Enantiomer

The brain is still kicking!  Called in at midnight for a case, finally got the patient at almost 2am, wheezy and tachy, so I call the anesthesiologist for orders and ask DuoNeb, Albuterol, or Xopenex, and she says "Xopenex, because that’s the one that doesn’t cause tachycardia right?"  I said "yes because it’s Lev-albuterol, it’s an Enantiomer of the regular albuterol", and she goes "wow! I'm impressed!", I just chuckle and reply "Yep, big words and everything at 2am!".  Oddly enough I feel like an Enantiomer of myself from 2 years ago: a stereoisomer that is a non-superimposable mirror image – I'm still me, the nerdy critical care nurse who is passionate about animals, coffee, good music, dry humor and fall weather, but I am not the person I saw in the mirror 2 years ago – I'm not grouchy, tired all the time, arguing with my husband, depressed, and sleepy. Albeit being buried up to my eyeballs in schoolwork, I manage to sneak in some fun in my free time, spending quality time with friend and family, I do crafts, I bake, I go outside. I feel appreciated at work, I feel like I contribute to quality patient care, I feel like I actually matter and make a difference. I can definitely handle 11 more months of school until I graduate with my AG-ACNP. Hard to believe it's almost been 2 years of school already; I am not only smarter academically, but also smarter as a healthcare provider, smarter as an adult, more mature, knowing a little bit more about which fights to pick and which to ignore.

Peaceful PACU

I haven't written a hateful blog post since I left the ED.  I actually haven't written any posts here because I've been too busy with school.  In fact, I rarely even get worked up at work anymore.  It's like the calming anesthesia gases permeate our little hamster cage and we all walk around and just chill.  The clinical coordinator is cool as shit, funny, educated, no drama.  The docs trust me.  The nurses ask me questions and look up to me.  I have friends I sit with and gossip about FERN ("Former ER Nurse" on the verge of retirement).  I re-read a few of my posts tonight, and I am in a tranquil state of inner peace.  The ER made me who I am, but I got out before it broke me and turned me into a miserable person.  It made me go back to school, and for that hard push I am eternally grateful to my former incompetent manager, director, and lazy-ass co-workers.  "You haters is what gave me this strength".  15.5 months left of school, clinical rotation starts in 6 weeks.  Lab coat fits awesome, and I look damn sexy in ceil blue scrubs.  Trauma NP or ICU NP?  Or maybe Cardiothoracic surg?  Or Cardiology in general?  The sky's the limit.

Transition

What happens when you take a 6+ year night-shift creature and switch to day-shift?  Zombies happen.  Waking up in your own bed to a 5am alarm, absolutely clueless and disoriented happens.  Blatantly running a stop sign on the way to work happens.  Spilling coffee on yourself happens.  I consider it a good day when I leave the house and have all my clothes on.  Not feeling utter disdain for humanity happens.  No longer checking ER wait times happens.  Not looking at every ambulance as the harbinger of utmost evil things happens.
Enjoying the job so far, not expecting too much, not getting over-the-top excited, firmly believing that it's just a job, nothing more, nothing less.  My life outside of work is much more important.

Leaving a job is like breaking up with a boyfriend

Three weeks ago I turned in my resignation to the ER.  I've been an ER nurse for 5.5 years, and have been in an ER/EMS setting for the last 11 years.  It's like we're practically married.  The ER has been my home and my comfort zone for the last decade.  I don't think I've done anything else for that long.  The ER has been a place of solace and a place of frustration.  A place of knowledge and a place of "holy shit I don't know anything but these people trust me to take care of them".  A place where I could go home triumphant that my coworkers and I kicked some major ass and snatched back a few people from the clutches of death, disease and pestilence; a place that makes you think like you got hit by a train, over and over again for 12 hours; and a place that makes you question how some idiots tie their shoes.

The ER is a unique specialty, and a very coveted specialty among nurses.  If I had to pick a single nurse to be stuck on a deserted island with or in outer space, you bet your ass I'd pick the ER nurse.  We are resourceful, passionate, highly skilled individuals who are innovative, creative, kind, fierce and have a wicked sense of humor.

The ER nurse must be flexible (physically, mentally, and emotionally), must be able to roll with the punches (physical and literal), and must be ready for absolutely anything that walks, runs, crawls, flies, or drives through the doors.  It is this very quality that is an ER nurses undeniable strength, but also her downfall.  "What's that, the unit is full so we have to board the two vented patients down here all night while our waiting room cup runneth over?  Suuuuure.  Bring it on; while you're at it, can you maybe find me a couple of traumas, and a couple more unstable patients to really spice things up?  We're down two nurses tonight, so we could really use some excitement."  The ER has always been society's safety net; unfortunately now it's also the hospital's safety net.  No room for that transfer?  Board them in the ER.  The floors are full?  Board the admit for three days and then discharge from the ER.  Have a rapid response the ICU can't /won't go to?  Get the ER nurses to respond to it.  Have an elective transfer leaving, pre-scheduled days ago that needs a nurse?  Pull from the ER.  Step-down full, but inpatient rehab needs to transfer a patient?  Send them to the ER for admission, and, you guessed it, board the patient in the ER.

I have approximately three weeks left until I transfer out, and here is the ever-growing list of reasons why I don't want to be an ER nurse anymore:

- Understaffed.  While this affects every specialty out there, the ER is a unique setting with a constantly varying census.  Although not at all unpredictable, patient census can go from 10 one moment, to 30-60 patients an hour later, depending on average volumes.  And then there's always that freak accident involving the bus full of nuns on Coumadin.

- Solving EVERYONE's problems, with very limited resources and limited authority over the situations.  The ER is absolutely a jack-of-all-trades.  We are expected to figure out problems of how to get someone's family member into a nursing home, how to perform inpatient care, how to manage transfers that are being boarded awaiting destination, how to deliver textbook perfect patient care  abiding by policy while missing equipment, medications, resources, and staff, how to collect evidence for a DUI, how to admit a patient whose PCP hasn't called back in 8 hours after multiple pages.  By the very nature of the job, we cannot say "sorry, that's not my job" or "not my problem".

- Drug seekers.  While addiction is a recognized medical condition with a complex etiology, it is not a life-threatening emergency, and the emergency room is not a place to manage detox nor a place to come get your fix.  No, we will not give you any drugs, regardless of how hysterical, violent, agitated, cantankerous, histrionic, or abusive you become.  And yes, I'm well aware of the fact that you will either get a satisfaction survey in the mail or a follow-up phone call.  I couldn't given a rat's ass.  I'm not getting you a damn turkey sandwich and blanket after you spit at me and tried to hit me.  I think surveys shouldn't count from people who are abusive to the staff.  

- The Bob's

Imagine having to answer to these people several times each shift.  Having to explain over and over again the rationale for your decisions and requests.  Having to justify your existence when it comes time for annual evaluations by tallying up points of how well you can practice scripted, checkbox medicine.
- The generally ignorant and abusive patients, regardless of what they want (pain meds, work note, footies).  The ER is one of the very few rare places where it's perfectly normally to be cursed out, spit on, and have something thrown at you by a patient or family member, and then they complain that we did not get them a blanket fast enough.  This type of behavior ANYWHERE else would not be tolerated for a split second, and the local police would haul them outside.  Yet in the ER, we are obligated by law to examine you and stabilize you, regardless of how much of an asshole you are.  Repeated exposure reaffirms staff beliefs that Nothing Changes, Nobody Cares.

It's simply time to leave.  I've fought this idea for a long, long time.  Kept telling myself maybe it will change, maybe it will get better, maybe I'll love it again.  The only thing that is still growing is this list and my disdain for the human race as a whole.  ER is not all it's cracked up to be and there are many other sandboxes to play in before walking away from the park all together.

Every single time I've left an ED job I had the same feeling: it was very similar to leaving a bad relationship: (1) once the idea to leave sets it, nothing can change your mind, you only prolong misery by staying; (2) once you actually leave, you feel an immense sense of freedom and inner peace, thinking "I should have done this months ago!".

A Leap of Faith

Time has come for me to bid adieu to my ER family.  I've accepted a job offer back up at Hood Hospital in the PACU.  All the joys of critical care, none of the headaches of long term care.  Essentially, a short-stay ICU unit, with no weekends, no overnights, and no holidays (only on-call).  2:1 ratio, 1:1 for ICU patients until stable, wide open department with full visibility and staff jumping in to help each other, average of 30-60 minute patient stay, then it's off to an inpatient bed or back to day surgery bed for discharge, occasionally an admission hold (not nearly as often as the ER).  Limited family interactions, and even those are always pleasant and grateful that someone is taking good care of their loved one.  Patient satisfaction surveys encompass all outpatient, so, while PACU certainly plays a role, many factors are out of control of the entire department.  Metrics are fairly simple: Beta blockers, Foley, Antibiotics, and DVT.  You know it's going to be a good place to work when the manager asks how you feel about downtime and will you be bored if it's slow.  I'm hoping that the switch to days will be a blessing in disguise, but since it is a fairly behind-the-scenes kind of place, I don't expect much administration to walk around, and as long as I'm off their radar I'll be happy.  Low turnover, one employee graduated as an NP, another one switched to the late evenings position, so day shift has 2 openings.  Staggered shifts four days per week for 9 hours.  Can get crazy hectic but not nearly as draining as the ER.  I will still pick up OT in the ER, simply because it's only a ten-minute drive, so I will have to still play nice nice, but I am glad to be making a switch.  I will miss my friends in the ER but it's simply a toxic place to work full-time, the staff is burning out and leaving, both Hood Hospital and Tiny Hospital.  The new director has her head in the sand and is completely oblivious to the department's problems, no matter how many times you bring them up or throw them in her face.  The Hood Hospital manager sounds like an evil sea witch, and the Tiny Hospital manager is quick to back pedal and protect herself whenever problems are mentioned.  I'm trying not to leave unhappy or disgruntled, but it's hard to see any positives anymore.

$20

Gotta love the feeling of having the attending offer you $20 if you insert an IV under ultrasound into a chronic seeker.

Ironically, that's also the amount that it would cost me per day to change jobs to Big Bob's Trauma Emporium PACU or NICU.  Applications submitted, fingers crossed for new opportunities.

Death and Molasses

Cue another busy Saturday night in the ED.  Steady stream of nonsense interrupted with acutely-ill people.  Down two staff members.  Oh well.   As always, we persevere and overcome.  I'm eager to get the night over with and get home to finish editing my final paper for my first grad school class.  Apparently the great cosmic universe had other plans:

06:38 - day shift is slowly trickling in as I let my r/o ACS patient up to the bathroom.
06:45 - said patient diaphoretic in the bathroom
06:52 - coding said patient in the trauma room
08:39 - TOD

In the few minutes that it took us to get the patient out of the bathroom and onto a stretcher felt like agonizing hours.  Like watching molasses drip out.  Already feeling completely defeated after no break and no food all night, this was enough to push my limits.  Emptied 2 code carts, central line kit, art line, every drug you could think of, and all of my emotional reserves.  It's been a very long time since I've cried over a patient, but this morning it came in stifled sobs, snotty sniffles, shaky voices, and trembling hands.  I sat in the corner of the trauma room, feeling completely drained, lost, and confused.  After most codes I try to keep busy, cleaning up trash and straightening up the room for family to come in.  This was the first morning where I didn't have the strength to do that.  I felt like a part of me left with her, and what remained behind was broken and scared and lost and confused.

Photo Credit: Brandon Plyler (Haynes Ambulance of Elmore County, Wetumpka, AL)

Coworkers said plenty of gentle words to try and comfort without much avail.  Two hours later I finished charting and went home.  I got to go home and she didn't.  And she never will.  For days, the what ifs will haunt me and keep me up at night.  As always, forever will I be haunted by the agonizing screams of a family that lost a loved one.  And I pray that the only thing the family remembers is that I treated her with kindness and respect, bringing her footies and warm blankets, calmly explaining everything.  Her granddaughter spent the night in the ED and I arranged a hospital bed AND an ER stretcher in the same room so they could sleep together.  I pray that's the last memory she keeps.  Not the one where she's standing in the hallway, watching us wrestle her grandmother off the toilet onto a backboard.

The good thing about all the tears is that I know I'm not as dead inside as I seem sometimes.  The cynical, gruff, tough ER nurse has a heart.  It's hidden far away, behind walls built up to keep the evil out, the evil of having witnessed too many codes, too many near-codes, too many traumas, too much violence, too much sadness, too much circumstances of life.  Occasionally some stories find a way under your skin, through the walls and into your heart.  Those will stay with you forever.

Photo Credit: Katie Duke

A photo by another ER nurse (who was fired from her ER job for this photo) sums up so much in one image.  You can almost smell the sweat and tears of the staff present in a resuscitation.  You can hear the equipment in the background.  You can feel the ribs cracking under your hands.  You can feel the hair stand up on the back of your neck.  You can feel your own heartbeat thumping in your temples as you search for a pulse during a rhythm check.  You can feel your heart sink to the lowest pit of your stomach when you know it's over.

My hands shake as I lower her eyelids over bloodshot eyes.  She trusted me and I can't help but feel like I failed.