Heck yes I’m “just a nurse!”

Just a nurse.. this phrase can certainly stir up a lot of feelings! For me though, they are not always bad.

In the hospital system where I am currently employed, nurses are empowered to get things started for patients. There are standing protocols approved by our ED physicians that allow us to preorder treatment we know a patient will need based on their chief complaint and presenting symptoms – which ultimately expedites their care. For example, a patient with chest pain will (obviously) get an EKG ASAP – but our protocol also allows us to give aspirin, draw labs, and sent the patient for a chest xray all before an ER provider lays eyes on them. This is especially helpful when the providers are backed up or we have a long wait – a patient may be ready for admission when the physician is first evaluating them! I am a huge fan of our standing protocols, because it makes me feel like I am actually doing something for the patient instead of just waiting for orders. Sure, other treatments and diagnostics will be added after the provider’s evaluation, but getting what I can started helps everyone in the big picture.

Sometimes however, being just a nurse can be discouraging. One instance of this for me is when patients are difficult or truly need more than nurses can “preorder.” The best example of this is pain medication. When a patient is truly writhing in pain, of course I will be an advocate and try to get a provider in to see the patient quickly (and start their IV so they are ready for meds!). However I must admit, sometimes I use the phrase “just a nurse” as a cop out. My go to phrase lately has been, “I’m sorry – I am just a nurse and that is out of my scope of practice” or “I am not licensed to order medications.” Sure, sometimes this makes me feel helpless – but other times I am thankful that I do not have to battle the patient over what or how many pain medications they will be receiving during their ER visit.

Other times, I stop and think of all the amazing things we DO do as nurses. We hold patient’s hand as they are taking their last breaths, get that amazing 24g IV in a finger vein, distract children when they are sick or scary procedures are going on… we are badass! According to the US Bureau of Labor Statistics, last year (2017) there were over 2.9 MILLION registered nurses employed in the USA. And nurses have been be ranked the #1 most trusted profession for 16 years in a row – that is pretty incredible. We are not just nurses – we are comforters, caregivers, educators, problem solvers and we take on so many other roles.

I am just a nurse – and damn proud of it!

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Happy Birthday, Flo!

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This week we celebrated National Nurses Week, ending today – on Florence Nightingale’s birthday. How did you celebrate? When is the last time your employer made you feel genuinely appreciated?

I float to multiple emergency departments and there is a different vibe to each one. They are different sizes, have different patient volumes, and of course different management personalities. Nurses Week brings to mind the annual “Nurses Week” gifts – a tote bag, lunchbox, or water bottle. I don’t need a trinket once a year to feel appreciated though, just a heartfelt “thanks for showing up today” once in a while is enough.

Looking back just a month or so ago, I was working at one of the busier EDs and it was an especially trying day. In the afternoon, the manager walked around the department and gave all the nurses, medics, and techs ice cream! Small gestures like this make the day just a little sweeter. He knew we were working hard to turn over our rooms to get the next patients back, and even though the ice cream treat was small and simple it really went a long way for me. This particular manager even comes out and cleans rooms in his suit!

That being said, I appreciate the amazing nurses I work with every day and every shift. In the ED, “teamwork makes the dream work!” I hope all you nurses out there got some treats, thank-yous, and appreciation this week!

6 Tips for NGTs

As ER nurses, we have many opportunities to do cool procedures. When I was in nursing school, we didn’t even learn how to insert IVs until the last semester, and then we just had to hope we had a chance to practice one or two during clinicals! Everyone has procedures they don’t like to do, don’t mind, and LOVE. It’s a little weird, but I personally love inserting nasogastric (NG) tubes.

Okay, that sounds a little sick. The reason why I particularly enjoy this procedure is that despite the fact that is initially quite uncomfortable for the patient, it instantly helps them feel better. In the ER the main indication for NGT insertion is for gastric decompression – usually in the case of a bowel obstruction or post intubation. For a bowel obstruction, once that tube is in place, all that extra air/fluid/gastric juices are instantly being suctioned out – and after bowel decompression  with suction a patient potentially may not even need surgery!

Today I will be talking about NGT insertion in the case of a bowel obstruction because this is the situation in which I have more experience. Also, in this case the patient would be conscious, thus there is additional concern for patient comfort and cooperation.

Here you have it.. 6 tips for successful nasogastric tube insertion:

1 – Coil the end of the NG tube around two fingers – this helps warm up the plastic and get it nice and bendy prior to insertion.

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2 – Get a large emesis basin for the patient to hold in their lap. Sometimes we learn by mistakes – I have been projectile vomited on during NGT insertion and now my patients ALWAYS have a basin “just in case.”

3 – Cover the patient’s chest/abdomen with a towel – it can get messy when you are trying to connect the suction tubing. Then if there is a mess you won’t have to deal with changing your patient into a new gown.

4 – DO NOT LOSE this piece! Just don’t!! You need it to attach your suction tubing. It can easily get misplaced when you are setting up all your supplies at the beginning. Sometimes I tape it to the top of the sheet at the head of the bed (conveniently, close to the suction).

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5- Be honest – I always tell the patient that this is an uncomfortable procedure but it is indicated to help them feel better in the long run..

6- Checking placement: When you see those gastric juices flowing, you know you’re in the right spot. But what if the patient’s belly is full of air? The “swoosh” sound when checking with the toomey and your stethoscope is one indicator. A general surgeon also gave me this tip – “If they can talk, it’s in the right place.” So far that has always been true!

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I hope these gems help in your practice, and that you enjoy all the cool things we get to be a part of in the ER!

Fear: Friend or Foe?

Working in the Emergency Department, we see all sorts of everyday accidents. Through the years, I think this has given me a realistic set of fears. For example, after Hurricane Matthew I was helping my dad clean up shingles that had fallen, and we finally had to get on the roof. I was on the top of the ladder, one foot on the roof, and all I could think was, “This is how people die.” A few weeks before the hurricane, I can’t even count how many patients came to the ED due to injuries from falling off a ladder or roof – while they were putting up their hurricane shutters.

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That being said – what is fear? That subconscious nudge to take a little extra caution. Fear has good and bad functions – it helps to sharpen our awareness at the moment but it can also hold us back. Starting a new job? Fear can be nervous excitement about a new chapter in your life, or it can be crippling and cause you to stay in a job you hate because you have accepted that as your “normal.”

This week I went to visit a friend in Colorado – I am a Florida girl and have only really been in snow once before. We decided to go snow skiing, which I have never done. The emergency room nurse in me is thinking of all the bones I could possibly break – but skiing is something I have wanted to try for years. We purchased a few items that we wouldn’t be able to rent (goggles, snow gloves) and drove to the lodge by the mountain- seems like no turning back! I think the real fear for me really set in when I was signing the waiver; it said something to the point of “you assume all risk of injury or death.” Being my first time ever on skis obviously we took a lesson. The instructor pointed out, “you don’t want to come down the mountain on that!” as people carrying a back board walked by us. I actually felt pretty confident until I was on a turn and couldn’t get my legs to work to properly slow down, I just threw myself down into the snow to stop — a bit comical in hindsight. But from then on I definitely had an aura of nervousness. I really, REALLY, enjoyed skiing, but I have to appreciate that I was able to push past the little voice of fear leading up to getting those boots and skis on.

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So how can we use fear to push us out of our comfort zones but still feel some type of security/safety? I think it is important to try new things, step out of our comfort zones (boundaries?) to broaden our life and experiences. I wouldn’t say to ignore that little voice of fear but to keep in the back of your mind a sense of caution going forward.

Assess Yo Patients!

I have two things I’d like to talk about today – EMS triage/assessment and sending EMS patients to the waiting room.
But first, a story:
I was assigned the critical rooms (my favorite). I heard the radio report of my patient en route, motorcyclist involved in a hit and run with possible alcohol on board. I prep my room, check on my other patients and wait. EMS rushes into the room with security; I literally can’t even see my patient because there are so many people around him. The paramedic kind of pulls me aside at the desk to give me report. I ask, “Can you give me report in there?” He smirks and replies – “Trust me, if I’m not worried – you don’t have to worry.” WOW we were off to a bad start there! What is going on in my mind: This is a trauma patient, does he have a cervical collar, is he bleeding, is he BREATHING?? I explained that I wanted to “lay eyes on my patient” which elicited a big sigh from Mr. Medic. I finally was actually able to check on my patient, who ended up being fine. However with all the hustle and bustle of getting into the room come on – I need to see this guy for myself and make sure at least the ABC’s are okay!
I think as you work certain places you learn which pre-hospital providers you trust regarding their handoff and clinical judgment. I had never seen or talked to his particular medic before so I wanted to see this particular patient ASAP. But sometimes what you are told and what the patients tells you end up being completely different! Also, sometimes what the patient EMS and what they tell the nurse (and what they later tell the doctor) are completely different – it is important to get the story for yourself!
On that note – different hospitals handle EMS triage differently. Some have a designated person who will triage or “check in” each EMS patient. Others send EMS directly to a room/area and the nurse who will be caring for that patient does bedside triage. What do you prefer? Personally, I prefer to triage my own patients so I can get the story from the paramedic or EMS’s point of view and ask questions. For a confused elderly person – I don’t just want their vital signs and BGL.. What did their house look like? Are they from a ALF/SNF? I want to have the opportunity to ask questions so I can better anticipate what my patient will need.
Next, different hospitals have different rules on whether a patient who comes in by ambulance can go to the lobby or must go straight to an ED bed. I personally love sending ambulance patients to the lobby – when appropriate of course. I don’t want someone to be rewarded for using EMS when their chief complaint is pink eye (yes – this has really happened) because they think they will get seen faster if they arrive by ambulance. That being said, whoever is receiving these patients and placing them needs to actually assess the patient so they go to an appropriate area. I was working in triage and had an EMS patient sent to me for a “thumb laceration.” It was busy so he did have to wait a while to be seen. Y’all – it was amputated!!!!
So the moral of the story is, from me, assess yo patients!!! You need to see what is going on for yourself for optimal patient outcomes. This goes back to patient safety and protecting yourself and your nursing license!

Unsung Heroes

I have a newfound appreciation for people who take care of their family members at home. I mean the family where Grandma is living with them because she can’t live on her own anymore, and maybe can’t get around as well as she used to. Y’all – this is HARD work!!

My Grandmother has been living with my parents for the past few months. She was discharged from a rehab facility after a femur fracture and subsequent surgery and we just didn’t feel safe having her living home alone (she had previously lived independently prior to the fracture). I would visit my parents for a couple days in a row on my stretches of time off and help with transferring, toileting, etc. There was definitely a decline in my grandmother’s health and strength where she ended up needing truly total care. We didn’t want her stuck in bed all day so we would get her up to the sofa or recliner, to the table for meals and of course potty breaks. A bout of diarrhea would turn into nearly an hour in the bathroom because she was only able to stand for short intervals, even when it felt like I was holding her up all on my own. My parents did try various home health care agencies but there were days when they didn’t have an aide available or the aide didn’t show up. My parents have never worked in healthcare (and both have recently broken wrists!) so I was concerned about them injuring themselves lifting/transferring my Grandmother. Fortunately they were fast learners and we did find a couple excellent aides.

According to the Centers for Disease Control and Prevention, the number of patients who received home health care any time during the year (in 2013) was 4.9 MILLION – wow! Think about all the prevented hospital admissions (and ED holds) for patients who can get their wound care of IV antibiotics at home. Any how much that number has likely grown as we enter 2018!

Now when I have a patient and their family members offer to take them to the bathroom “because we do it all the time at home,” I just want to give them a big hug. And a break – let me take Grandma to the bathroom this time.

New Year, Better Me

It’s that time.. bring on the New Year’s Resolutions! I don’t know about y’all, but in the big picture of things I am happy with myself. Sure – there are tons of things I would change or improve – but I don’t think I fit into the “New Year – New Me” announcements that we are about to be bombarded with. As I write this, I can’t help but laugh because I recently stopped my gym membership because I am working so much these next few months the schedule won’t really line up for me.. so I may potentially be one of those January gym crusaders!
My mantra as we enter 2018 will be: New year – BETTER me! I want to live my best life and become the best version of myself. There are all kinds of things that we say we are going to do “someday,” and while yes realistically they can’t all happen tomorrow I am starting to realize that we have to make that day happen! Want to travel more? Book a trip for later in the year. Just do it!
Professionally, I want to become the best emergency department nurse I can be. I hope that I can be a resource to my coworkers if they need help with something or are unsure about a procedure. One nursing skill I plan to work on this year is ultrasound guided IV insertion.
I have goals for improvement in various areas of my life. I would really love to cut some time off my mile run. I acknowledge that I need to put in the time, effort, and.. ugh.. running. I am currently trying to enjoy reading for pleasure again – I hope to continue this effort into this new year. I don’t know about you, but nursing school kind of squashed my love of reading. I am slowly getting it back – my goal is to read one new book each month. That seems realistic and achievable right?
Taking it back to those college days, when setting goals it is recommended to make SMART goals. That stands for Specific, Measurable, Attainable, Relevant, and Timely. These are all important aspects of a goal – dream big but be realistic, and set a timeframe to help motivate yourself and create some accountability!
What are your goals to become a better version of yourself this year?