Sunday, October 26, 2008

I did not realize ER can be boring at times

Yeah, we all heard about ER nurses being adrenaline junkies...I was quite anxious I would be too tired every time I come home from work. However, lately, I realize that the norm here where I work is that we get slow during the hours from 2am to 5am...usually.

Not that I do not like that. I actually enjoy that extra time because now I can make blog posts during those hours. And for those blogs that usually require photos, I just upload the photos to my picasa web album then later embed them as I make a new post during work hours.

My charge nurses do not care as long as our work is done. Or in cases where we have patients, we should make sure we have done all that we have to do before we "play." They themselves play online games when they get bored.

I used to do my online ENA training. But right now I am caught up with all online trainings. I should also try to make use of the time for reviewing for NCLEX...but how do I hide from my co-workers about me planning to take the USMLE?

It is not that concrete yet. I am just trying to see if I can actually find the time to prepare, and if I will indeed be prepared in a year to take the step 1...So far no luck. I have had my Kaplan reviewers for 2 months now, and I have just finished chapter 1. Pathetic...

Thursday, August 14, 2008


I might have said I never wanted to be in Pedi. I still feel that way.

But I had a child patient tonight accompanied by mom who is a med asst somewhere. Child was shy but cooperative with a little coaxing. MD and PA did their stuff. I did mine with some PE as well. After administering a PO med, she was ready to go. MD came for the last time while I was there, to hand me the discharge instruction. Mom said, "[Child] is usually shy, but she did great tonight. She (referring to me) must have done something right at the start, that made her comfortable enough to do good with all of you."

I said, "I connect." with a smile. Child smiled back at me every time I winked at her. Cute.

I still do not want to be in pedi.

The story of B

It's not the book by Daniel Quinn...It's about the charge nurse I worked with one night (I was still in my orientation). Let's call him BAH.

Scenario: 10 year old patient who came in with abdominal pain, diffuse, persistent. Nausea. Patient vomited once in the ER. Given GI cocktail. No relief. IVF NS 600 mL/hr.

Easy IV start. Prominent veins on AC.

I used regular tube, and ran it around 2-3 drops per minute (600 ml/hr divided by four equals 150 drops per minute. Or 150 drops per 60 seconds. Or 15 drops in 6 seconds. Or 5 drops in 2 seconds. Or 2-3 drops in 1 second. And I am talking about MACRO drops.

BAH later on calls me into the med room and shows me a pediatric buret. Told me to use that on Pedi pts to avoid overloading. I'm an orientee, so I said...."Okay."

Okay convert that 600 ml/hr to microdrops and it turns to 600 microdrops per minute. Or 600 microdrops per 60 seconds. Or 10 microdrops per second. Can you count that fast? I cannot convert that to smaller units. So I made it fast drip using microdrop. Who can count 10 in 1 sec???

Both parents of this kid were MDs (physiatrists). They should have an idea of what's going on.

Later on, BAH, while seated behind the ordering MD, was lecturing me about how given the rate ordered, I should get the idea that MD did not want to overload pt with fluid (Duh....that's even a faster rate than what we give to many adults. I kept my mouth shut.). MD seemed ready to chuckle...

Anyway, later on, IV antibiotics was started. My fave co-RN started it for me but told me she would use a regular tube. I told her about the incident with BAH. She said, "Oh, BAH is stupid." So we were on the same footing there.

An introduction

I used to work as a general medical practitioner in the Philippines before coming to the US. Having said that, I can safely say I know very little in everything medical. I am not a specialist, so I do no really know much. I admit that.

Now allow me to brag some. I graduated with BS Biology degree from UP Diliman, had 97%ile ranking in NMAT, got a scholarship for Medicine in Fatima (my parents were very happy!!! Free tuition, books, board and lodging, including free review books for boards), got pregnant at age 24, struggled to finish Medicine despite having a baby and a husband afflicted with CHF, graduated 1st among 200++ Med grads but without honors, had my internship at EAMC, passed the boards without landing in the top 10 (my school would have wanted me to land in top 1 so they subjected me to 1 yr of (useless) review classes.

Despite some friends (and other patients I had later) who would have wanted me to go through IM residency because of "my brains"m (what brains they were talking about, I have no idea), I wanted to be in OB-Gyn. Less morbid. Less problems with patient compliance. Less headaches. More surgical skills. But at the time I was going to apply, the QUERT (qualifying exam for residency training) came into effect. So the powers that be in the DOH now had a say where their babies could get into for residency training. I did not know anyone in DOH. Can you guess??? That's right, I ended up not going into residency. Later on I got pregnant again and became a widow, so that now I had two kids to support, and I was alone (save for my Nanay and sister, that is).

I practised in a very busy clinic in Makati that was like urgent care type serving patients from annual/pre-employment medical exam types to common community illnesses to NSDs and D&Cs. Nothing medically/surgically complicated. Some of the consultants working there have actually offered to back me up if I applied for residency in the private hospital they were affiliated with. But with two kids to support, the salary I would get just would not cut it. So I stayed moonlighting for 5 years, with Quality Assurance Management on the side. (If you are familiar with JCAHO, you must know about quality assurance.)

I got to the US with a BSN from Philippines. Got a job as a Medical Transcriptionist and saved some money for NCLEX. Passed NCLEX and got a job at a nursing home. Stayed there for barely two months (never enjoyed it) and got a job at a hospital. Rehab unit.

It was a good introduction to the hospital culture here, with all the high-tech equipment and the new people, new set of policies and rules.

I got bored after a year, applied at the ER and got accepted. Now on my 5th month. First two months were spent during day shift I applied for night shift) and it was like hell...I got rattled because, even as I was still trying to learn the ins and outs of flow of patients here, the rules and policies, etc., they were throwing Category 2s and 1s at me, and I got too busy I was ready to scream when they would tell me I had another patient to get (uhhh...can I chart first on my other two patients?). Finally, against my first preceptor's recommendation to prolong my orientation on days (for purposes of exposing me to more cases), I was started on my orientation on night shifts. After a week there I was really considering applying for another job (even medical transcription), but as I was slowly released to be on my own with only a resource nurse to go to for questions, I became more comfortable and the clinician in me re-surfaced. My doctor-thinking came into play in trying to predict the management of patients, so that I easily got into the flow of when to start IV's and EKG's etc., without fear of being scolded by the MD for doing so without an order. Well, actually, the reason I was hesitant before to just jump into action was that I was not sure what my limitations were as a nurse. Apparently, the nurses here have enough autonomy, and even if the MD did not order, let's say, an IV line, it would be pretty safe for me to start one and draw blood (then dispose of them if they would not be used anyway). No big deal.

Because of being more comfortable, my resource nurses (usually the charge nurse) have observed the marked improvement, that everyone now says they are hearing good things about me from other CNs. Even my clinical manager and ED educator told me, "Finally, it has kicked in! I told you so."

So now I am enjoying the ER. It is quite a good exposure in my plan to pursue the MD license. Somehow, I am getting an idea of their treatment protocols, how the ED MDs proceed with consulting for possible admission. I am also getting a chance to review things indirectly, and I find myself doing the critical thinking again. Interpreting lab results mainly, in correlation with the presenting symptoms/complaints. However, my main disappointment is that I do not see the imaging results (the MD's see the images and make their "wet readings" then wait for official reading from offshore -- Australia, I heard). The official results usually come up the next day when the Radiologists of our hospital are able to officially read and sign electronically to make the report available on the computer.

I will be off orientation by the end of August. Some patients are quite needy, but most of the time it is the usual abdominal pain, chest pain, altered mental status that I see. Sometimes those brought by EMS are not really high categories. I have learned once again the art of being cool in the middle of this chaos.

Behavioral patient

I inherited AF from an outgoing nurse. I went in and introduced my self. Patient wanted some medication before going to the BH hospital ce. MD did not want to give her any as she was not anxious when she came in. Then she began saying things like, "Ok, I don't even want this lady in my room. Please." in front of her mother. I did not even get a chance to do some therapeutic communication.

I swear, if this was my child, and she does this to me, I am gonna slap her on the face and ground her for at least a week. More so if she does this to a stranger who is trying to be helpful.

Glad the EMS personnel came right away.


That's why I never considered to be in Pedi.

Wednesday, May 28, 2008

On my First Month of Orientation

One thing I love about my hospital is that we have a very good orientation program. Having been exposed to Quality Systems Management while I was in PI, I could see my hospital addressing the elements of a quality system. And knowing so, I have the confidence to voice out any dissatisfaction in a constructive manner, for purposes of quality improvement (it is always a good reason) which will have patient satisfaction as an end-result.

First week of my training was spent working on my competencies, mainly the paperwork. Second week, I had my Basic EKG interpretation training, a prerequisite (aside from BLS- Basic Life Support) for ACLS, which I took and passed yesterday (yehey). Of course I have been going on duty with my wonderful preceptor. Whoever told me ER nurses here ate their young, well, I do not see that happening. I have the most wonderful preceptor (even better than the one I had in rehab, I would say). I'd say we do have a good chemistry. I had exposure in the triage room, and I actually am contemplating on sending copies of the triage flow diagram back to the Philippines for nurses to learn. I had a case of AMI (acute myocardial infarction) on my first day there, which was the highlight of my day.

Next I should sign up for PALS (Pediatric Advance Life Support), then sometime before the end of my first year, I plan to have the TNCC (Trauma Nursing Core Curriculum, if I remember it right) at least.

I have been trying to involve my kids to at least know how to do basic CPR...I gave them a lecture before, along with video viewing, several months ago. Yesterday, I kinda gave them a quiz, asking them what to do if they see me on the floor unconscious and unresponsive...Ben gave the best answer, then I recounted to them how they should approach it.

I told them they might someday consider ER nursing, but then I said they might not like seeing blood and what not, but both the boys seem not to fear that at all...hmmmm...we surely need more male nurses...

I will sign up for ENA (Emergency Nurses Association) on the next payday.

Emergency Department - my new area

OK, I dunno why I looked for new openings in other departments...maybe because at the rehab, we usually would be RIF'ed (reduction in force when the census is low), or maybe because I was getting bored with the routine no-challenge type of work there (the only challenge was physically because we RNs also needed to help the techs prepare the patient for the rehab day -- i.e., bathing and dressing of patients, which could mean from the independent hip replacement patient to the bedridden stroke patient).

In any case, I looked in the employment opps in our website -- OR nurse. I guess I applied too late. One of my co-workers applied ahead of me and got accepted I guess even before I got the chance for my resume to be reviewed...OK...on to other opps...

Behavioral Health...nah...I always fear for my own sanity. I believe there is a very thin line between sanity and insanity, and that can easily break when you are surrounded by pathologic personalities.

CCU (Critical Care Unit)...too morbid for me...I have never liked taking care of very sick people...that would be too stressful.

MCH (Maternal Child Health)...I would have loved to be here but they required current OB-Gyn experience in any of the areas in L&D and Nursery. I have experience, but whether they are current per their standards, I don't know. I don't even know how to use the fetal monitor, but I can do it manually, including manual monitoring of labor. But they do it here with machines. I heard from another Pinay nurse (old-timer) that they wanted the experienced nurses because they were desperate to find ones who needed minimal training, as they were expecting 400++ deliveries for the month of May. Oh well...

ED (Emergency Department)...well, it's not exactly the kind of stress you would have in CCU, but the kind of cases, the variety, the surprises, the critical thinking, the more practical applications towards my own life...the similarity with my past experience while I was a GP in the Philippines, I guess I don't have much to fear. There may be different equipment that I needed to learn, but I am quite a gadget junkie so equipment do not intimidate me, nor computers. The one thing that almost stopped me from trying that one was the circulating reputation of the ED personnel: that they eat their young. Well, I guess that is not entirely different from the scenario I suffered in the hands of senior nurses when I was undergoing my clerkship and internship rotations before getting my MD license in the Philippines. Given the past circumstances of my life where I have had humbling experiences, and have come to accept that whatever I know now or understand now just made me realize how little I actually do understand (as in, God's work is just so amazing I cannot pretend that I understand exactly how He designed the human body), I have learned to get along well with people, and have converted several toughies into softies when they interact with me. Not that I suck up, I just make them realize I am not someone who will challenge them or intimidate them, that I will willingly accept whatever they can and will teach me and I will be very appreciative of that, because I know I DO NOT KNOW EVERYTHING.

Well, despite the warnings I received from friends and co-workers, I went ahead and applied. Not sure that I would like it. But I did think that if I would get stuck in rehab for another year, I would get stagnant mentally and skills-wise. ER, on the other hand, is such a very good experience to have, because after a year or so (or even less), I can find work virtually anywhere. One thing that attracts me to nursing is the TRAVEL NURSING opportunities, and the per diem rates. The hospital closest to me always have ER openings, both for per diem and regular positions. ALWAYS. And since ER nurses are in demand, I will never fear of becoming RIF'ed. Rather, I might always be called to fill in for one who calls out. Plus, I want to get all those certifications that are a requirement of other in demand departments -- ACLS, EKG interpretation, PALS...

I got an interview, and there was instant feeling of being at home. I had positive vibes with the two interviewers (manager and educator). I got the job (well, according to one of my co-workers, ER's are always desperate for nurses). After learning more about my past experiences, they even went as far ahead as me probably being a mentor, taking the TNCC and other higher trainings. (I was thinking, hey...slow at a time). Anyway, maybe I looked confident enough that they became confident about my abilities, although I was quite upfront about the lack of abilities for the more complicated cases that really warranted a hospital (not clinic) visit, but they knew I could be trained. Ain't that the most important trait anyway? --- trainable. Another area they were concerned about was the use of the new computer system. I assured them I was, as a matter of fact, a superuser back in rehab. I was one of the few who had to walk others through the new system, simply because training for that was a breeze to me.

I started 1st week of May, when I was suffering from severe allergy that I almost feared I would be very vulnerable if I worked in the ER because my skin was so damaged (and on this very day I am posting this, is the first day I saw and felt my skin come back to an almost normal state that now I can expose it to air without sloughing skin and itching). It was a nightmare allergic attack-turned to atopic dermatitis event. Luckily, today I realized I am not that immunocompromised, and I can continue to enjoy the ER.

Why I like it: some days are busy, some days are not. Never boring. Variety of cases and people. Critical thinking developed. My clinical skills will be put back into practice, and they will probably benefit from skills I gained in IV insertion and blood draws (I used to stick even neonates without much problems). What I hated when I was a GP in PI was that I did not develop the skills needed to respond to emergencies such as stroke and acute MI (heart attack), and that I did not really learn much beyond treating common community acquired illnesses, etc. I wanted more...although I would not be the one who would actually treat (doctors would be) at least I would be exposed as to how they do it here...I can easily learn the why's. I can easily follow the rationale for the treatment because of my background, but learning their protocols will be great. I might in the end consider taking the USMLE, or maybe become an NP, who knows?...But this ER experience will surely be a gem in my resume...

Wednesday, May 21, 2008

Contact Allergic Dermatitis that turned into a NIGHTMARE!!!

Are you like me, who, after having immigrated to the US, have encountered a lot of new things to which you react (i.e., allergic to)?

During my first year in the US, it was the year of exposure to new trees, new bacterial/viral strains, etc. That first exposure made my immune system create a counter-attack force for future re-exposures...

On my second year I had a brief episode of urticaria, which lasted 3 days. I could only think of having eaten Chinese food as a culprit. I used Benadryl and Aveeno oatmeal baths to help soothe the itching.

On the third year, I suffered another episode of urticaria for almost two weeks. Aveeno oatmeal did not help much to soothe. I was glad it was over by the end of the second week.

Fourth year here, I seemed to have succeeded avoiding re-exposure to whatever triggered my urticaria (I avoided gardening).

This year I attempted gardening during the first nice weekend of spring, and suffered from a new type of allergy that led to the nightmare depicted on the photo. As of this posting, the whole event is now on its 5th week. Yap! That's how long I have been suffering from this predicament.

As I mentioned in my previous post, I was suffering from dishydrotic eczema and was on prednisone treatment. I was at the last days of my prednisone taper when my allergic dermatitis started.

See my slide presentation for the series of events explaining the whole thing. I will keep updating this slide show as I progress.

The flare-ups of my skin inflammation apparently was caused by my alternating use of petroleum jelly then lotions (which I would dare use once I felt my skin was getting better). Upon my derma's suggestion, I stopped all lotions or special soap for sensitive skin and stick to petroleum jelly, soak for at least 15 minutes in shower or tub (to engorge my skin cells and close the cracks), then slather a thick layer of the petroleum jelly to trap the moisture. Also, he prescribed desonide lotion which I had to apply to affected areas twice a day. I did that, and the desonide use had immediate effect on inhibiting the itching and inflammation of my arms/hands, and with showers twice a day at least, using the (self-prescribed) hot water treatment (counter-intuitive, the treatment regimen was effective for me. I believe that the increased rush of inflammatory chemicals like histamine, bradykinins, interleukins, etc. overload the receptors so that after the initial sensation like that of being scratched when in fact it was heated water, comes pain, then relief from itchiness for at least 4 hours (so finally I would get at least 4 hrs of straight sleep). Increased sleep boosts health and immune system. Less irritation (use only petroleum jelly) and more hydration of my skin (showers soaks)...finally my skin was back to normal after 6 months. When I mean back to normal, there is no longer that thin layer of skin with fast turnover, which was very very prone to losing moisture.

Well, during the first few months when I thought I would never get my pre-morbid skin, I was getting depressed because not only could I not wear tank tops/shorts without being so self-conscious, I also was not sure if there was ever an end to that suffering. I also felt so vulnerable since my skin was not intact and I was working at the ER (skin is the biggest organ of defense, so I felt defenseless). I even recorded songs for my hubby (although I did not tell him then that those were in case my skin issue would lead to my early demise eventually).

Now, I am happy with my skin, even if I still suffer from itchiness and cracks every time I go on duty at the hospital and have to wash my hands often.

Sunday, May 04, 2008

Dishidrotic eczema

It all began when I started working as a nurse in April of 2007-- the soap (I thought) irritated my skin so that at the end of my shift, I would drive home constantly scratching on my hands. I developed maculopapular rashes by May 2007 and sought an appointment with the Employee Health for an alternative soap (upon my Manager's suggestion). Okay, so I used a gentler soap, but continued to use the hand sanitizer (which seemed to be better despite making my skin red; it did not cause itching).

However, I did develop dryness, flaking, and eventually cracks on my skin. Once you have skin cracks, washing (especially with hot water) was agony. I almost was quite phobic of handwashing, and was using the sanitizer more. I also decided to use an OTC soap that was moisturizing, without the approval of the Employee Health. My symptoms were controlled, although I still got dried flaky hands on duty days. I also went to my family doctor and asked her to write a note that I can show at work that I was to avoid the hospital soaps to control my dishidrosis (aka pomphylox).

Then I was contacted by EH, and was asking if I was doing ok with the soap, to which I said yes. And that they would send a whole box, which I received that week. My manager told me to keep the used up bottles in the utility room so they could count. I started using it again. My condition worsened again, and I would get cracks during duty days, which would heal during days off. It was torture every time I washed my hands or used the sanitizer because of the cracks! Despite use of lotion, I could not help the progression of my condition.

Then our manager started implementing a handwashing program, targeting 50 handwashes per shift! I tried to stick to it as much as I could, which led to soreness and swelling of my fingers, it was just too painful to even bend them because of too much swelling, and forcing to bend led to cracks and bleeding. Too thin because of flaking, my skin would also bleed at the slightest touch of a side of a paper...That bad. The EH nurse arranged for me to see the Workplace Health doctor. Nothing new prescribed aside from what my family doctor did. Nothing new suggested; just keep trying new soaps until I found one that would not exacerbate my condition. I did, but I still had the problem. After a week, I called the EH nurse to arrange another visit, because I could no longer sleep straight with all the itching and pain and severe dryness, and this time, even 5 days off did not result to healing. I knew the soreness/pain was due to infection already. I felt like amputating my fingers...

A nurse practitioner saw me the next time, and I liked his approach. He listened well, suggested specific creams/soaps, treated the infection and gave me prednisone and topical steroid. As expected, it cleared up. I was quite happy, but he had reservations, because he knew (and I knew) that eczema can flare up again, and is a chronic condition. We would have to see whether once off prednisone, the use of mild soap and cream would help control the issue.

These are before and after shots (not all have corresponding photos, though.)

row 1, cell 1row 1, cell 2
row 2, cell 1row 2, cell 2
row 2, cell 1row 2, cell 2
row 2, cell 1row 2, cell 2
That crack was extremely painful!!!day 3 of commencing antibiotics
row 2, cell 1row 2, cell 2
I was happy to be finally free of pain, and during the final followup, I had no problems anymore...but then at the end of my shift, when the EH nurse called me to remind me to have follow ups with her, I told her it was starting again...but then I had some more prednisone tabs to finish, and one more week of topical steroid cream plus the barrier cream to apply...

I was hoping the problem would go away, especially that I would have one week off before I make the transfer to ER...

Sunday, February 17, 2008


Sometime in January 2007 when I was busy preparing and submitting resumes and getting ready for interviews, I bought this PDA because of the hype I have been hearing about it being a necessary tool when you are a clinician (doctors, nurses, etc.). I was excited when I got it, downloaded several (medical and nursing) freeware, and bought programs online to download (nursing procedures, drug guide, etc.).

The reality is, I barely use it. Most of what I do at the hospital as a Rehab nurse can be easily learned hands-on. I have used it more to remind me of appointments, etc. But to remind me to follow up on something? No. It takes a lot of time to type (and I do not want to carry around a keyboard to attach to it.

It would probably be of more use if I were a doctor or NP who had training including the application of PDA in the practice.

It can be used to store photos and music, though, but I go to work basically to work, not to boast about how cool my gadget is...And even if I could, in theory, use this to browse the web, first I would need access to hour hospital network (how would I justify that when we have access to the internet using our own work station?). Second, the screen is small that I really would prefer the desktop whenever I could use it.

I am thinking at this time of selling this, but I do not know if any of the doctors at the hospital would be interested. They seem not to be too computer savvy and I have not seen any of them techie enough to carry such gadgets. Or maybe they are using Blackberry already...

Maybe I should sell it on Uncle Henry's...or ebay...or amazon...anyone interested here???

What I would want to replace it with is Nokia N810. It uses Linux (not Windows) so it is more secure, has less trash and is faster. It has built-in Skype, webcam and mic so you can use it for VoIP applications and talk to others (free if it is another Skype user, minimal fee if landline). You can browse the internet, including playing youtube videos on a screen with satisfactory resolution and size. It has a good-sized slide-out keyboard. It even has built-in GPS (additional purchase of $120? if you want the voice guide as well, although I already received a GPS from my husband last Christmas that he bought on sale).

Well, I am quite the gadget-lover, although I do not see myself geeky in any way (not in the same breath as my hubby). I had been trying to avoid posting about them on my blogs, for fear of sounding like I am boasting. But hey, sometimes you read about these gadgets you never heard of before, and become interested, so why not? It is quite nice to hear about a gadget you have been considering of getting if you get the info from someone you trust --- another consumer -- both the mediocre and the geeky types. So this post and the next few ones will probably focus on what I/we own and have experienced using.
Nokia N810

And yes, I feel that some of my ad affiliates would be more applicable for posts related to these gizmos. I figure, if I can earn additional revenue posting about a gadget I actually own and have used for some time, it will not be too bad.

Monday, January 07, 2008

Why do some people easily dismiss a case as something so simple???

As I was saying in my earlier post, it was a toxic duty day.

I had a patient: in rehab for deconditioning following a colectomy after infection of her bowels post polypectomy. History of COPD, asthma, anxiety. She had a skin graft on her abdomen, with graft donor site from her thigh. Both had dressings. It was my first day to take care of her.

Early in the morning I changed her dressing on the thigh. She was so sensitive there, but I was gentle enough for her not to scream.

Around 10 am, she complained of abdominal cramping. Her colostomy bag usually had minimal output, since she also had very very poor appetite, per the report I received from the night nurse. Her prn meds for abdomen-related symptoms only had dulcolax supp ...what the??? What for? She does not use her rectal ampulla anymore. Everything goes to the colostomy bag. Even if you stimulate the rectal vault, that would not help. Possibly it was a protocol order entered by a nurse.

anyway, though there were other protoco laxatives, given the complicated nature of her condition and her colostomy, I wanted to make sure it was okay for her to receive a laxative. The doctor okayed. So she got it, and after a while, she felt better.

Lunchtime, her children came, and while her lunchtray was there, they were encouraging her to eat more. I dropped by to check on her...She was hyperventilating and complaining of neck pain. She wanted to lie down on the bed, and promised to eat. I got her pain pills, and in the process, checked if she had anything for anxiety. I wondered whether it was real anxiety or psychological only, as in acting like a baby in front of her any case, I gave the pain pills and antianxiety. I also asked a CNA to help me lay her down on the bed using the Hoyer lift.

She was already calmer when we were transferring her. Upon laying her down we made her turn side to side to remove the pad that we used for lifting her. Soon after that she turned pale, eyes rolled upward, skin got cold, and she was unresponsive. We called a code.

Briefly she responded to my call while I was trying to measure her BP. She was breathing, quite a different pattern, though. Not as rapid as prior to lying down, but quite rapid and shallow. But we were afraid she was having a stroke or a seizure, although there were no such history. BP initially I could not get, but at second attempt was 80/50, with tachycardia. Then the two nurses from 5th floor came and saw that the patient was already responding and pinker. They easily dismissed with CONFIDENCE, after asking me what the diagnosis was, that it was probably a vasovagal complex. I could not easily dismiss it. Delta team came (EMS) and continued monitoring and evaluating the patient, while I went out to talk to the doctor. Delta team rep followed and talked with the doctor. Initially, we were asked to just monitor the patient. But Delta team went back to her, then I followed, and learned that she had another episode, BP going down, O2 sat could not be measured because she was too cold. They finally decided to transfer her to the ER, and started a mask and IV.

I notified the doctor. I called the ER nurse to give report about the patient they will be seeing. As I gave report and reviewed the history, I saw she had an episode of torsades in November 07. That was probably it, I said.

I stayed an hour and 1/2 more to catch up with my charting on my 6 patients that day.

I received a call this afternoon as an update on that patient. It turned out she had a pulmonary embolism. Nothing that I had done (basically medications administered) could have caused it, I was assured by the unit secretary.

But I wonder how she is doing now??? The therapists in our unit who have worked with her have said that she is not a candidate for rehab.

BUT THE THING THAT REALLY IRKED ME: Those two nurses who so quickly dismissed it as vasovagal syncope. NEVER EVER consider something to simple in a complicated case unless you have observed the patient for some time after the event.

Those nurses were orienting at the same time I was. I have been working more than 6 months now in rehab, but never acted like I know everything. I know a lot more and deeper than they do because of my medical background and experience, and I could not ever allow myself to think in such simplistic terms, especially where life is concerned.

I wonder how many are like that????

Sunday, January 06, 2008

It was a very toxic duty today

I work at a Rehab most of my patients are stable, undergoing rehab to get back to their optimum function. If they do get unstable, we send them to the ER, and if ER deems appropriate, the patient is sent back to acute care units (Med-Surg, ICU, etc.)

I love Rehab. For many new nurses, they will probably get bored in this unit, because they are eager to learn new things, eager to put into use what they learned from school, and eager to hone their skills. Here in rehab, there are not such skills you will learn. You basically give medications, period.

I love it because you see the patient's progress from debilitated to well. Fast.

I love it because I have had my taste of "toxicity" from my days of medical clerkship and internship, in the Philippines, both private and public hospitals...overworked, no pay. Very stressful...I learned a lot, but for now, when I have a family to take care of as well, I do not like to have more stress. I like it when I go home and just forget about work. I like that I do not ever fear of going to work in the mornings.

The story would have been different if I were single.