Wednesday, July 30, 2008

One at a Time, Please

I hate having two rooms open. Yes, it is nice to be able to have a little breather, but it almost always means I am going to get two patients at the same time, and anyone who works in an ER can tell you that almost every patient encounter is extremely front-loaded. When a patient comes in, they are going to get a whole big pile of stuff dumped on them at the beginning of the visit: assessment by the doc, and assessment by the nurse, labs, IV start, EKG, radiology tests, registration, medications, and a whole host of other things. Then we enter the sit and wait phase, while the lab tests get done, the x-rays get read, the medications do their work, and the IV fluid infuses.

As the RN, I am very heavily involved in the initial phase - I'm doing an assessment, making sure the EKG is done and the urine is collected, starting the IV, giving the medications, etc. During the sit and wait phase, I'm mostly sitting and waiting with the patient. I generally like to do my own vital signs, but that is certainly a task that can be done by the Tech.

So if I have an open room, and my other patients are in the sit and wait phase, I have no problem receiving a new patient. In fact, it is nice, because I like to stay busy. when I get another patient and I'm still somewhere in the initial phase with a patient, then things get broken up. I don't want to leave the new patient just sitting and waiting to get all those things done, but I can't just leave my current patient to sit and rot, so I end up trying to bounce back and forth as much as I can, which, in the end, is slower, because each time I go into a room, I have to regain my bearings about just where we are.

Despite all that, this is part of life in the ER and one of the things you just have to get used to.

So all of what I just said was to set up this scenario from a while ago:


I had just triaged an ambulance patient - 17 year old with arrythmia and atypical chest pain. I got in there and completed my secondary assessment. I tried to do it quickly because I knew we were getting full and I had another open room, and I didn't want to still be in the middle of the initial phase with this kid and then have to start at the same time with another patient. The assessment was slow going, because the kid didn't know much about medical history or meds or what was currently going on, or really anything, for that matter. I felt good, though, because nobody had popped thier head in the door to say that I was getting anybody in my other room.

Then I stepped out in the hall.

12 people were standing outside of my other room with IV trays and drug boxes and stethoscopes.

Someone had coded in the hospital and was brought to the ER and put in my room almost 15 minutes earlier, and for some reason nobody had bothered to tell me. So I went in the room (remember that I just finished the secondary in the other room and so I haven't even seen the chart yet, and my third room had a patient who had just gone to CT scan, and who I had just inherited from another nurse and knew very little about) and found that the charge nurse and the float nurse had the patient sedated and restrained and had given Ativan and had started two IV lines. That's nice. But nobody had charted anything, so I walk in and there are crying family members and chaplains and pharmacists and lab techs and ER techs all over the place, and the charge nurse looks up at me and says, "maybe you should get an ER record sheet and start writing down what is happening."
Okay. Maybe you should have someone pop their head in my room and let me know that I'm getting a coding patient. But I didn't say that. I don't like conflict.

The other two nurses helped me for a few more minutes and even put a foley in the poor lady and then left, with the float nurse asking me if I needed more help. Well, at the moment, I didn't need any more help with this patient, I just needed to get my hands around what the situation was and do a secondary and start paperwork for restraints and all the other little legal stuff that goes along with ventilated patients, so I asked her if she could keep an eye on my other two patients for a little bit, and mentioned that the doctor had said something about pain meds of the 17 year old before I had been sucked into this room.

Anyone who has worked with newly ventilated patients can tell you the struggle it is to keep up with all the paperwork and the legal requirements regarding restraints and sedation and vital sign monitoring. Add to that trying to balance the different sedating medications (Propofol, Ativan, Fentanyl, etc), IV fluids, ventilator settings, family sensitivities (a greatly overlooked skill in nursing), and GCS assessments, and you have an extremely time-consuming task.

But it's okay, because we are a team, and teams work together.


So finally I get a chance to get away for a minute after about an hour. I pop my head in the room next door and make sure the patient is alive and I ask Mom if other nurses have been in to help them. She says that yes a couple nurses came in, and so I am relieved, and head back in for round two on the vent patient. Nearly an hour later as I'm finally getting to a point where my paperwork is done and the patient is satisfactorily positioned and sedated (and it was a very hard battle because the Propofol was hung almost 20 minutes after the RSI, so we were constantly behind the curve). In walks another nurse with my 17 year old's chart. She pulls me aside (kind of) and says, "don't you realize that this is a yellow chart and there is nothing at all charted on here?"

So much for teams working together.

It turns out that someone went in that room to fix the Oxygen Sat monitor, but that was all that was done and nothing was charted. And although I felt betrayed and angry that nobody thought to watch my back while I dealt with the critical patient, the blame was technically on me because that patient was technically under my care. The charge nurse pulled me aside (kind of) and proceeded to tell me that I need to be sure to assess the patient every hour and chart it whenever I have a yellow chart. I bit my tongue again.

I asked the doctor about where the order was for the Toradol he had said he was going to give the patient, and he said, "I gave you a verbal order for that. Why should I have to write it down?" Well, Dr. E, because 1. verbal orders are not permitted in non-emergency situations, 2. because even when they are permitted, that is only when they can be writtn down by the nurse and read back to you and I didn't have the chart, 3. because you never said it as a verbal order, and 4. you didn't give any specifics (dose, route, frequency). And frankly, I don't think that "we'll give this patient some Toradol" qualifies as an appropriate verbal order.

So perhaps you can understand why I was frustrated and a little angry on top of the soreness and fatigue I was feeling from working as much as I have been lately.

You might even understand why I was not my usual sympathetic and empathetic self with the poor lady who came in with right flank pain and was squirming all over the bed and not holding still while I tried to get her vital signs (where was my tech, anyway?) and start an IV.

And hopefully you will understand my distress and remorse when I learned that it wasn't kidney stones, but rather a hemorrhaging Renal mass that required ALS transfer to a higher-level facility. Luckily for me, I was able to make it up to the patient and by the time the ambulance gurney wheeled out of the department, the patient held my hand and thanked me for my wonderful care (the best reward I ever get as a nurse).

Moral of the story: No matter how much things fall apart around you, in this game, you have to keep your cool.


Karen said...

Hey Braden. I don't know how much it helps at this point, but I just wanted to let you know I read through what happened to you today and I really feel for you. Makes me glad I'm an OR nurse. Yeah, crap happens, and often it falls directly on my head. But at least I only have one patient at a time to deal with.

No Cap Here said...

sometimes keeping your head above water is all you can do- even though you feel like sinking! I am glad your transfer patient brought you back.

Prisca: said...

This post sounds so similiar to some days I have had lately that I just had to respond with an internet pat on the back.

I can so relate! And the verbal order thing just cracks me up!