Psych

I recently attended a class which was mandatory training for all ER personnel. It was a CPI class (Crisis Prevention Intervention). The instructor was the director of the behavioral health department. Now I have worked with him many times because he performs the psych intake interviews in the ER when we have a behavioral patient. I did not know he was the director of the department. The class was suppose to be a large one, but only 3 people showed up. Not too good for the first day of this particular class.

The good part was we could go quickly through the material and the instructor wanted a lot of input from us. He surprised me after I answered a few of his questions regarding 'what would you do in this situation' or 'how have you handled a patient like this in the past?" and offered me a job in his unit.
Throughout the class, he heavily recruited me. He offered me the job, training and said he would pay me more than what I made in the ER - all in front of my coworkers.

I'm thinking about it. However, I don't know if psych nursing is a good fit for me. I remember when I was working on my psychology degree, I got a part time job in a residence for children with autism. My assigned child was a kid with severe symptoms who had parents that would take him home every weekend and basically reverse all of therapy during the week by not following his plan of care. He performed self stimulatory behavior every chance he got. When I had him, I was suppose to perform positive reinforcement to stop his behavior. He would pick up pencils, straws, his hands, etc, and flap them in front of his face. I was mentally exhausted by the end of the day. My last day there (I didn't keep the job very long), they had a BBQ outside for all the residents. The landscaping did not have mulch, but little sticks - everywhere. It was a field day for him and a nightmare for me.

I'm wondering if it'll be like that. I guess I could speak to the director and see if I could start training - sort of a trial. The one thing that did concern me was the fact that there is no security at the facility and only 4 staff members in the unit which is a free standing building and not attached to the hospital. My concern would be my safety. I may talk to him about it - I haven't decided yet.

Foot Tickler

I already assessed my patient who was here with a complaint of leg pain. I had forgotten to mark his pedal pulses, so I entered his room. He was talking on the phone which normally I mind, but in this instance, all I had to do was mark his pulses. He continued to talk, so I decided to just do what I came to do.

"Hey Joe, I've got to get off the phone, there's a nurse who just walked into my room."
Then he laughed.
"Yeah. Yeah. Listen, I've gotta go - this hot nurse is tickling my feet and drawing smiley faces on them."

I stopped what I was doing and looked up at him.
He gave me this big smile, wiggles his eyebrows up and down, and then continued talking.

I silently pointed at him then shook my finger to say no, no, no and left the room.
Some people are amusing.

It's Not What You Think....

Recently I've had a string of patients with ordinary complaints that turned out to be something entirely different. I think I have good assessment skills, both verbally in interviewing patients and in physical assessments. I've been labeled a "sh!t magnetic" in the past, meaning that if I was working on your shift that day, our ER would receive a lot of critical patients. Now the term defines me in a way that we will get strange situations.

Patient's complaint: simple cough. Diagnosis: ischemic stroke.
     The patient denied all questions regarding some type of infection. Once I dug a little deeper while triaging him, he answered some questions which revealed he had some tongue numbness and the weakening of his writing hand. "I can't write things anymore." Boom!

Patient's complaint:  knee pain from a fall  Diagnosis: third degree heart block
     The patient didn't want to be there. His wife just wanted his knee checked out because he had problems with it before.

Patient's complaint:  possible urinary tract infection  Diagnosis: PSVT (paroxysmal supraventricular tachycardia) meaning a very fast heart rate.
     While the patient was receiving some antibiotics, she mentioned feeling like there were bubbles in her throat. I threw her on our cardiac monitor and her heart rate was in the 180's.

Patient's complaint:  follow up visit from an infected animal scratch. Diagnosis: nonSTEMI (heart attack without ECG changes).
     Who could have guessed this?! The patient felt really sore from an injection - it was actually atypical symptoms of chest pain.

Patient's complaint: feeling bad all over and a cough that over the counter cough medicine won't get rid of.
Diagnosis: Stage 4 lung cancer with metastasis.

Patient's complaint: partial facial paralysis, already diagnosed with Bell's Palsy. However, his hearing and vision on the affected side had diminished. Diagnosis: Ramsay Hunt syndrome.
     This was a new syndrome for me. I did notice a rash on the side of his ear and his pupils were unequal. I didn't know the diagnosis, but I knew something other than Bell's Palsy was occurring.

Patient's complaint: leg pain of unknown cause. Diagnosis: leukemia
     Now the mom of the kid told me he wasn't eating as well, felt really tired lately and he had an enlarged lymph node. I was seriously hoping this would not be the diagnosis.

It's always interesting to hear about a complaint and dig a little deeper. Sometimes a cough is just a cough and then, sometimes it's not.

It is Done.

It's the straw that broke the camel's back. The last nail in the coffin.

My main ER job went paperless. Now, I have another ER job where we use computers for all charting, triage, etc. It's the wave of the future (unfortunately). The program we use there is emergency department friendly, so it really doesn't take away from patient care and the speed in which we work has not been affected.
The system my main ER decided to use is not designed for the ED. It is a program designed for the floors and completely inefficient for ER use. I know whenever you change a process, it will take the participants some time to adjust and get back up to speed. However, the administration has changed every process the ER. Everyone was slow, extremely slow. For example, a patient I had for a simple antibiotic injection and discharge normally took about a half an hour. That included triage, the nurse's assessment, the doctor assessment, the injection, injection wait time and then the discharge teaching. Not too bad for everything that had to be done. The whole process now took around 6 hours for a simple visit. 6 HOURS.
I had a simple oral dose of benadryl to give to a kid. Before, I could do it in a minute - give the med and chart it. It took over 20 minutes for the whole process to be completed. The inadequate computer charting for medication administration has added 15 additional steps to be completed and this is prior to giving the med. I have more steps after to chart. It also didn't help that the area where my rooms were located does not have good WiFi access. That's just peachy when you have to rely on computers for every task you perform.

We had numerous patients leave in the lobby without being seen, multiple AMAs (leaving after the doctor has seen the patient) and elopements (people leaving after being in a room and not telling anyone).

People were angry. Patients were hostile because they were waiting hours for the doctors to get in there, all the doctors and nurses were because no one knew what the hell was going on and the computer people were miffed because we did not like the inadequate system they had chosen for us. No ER doctor, ER nurse or any ER personnel for that matter was involved when this 'system' was being revamped.

The day and patient load was actually not bad if we had used our old system. It was intolerable with the new system. I'm wondering how we'll have to work when we have a busy day.

I dread going back to work on Monday. Absolutely dread it. I decided to apply for some positions I found online and quit this ER. Although we have lost a lot of nurses recently, I still enjoy working with the remaining nurses and the doctors who I know well and have had a great working relationship with for years. I've been at this ER for over 6 years. I've seen the ups and downs and rode through them. This downward spiral is something I can't ride through.

I hope I get hired for something soon. Very soon.

Baseball and Hematomas

Well, it's that time of year again for my kids to start baseball and softball season. This means hours spent at the fields in cold weather watching them run around the bases, drop fly balls and swing endlessly at curve balls.
I was at the parent/ coach meeting outside where we would get all the information and have the kids fit for their uniforms. My son was playing with some other boys running around like escaped lunatics. This one in particular was especially rowdy past the point of being obnoxious. I told my son to stay away from him when he started throwing dirt and rocks at other kids. As the meeting progressed, suddenly we hear a scream, crying and a bevy of children running up to parents to 'tell on' the rowdy kid who threw a large rock at another kid's head. The boy came limping up to his father looking like a horror movie actor - blood all over his face and arms, blowing snot everywhere.
I must say, the father showed more restraint than I would have. He loudly told the kid a thing or two and then attended to his bleeding son. I figured that the dad and another adult had the situation under control, but then by watching them, I decided to walk over there to see if I could help. I got a roll of paper towels someone had grabbed out of the little concession stand at the field and led the boy into the bathroom so I could see the cut.
He didn't require sutures, but had a decent hematoma with no obvious skull deformities palpated. I cleaned him up and helped him blow his nose because snot was dripping off of his chin and it was grossing me out. I told the dad what I thought, that ice needed to be applied to the head and then started to advise him of signs and symptoms to watch for and then he interrupted me, "I know these things, I've coached in the past."
"Oh. Okay. Well, I'm going to tell you anyway and you can ignore what you already know."
I continued on and when I was finished, he said, "Oh, I didn't know about those last two things."
Yeah, well, if you notice any of them then take him to the ER for a head CT.
By the time I returned to the meeting, it was wrapping up and I only missed the boring parent behavioral agreement that they have to review with us.
The kid is fine now. I never saw that derelict kid's parents. I wonder if they were even there.

Update

Update to the downward spiral of my ER:

To my knowledge the last of the nurse resignations happened a few weeks ago. We had two mass movements of resignations, so we are extremely short in the nursing department. The admin decided to fill in with agency nurses for the time being. Last week, 2 new nurses were fired for legitimate reasons and our brand new director was also canned. She since has been replaced with a newer director. Also, our hospital chaplain retired because according to him "he saw the writing on the wall" and knew he would be laid off next. Unfortunately, he won't be replaced. He provided an invaluable service to our patients and families during critical times and codes.
I was begged to work the other day because they only had 3 nurses on shift for the whole ER for all of day shift. I agreed to work because I felt bad for my coworkers stuck in the schedule and I knew it would be a horrendous day regardless of how busy it was for them. Well, it was a terrible day. As I triaged patient after patient in the little triage room without a break (I managed to leave once to use the restroom), I became angrier with all the bullshit reasons coming into my triage area. I had to take a little mental break because I wouldn't be able to finish the day without yelling at someone. Everyone felt like they had an emergency or that their problem was the most important of the day. People had to wait, a long, long time and they got angry about that. A patient actually called ahead of time to make an appointment which we told her she couldn't do.
I was able to get quick rooms for the truly emergent patients, thank goodness. Those who had to wait for trivial things such as not wanting to buy tylenol for their kid or decided that today would be the day to take care of a problem they had for over a year sat in the lobby. After hours of hearing the snide remarks, the yelling and the insults - I stopped caring about catering to their whims and complaints. We did not have the nurses to open more rooms, their problems were not emergencies and simply put - they would have to wait.

Flying would be fun.

Surprisingly, I had an opportunity proposed to me for a different job. There is a flight nurse position open and I have a contact to get me in the door. This has always been the most difficult part, you have to know someone in order to get your foot into the door. However, there are many drawbacks. The base is 2 1/2 hours away from me. The upside is that they offer 12 hours shifts instead of the usual 24. They do have a base very close to my house, but presently, they are waiting to move it to a neighboring town, so no new positions at the moment. I was told that I could start at the one 2 1/2 hours away and transfer later. The closer base would be massively hiring sometime in the future. The other down side is that the salary is depressingly low. I'm guessing they bank on everyone wanting to have the cool job of being a flight nurse, so they get away with paying lower than normal for a critical care nurse.
Although I want to jump for joy about the possibility of flying, I have to be realistic under the present circumstances. I guess I'll have to wait and see about the hiring at the closer base and make a decision then.