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.