to work with a much improved attitude, a better ability to handle the frustrations that I cannot change and a renewed motivation to have a positive impact on the culture in our department. My advice to anyone feeling a bit negative or unmotivated, do yourselves and your colleagues a favour and book yourself in for some leave. I took three weeks leave and planned it so I would have a week to “myself” (and I use that term loosely, there ‘ain’t no such thing), before the kids were on holidays, I went out for coffee with a different friend every morning that first week. The kids and I then spent a week at the beach and then we had a week at home. In that week we renovated a child’s room and I got to do some spring cleaning. Call me weird but I love the feeling when that’s done. It satisfy’s those borderline OCD tendencies that decreasingly get accommodated due to being too busy.
Looking back over these lists I would have to say that writing my blog provided me with the recognition of the burnout.  It has also allowed for some reflection and some of my own self styled therapy, it is very cathartic to get it all out by writing it down. I have written more blogs than I have posted, some will never be posted but they have allowed me to vent. I have taken some time out with my friends and family. The chicken soup for my soul would definitely have to be spending time at the beach with my kids and they are ultimately the priority in my life. So focusing on the positives, nowhere’s perfect but I work in the hospital and the department that I want to be in. I work with some fantastic staff and I really appreciate all the resources and processes of our department when I spend time working in other places.
So, glad I’m feeling like me again, and I’m sure everyone else is too!
If your due for some time off, my advice, book it in, by the time you take it you might just need it.
Do you have a similar story, what did you do? I would love to hear it.
Stay safe, be happy.

Pre holiday burnout.

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I really need a holiday!
I have just finished night shift, it is eight a.m and I am now on holidays. For about four weeks leading up to these holidays I have struggled coming to work everyday. I have been having serious thoughts about changing what I do. After twenty-two years of nursing, and possibly another twenty-two ahead of me. Do I really want to ever say I spent forty-four years nursing? I’m also a bit worried about what a cranky old cow I’ll be by then given the apparent “years worked in ED v’s cranky old cow ratio”. There are so many issues in nursing, in my own workplace and in my life, that I am frustrated with.  So I have been mulling over the question what do I want to do? Do I want to be a nurse somewhere else in the hospital? Do I want to be a nurse in a different setting like a clinic? Do I even want to be a nurse at all? I have looked into a couple of things, but it’s hard to search for a job when you don’t know what you want to do.
My current work issues at the moment are wide ranging, the following are just a few:-
New junior doctors with “know it all attitudes”.
Extreme paperwork overload for every patient.
Poor nursing skillmix (not enough senior nurses).
Things that change overnight, department wide with no notification.
Gossip.
Mess.
Petty people.
Shift work.
People who think they are s#%t hot but their not.
Poor nursing care (relates to previous point).
My frustration that the Emergency department serves as the “too hard basket” for others.
No beds.
Payroll problems.
Vicarious trauma.
Illicit drug takers.
Drug seekers.
Drunk drivers.
People who take no responsibility for their own health care.
People who expect taxi vouchers but have 2 packs of cigarettes in their hand.
People who request Christmas and new year off even though everyone knows you can’t have both.
The things that currently keep me where I am.
All the fantastic doctors and nurses that I work with every day.
Working in the best Emergency Department in this state (I can’t compare to other states).
Working in the only hospital I really want to work in.
Ocassionally making a difference in peoples lives.
The effort required to be bothered applying for a new job.
The “same s#€t, different bucket” thought.
Not knowing what else I want to do.
Not wanting to go to uni again. Yet.
So right now I need to go to bed, have a sleep, have my holiday and write another blog in four weeks time and see if I’ve been cured by holidays or wheather I need to update my resume.
Have you ever felt like this about your job? Help! What did you do?
I would love to hear from you.
Stay safe, be happy.