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...