Gifts in the ER
Lesson of the day: Never accept a "gift" in the ER from an EMS you made wait.
I'll be ok.... maybe
"Possible seizure at school," the EMS said to me as he wheeled his patient into my room. The patient had never been diagnosed with seizures, but this was his fifth similar episode. At school, the boy suddenly became quiet and sat there, staring straight ahead. He would not speak to anyone or move, even when directed to do so. An altered level of consciousness like this could signal many scary situations- seizures, brain tumor, blood sugar problems, drug toxicity, etc. What was wrong with my patient? The resident ordered all of the appropriate and expensive tests, and the neurologist was at the patient's bedside quickly. She was not sure what the problem was, but planned on admitting the patient after the MRI was complete. The boy's mother was begging him to respond to her, but he sat there quietly. When I was in the room doing an assessment and checking his pupils, I noticed that he had tears in his eyes and that his lower lip was quivering. I asked his mother if I could speak with her son for a minute, and brought her to a chair outside the room. I sat down next to him and said, "When I was in school, the kids made fun of me because I was so short. I came home in tears all of the time. I hated going to school." This made him start to sob. "The kids all say my mom is crazy," he replied to me. "That must really hurt," I said. This made him cry harder, which made me want to cry. "You can't tell your mom why you are upset, because this would hurt her feelings too," I asked him. He nodded his head. I asked him what he did when the kids upset him but he couldn't tell his mom. "This," he replied. I talked with him for a few more minutes, and then went to tell the resident that he was able to speak. She quickly went into the room and came out a few minutes later. He wouldn't say a word to her. I went in with the doctor and explained to the boy that I knew it was difficult, but that the doctor really needed to hear him talk. I asked him what his favorite subject was. "Math," he answered. I left the room to take care of my other patients and when I checked back a bit later, he was no longer being admitted. They performed a CT scan just to make sure things were ok, and arranged for him to follow up with a psychologist. When he was leaving with his mom, he walked up to me and gave me a huge hug. Finally, I felt like I could handle this ER job. I was making a difference. What have I been stressing about? As I stood there filling out the rest of his paperwork, smiling to myself, the housekeeper rushed in to clean the room. I looked behind me and saw another EMS guy coming towards me with a young boy. Can't I get a minute to recuperate!?! He started giving me report before the room was even clean- dog bite to the lower leg. No big deal, probably just a few stitches, I thought. They brought him in the room and as they passed me, I noticed the word "Flight" on the back of their jackets. "He was flown in?!" I asked, panicked. "Yes, it was a pit bull," the man responded. Thankfully, an attending doctor walked by as the EMS said this, and the attending followed me into the room. He took the bandage off the leg and immediately instructed me to find the other attending and bring him STAT. I looked up and immediately regretted it. There was barely anything left of his calf, and I could clearly see his exposed muscles. I found the other attending and overhead paged my preceptor immediately. Before she was there, both doctors were giving me orders - Morphine, IV fluid, sterile saline, portable x-ray, antibiotics, etc. I froze. Morphine and what else? What am I doing here? Did I really just see that boy’s calf muscle?! Was that his bone? I want to be a receptionist again.....
Lessons from the ER
~ Slamming your finger in the doorknob side of the door hurts. Slamming it in the hinge side of the door will take your fingertip right off.
~ Texas football fans are insane. Our ER is dead during any big football game, college or professional. An hour after the game, we get slammed with the kids who should have been brought in several hours earlier.
~ An untreated ear infection can lead to brain surgery.
~ An untreated cavity can lead to an ICU admission.
~ Some parents will choose buying cigarettes over buying their child's asthma medications. The result? The cigarettes can trigger an asthma attack, and there will not be any rescue medication available..
~ When making up lies for how their child was injured, parents usually forget to take into consideration their child's developmental age. A one-month old is not going to roll off of the bed and break her femur.
~ ER rooms can somehow become cursed for the day. On my last shift, every patient who was sent to room #6 ended up being sent to the ICU. Ashley, another intern, had two patients in room #1 get intubated. Some days every patient in a certain room will have the same condition- seizures, vomiting, etc.
~ Partially or completely amputated fingertips do not bother me. But cuts on the fingers slightly deeper than paper cuts? They make my stomach drop.
~ I desperately need to learn Spanish.
~ Popsicles have more healing power than Bandaids.
~ Ariel is the most popular Disney character.
~ When siblings are present, it is important to let them know that their brother/sister is going to be ok. If you fail to do this, you will quickly have two screaming children to take care of.
~ The most important thing you can say to a child when you first enter the room carrying something is, "This is not a shot."
~ Unless you are actually carrying a shot.
~ When you find out that one of your patients has died, such as my little cardiac baby from a few months ago, you have to make yourself move on. This is much easier said than done.
~ The best cure for an infant with constipation? Taking a rectal temperature. It seems to unintentionally work way too often.
Triage according to Katie
Every patient who comes to the ER is triaged when they first arrive. When triaging a patient, a complicated formula is used to determine what "level" to make that patient. Here is my own version of our levels:
Level 5 - should have gone to a pediatrician's office- send down hall to First Care
Level 4 - same as level 5, but higher priority than level 5
Level 3 - stable for now, keep close eye on
Level 2 - kind of stable, requires a lot of work, could go downhill any minute, send to Katie's room
Level 1 - trauma, life or death situation
I don't know why, but for my last few shifts, all of my patient's have been level 2's. The first few days I handled things without too much difficulty, but on Wednesday, I was put in the Asthma room. The Asthma Room is a little taste of Hell. It is a small room with seven reclining chairs lined up against the wall. There is one nurse responsible for all seven patients, and unless there is a trauma in the back, there is a respiratory therapist there as well. That's right- a seven to one patient to nurse ratio for children having TROUBLE BREATHING! For those of you who are not medically inclined, a patient's airway is the most important factor in keeping patients' alive, and children are known to go from respiratory distress to cardiac arrest in just minutes. Any one of my seven patients could quit breathing. When I am in the asthma room, I feel like I am holding my breath the entire time. Just keeping up on the hourly vital signs for seven patients keeps me busy- but then there are meds and admission papers and nursing notes and PARENTS to deal with. When I find out at the beginning of the shift that I am in the Asthma room, I say a little prayer asking God to give me the strength not to cry until I get to my car at the end of the day. Wednesday I barely made it to my car before the tears started flowing. I forced myself to return to work on Thursday, and was given a normal room assignment. Thankful that I wasn't in the Asthma room, I thought I was going to have a good day. I was wrong. My first patient was supposed to be a direct admit to the floor, but they didn't have any rooms available, so I had her for six hours. She was on a ventilator and was having difficulty breathing. Then they brought me a "Level 3" who ended up being admitted to the ICU, except there were no ICU beds available, so he stayed in my room. My next wonderful surprise was an autistic child having seizures, two of which he demonstrated for me in his room. When he started seizing, all I wanted to do was leave and never look back. How can I handle these three patients at the same time? I barely made it through the day without losing my mind. I guess I was hoping that they would save the severe patients for the more experienced nurses, but that is not how things are going to work. So here I am now, nervous about going to work, but somehow loving it at the same time. I know that I will get through it and am thankful that I have found a few experienced nurses that I can turn to for help. For now, I am keeping my fingers crossed that I start getting a few more Level 3’s my way, but that I will be able to handle the Level 2’s I am somehow destined to get. At least the level 2's make for good stories, as soon as I get the energy to write them....
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