Patient Shot by Police Inside the ER

There was no loud bang. Just a sudden tension and sense of wrong as a flood of officers rushed through the ER and Code Gray was repeated overhead.

A patient in custody was brought in, after being off meth for 2 days. He wasn't getting it in jail, and he was not going to get it in the hospital. He was refusing all treatment, and finally decided to sign out of the hospital AMA.

Ironically, the risks noted for signing out AMA included Death.

The patient had both hands handcuffed to the bed. The deputies escorting him uncuffed one hand so he could sign the AMA. That's when the patient lunged for a gun on one of the deputies. The nurse ran out. And the other deputy shoots the patient in the head.

The patient is on the floor, one hand still hanging handcuffed to the gurney, a bullet hole is through his head, and there is blood and brain all over the floor. Two nurses run back in and in a panic, one screams, "What are we supposed to do?" And the other yells, "Call the doctor!" The doctor comes in, checks the patient's pulse, and pronounces his death.

The area is closed off, the police start interviewing everyone, they close the ER to all BLS and ALS runs, and management tells the staff they can go home if they want to.  From a crew of 21, only three nurses stay to man the rooms, one triage nurse for walk-ins, the charge nurse, one EMT, and two unit secretaries.

At 2 in the morning, the ER manager and Medical Director come in. News camera crews set up outside the ER.

Night Shift

I had my first two night shifts this last week. It usually starts off pretty crazy--like I literally started with cleaning up diarrhea of a 400lb man; me, my preceptor, the day shift nurse, and an EMT had to all help hold and clean him up. By the end of the shift, things start to slow down and it's much easier to get caught up with all my work.

The night shift nurses all love me so far! There are new hires that started Day 1 of their orientation on night shift, so compared to them, I'm pretty knowledgeable and independent since I'm on my 2nd to the last week of orientation. I'm also used to staying on my toes during the busy hours of day shift, so I stay proactive even as the night shift starts to slow down. My preceptor told me I'm ready to be on my own and she doesn't know why I'm paired up with her, which is so encouraging to hear, compared to day shift who had seen me when I was new and awkward.

I do know though that I'm lacking in experience with critical patients. Two weeks in the critical rooms and still no full code with me as the primary nurse or pushing critical drugs. Hopefully I experience that before I'm off my preceptorship. Four more shifts to go till I'm on my own!

Enter Sandman

After a 6-week orientation on day shift, I am transitioning finally to night shift this week. My biggest concern: how to get my beauty sleep! Here are tips I've gathered from talking to night shift colleagues.

1. Make sure you're in the bedroom with windows NOT facing east where the sun rises, far from the freeway or main streets, quiet roommates, and the upper apartment/room so you don't have to hear people walking around upstairs.

2. Blackout curtains - I just bought Eclipse Blackout curtains at Target, only $13.99. I bought the tan color which is room darkening, but actually doesn't completely block out the light. I don't know if it would make a difference if I bought the black, dark brown or blue. Luckily my windows are small, so I folded it in half and that does a really good blackout job.

3. Sleep mask - A much cheaper solution than buying blackout curtains (unfortunately I had already bought my curtains when I realized I could do this too)! And you can pick cute styles like animal prints or designs, chic colors, or printed words like "sexy" or "angel."

4. Melatonin sleep aid - Melatonin is basically the hormone that helps our circadian rhythm, which tells us when it's time to sleep or stay up. It's over the counter, so you can just get some at your local pharmacy.

5. Ambien or your benzodiazepines - If you really can't sleep, get a sleeping aid prescription from your doctor. Ambien is a sedative, while benzodiazepines are relaxants (which ultimately can help you sleep too).

What are your tips for transitioning into night shift mode, instead of trying to block out sound/light under the pillows and covers?

A System That Works

Most students and new nurses usually get that one preceptor to follow and learn from. I was the lucky one to have had three during my nursing school preceptorship, and will have had at least five (it is not over yet) during my new grad program. While it has its downsides, the good part is I have been able to observe how several nurses go about their day, handle their tasks, chart, and talk to patients, family and patient care team members. From there I can pick out what I think are the best techniques.

There is no "One Way" to go about your day. There are several techniques out there, like using a timer, using sticky notes or a notebook, charting as you go along vs. charting at the end. I'm going to talk about what has worked best for me.

First, before the day starts, I make sure all my rooms are set up and stocked with the right equipment and supplies (alcohol swabs, leads, gloves, gowns, blankets, etc), but particularly oxygen masks/nasal cannulas. I now also bring in a couple of urine sample cups, which is actually not in the room usually, but I've personally gotten behind in my day only due to collecting urine specimens. This way I remember to get a sample the second my patient walks in. So if there's something you know that your patients usually need on your floor that's not usually not stored in the room, bringing it at the start of the shift is a great way to help you remember as the day progresses. I also like attaching 3 leads onto the monitor already, which makes one less thing to fetch when I have a new patient. Finally, I wipe down most everything I'm going to be touching (computer keyboard, mouse, monitor buttons, light switch, door handles, etc).

When a new patient comes, I say hello, introduce myself, and ask them their name. Honestly, I get annoyed when the EMT bringing them in answer for them, since (as all nurses know) I'm not asking the patient their name just to be nice, I'm actually assessing their cognitive level. While getting report from the EMT or triage, I start grabbing (1) gown, (2) belonging's bag, (3) urine cup, (4) blanket and (5) leads if there aren't any on the monitor. I instruct the patient to put the gown on then go fetch the rest of the things needed for them while they are changing. These things are: (1) blood pressure cuff, (2) pulse ox, and (3) IV start kit. In my ER, these can't be kept in the room because we charge the patients individually for them as we take them out. If it were up to me, there should just be a whole New Patient Kit with these eight items that every new patient gets when they come in. Anyway, I attach the patient to the monitor and get a baseline reading for their vitals while they tell me what is going on. Then after my primary assessment, I immediately ask for a urine sample (since most likely the doctor will order a urinalysis).

While ideal, I obviously have to keep this system flexible. Do I need to help the patient remove their clothing? Can the patient ambulate to the bathroom? Is the patient in acute distress? Do I have other patients that need more immediate attention?

Similarly, if I had all the time, I would prefer to chart as I go, but when we get slammed with tasks and new patients, obviously the priority is to complete the tasks and patient care instead of sitting at the computer documenting. In which case I made myself a backup plan. I take a sheet of bond paper, fold it into six sections (twelve sections total back and front), and label each section by the hour from the start of my shift: 0700, 0800, 0900, and so forth. That way I can quickly jot down if something happens when it happens, then document it on the computer later. I even make check boxes for tasks I need to complete at a certain time, such as medications, then check them off when I'm done.

This is not the system I started with at all, and I'm sure I will continue to modify it as I pick up new techniques. It will also definitely change depending on the needs of the floor you're working on or the system in place at the hospital. However, I believe finding a system that worked for me is definitely one of the top things I had to work on as a new grad.

24 Hour Service

"Look at a day when you are supremely satisfied at the end. It's not a day when you lounge around doing nothing; it's when you've had everything to do, and you've done it" - Margaret Thatcher

Blood transfusion, hyperkalemia, hypertension, heart failure, conscious sedation... my day has been crazy enough.

Tasks to Do Before Shift Ends in 15 Minutes:

Patient 1: Pending transfer information to different hospital

Patient 2: Pending admit to the floor

Patient 3: Pending ability to ambulate steadily before discharge

6:45

- Finished belongings list on Patient 1. All the paperwork that can possibly be done for him at this point is complete. All the night shift nurse has to do is wait for other hospital to call for information on a new bed.

- I'm notified that a bed is available for Patient 2. Perfect timing because I had completed all her paperwork as well.

6:50

- Called the floor to give report for Patient 2. Receiving nurse was unavailable/trying to pass it off to night shift, and asked me to call back. Decided to take the time to have Patient 3 ambulate to bathroom and back to bed so I can see her walk.

6:55

- Patient 3 in bathroom.

- Called floor back to give report for Patient 2. Admit paperwork completed and printed. Patient 2 ready to be sent up to the floor.

7:00

- Patient 3 back from bathroom. Giving patient her discharge paperwork as night nurse walks in. I tell the night nurse to give me a moment as I discharge the patient.

After the discharge, I go to patient 1's room where the night nurse is looking at the computer. I'm feeling particularly pleased because all I'm leaving her with is one patient. I got everything done in FIFTEEN minutes before the end of my shift, and I also had only been able to do that because I had been on top of all the paperwork prior to all the craziness. She better be ecstatic.

And then... "Did you send his urine? He had an order for urine."

"Well I gave him a urinal at his bedside and he just hasn't gone up to now."

"Well you need to tell the doctor that and get an in-and-out because that was ordered 3 hours ago."

"No problem, I'll ask him."

I ask the doctor and he says in-and-out is not necessary, if the patient goes, he goes. I let the night nurse know and she stops me one more time, "What's this med? Have you given it?"

Confused because I was sure everything was done, I glance at the chart. There was a med ordered at 6:55pm, five minutes before my shift ended and mid-transfer and discharge of my other 2 patients. Seriously? Didn't she see me discharging one and the other leaving the room to go upstairs at the same time? Would she rather I made sure ONE patient peed and got meds in the 15 minutes I had left, and then she take care of discharging/transferring/admitting THREE patients? After feeling so satisfied with what I had accomplished that day, it was not a good feeling to be told it was not enough.

As a common courtesy, of course we do not want to leave unnecessary tasks for the next shift to do, and vice versa. We do the best that we can. The best that we can is not everything, but it is still something. Especially in a crazy ER, tasks don't end at 7 for the next shift to have a completely new slate. There will always be something more to be done. The hospital is a 24 hour service.

Time to Breathe

"There is more to life than increasing its speed." - Mohandas K. Gandhi

From my last The Real World post, you can tell that work has been absoultely insane (although at the end of the day, always gratifying). A normal day is busy with always one more patient waiting for a bed, a bad day is crazy busy with ten more patients already being treated in the hallway. I had a friend from another hospital tell me she had a bad day because she had one difficult patient, and I wanted to tell her, "Just one? Wow, lucky!"

In times like these, it's always important to remember to take two deep breaths and make some time for yourself. Last week, I bought two books to read: Chicken Soup for the Nurse's Soul (101 Stories to Celebrate, Honor and Inspire the Nursing Profession) by Jack Canfield, Mark Victor Hansen, Nancy Mitchell Autio & LeAnn Thieman (2001) and The Everything New Nurse Book: Gain Confidence, Manage Your Schedule, And Deal With the Unexpected by Kathy Quan (2006).

You can find The Everything New Nurse Book for $3.74 plus shipping on Amazon. Personally, reading the book so far, there is nothing new that I didn't learn in nursing school or that I wouldn't have to learn on the floor myself. For example, Quan talks about time management or handling nursing politics, which I've always known I would have to work on even in nursing school, but those kind of things you'll only figure out once you're actually doing it yourself, no matter what other people tell you. I did really like her explanation on the nursing shortage and baby boomers, and yet there's still no available nursing jobs for the new grad at the moment--something I never fully understood before. Hopefully she has a couple more good spiels in the book, but I suppose overall, it's still good reiteration on all the points a new nurse should remember before starting a new job.

Chicken Soup for the Nurse's Soul can be found on Amazon for $9.85. So far, it is definitely a great buy with great content -- a mix of stories, quotes and comics that can make you laugh, make you cry, or inspire you. I love it! I don't know any nurse that wouldn't. I want to buy one for all my nursing friends on their birthdays now or leave it at the break room for everyone at work when I'm done. They are short stories too, so I can just take a 5 minute break and have something to read, or read several stories at a time.

What are you doing to make time for yourself?

Real World Nursing

A patient comes in on full arrest. She needs an IV STAT so the ER team can get meds on boards and save her life, but her arm is at an awfully awkward angle and she is too obese for one person to move. The doctor and respiratory is busy intubating her, the primary nurse is busy getting the low down from the firemen, the EMTs are busy hooking up the patient to the monitor and performing CPR. The IV should have been in 10 minutes ago. Forget improper body mechanics, get the IV in NOW.

As a new grad, I really notice the difference they taught me in nursing school vs. "real world" nursing. I didn't pay much attention when this comparison was mentioned in school, but now I'm actually immersed in its reality. Supplies run out, staff runs short, patients are erratic--and I have to figure out how to make it work even if that could very well mean compromising legal issues, patient's safety, or even my own safety. I have to weigh the risks and benefits, and make a decision. Sometimes, that needs to be a done in a split second.

When I graduated, I think I was most concerned over if I could still retain my assessment and technical skills, know how to care for the patient and the pathophysiology going on with their disease, or be able to apply the nursing process. Little did I realize, these concerns should have been dealt with back in nursing school. By the time you hit the floor, they should be second nature because there are a ton of other things to be concerned about when you start a new job. Where are the supplies, what's the phone number to pharmacy, what's the protocol in this hospital when transferring a patient, which paperwork do I fill out, who is this doctor evaluating my patient, what is the EMT's name so can I ask him for help, why is my password to the medcart not working? And don't even get me started on hospital politics (luckily I haven't encountered any yet, so far my ER team has been awesome). So many things that I thought shouldn't matter in comparison to taking actual care of the patient, but end up becoming the hardest and most time consuming part of the job.

The world is not just black or white. There are tons of colors as well as tons of shady gray areas. There is not just one right or wrong way to do things. Hopefully this new year, I can figure out at least one of those right ways and survive the struggles in my 1st year as a nurse.