martinalpn 5,965 Views
Joined Apr 24, '11.
Posts: 137 (50% Liked)
Unfortunately, not all of the family members have good social or coping skills...stress increases the likelihood that people will behave badly...
Thank you so much for sharing and it means a lot you took the time to tell us about this because at some point I am sure we will have one of those experiences that haunt us. You did everything in your power and what you could, but I guess it was time in God's eyes. I am still a young nurse and there are times I feel at a loss. I am sorry you had that experience, but your strength to do all that through that night is tremendous. You are showing us we have strength to do things we never thought possible, but its also okay to cry and feel as well. You are a great role model and are teaching me that its okay to be human, but to do take time to take care of ourselves because we do deserve it and need it too.
One night as the charge nurse working in a Pediatric Intensive Care unit for a Level I trauma center, I got a call from the ER. It was the kind of call that immediately sends your adrenal glands into overdrive. "We have two children coming in with multiple gunshot wounds. Can anyone come down to help?" My answer was an immediate "yes" before I even knew how to cover my unit. Everyone was in an assignment except for one who was our resource nurse for the shift. I quickly told her what was happening and asked her to call our doctors to see who could be transferred out in order to open beds in the event we would be admitting these two children. The rest would have to unfold as the night went on. I then grabbed my stethoscope and ran. As I was running down the hall to the elevators, and then across three units, through a long corridor connecting the "old" section of the hospital to the "new", down several floors, my heart and thoughts were racing. What will I see when I get there? Will I freeze? Will I be able to help? Who could do this sort of thing to a child?
I entered the ER through a door only hospital personnel had access to. And usually, my badge didn't work and I would frustratingly search until I found a way in. This time, the door opened on the first swipe as if to say "Come on in. We are expecting you."
Immediately, one of the ER nurses saw me and directed me to the trauma bay they were setting up for the children. I quickly donned my cover gown, gloves and mask.
The room was packed with people who all had that look about them one has when you are about to face something horrible. I remember scanning the room looking for the best place for me to be and busied myself assisting those setting up central line trays and whatever else I could help with when the first patient arrived. BAM! The doors flew open. The paramedics brought the patient in and placed her on the gurney. It wasn't a child though. It was an adult woman.
The ER personnel immediately began attending to her as I overheard the paramedics give report. "This is the mother. The four year old was pronounced at the scene. The two year old is on the way right behind us." Within seconds, the two year old was there. At that moment, the experience that changed my life forever began to unfold.
The rest of us who were there for the child jumped in. Most of that time was spent trying to get any sort of IV access. Two physicians worked on either side of her trying to start femoral lines. The IO she came in with failed as did several other attempts to place another. Several attempts at PIV's failed. There were no less than four people working on her simultaneously as nothing could be done, aside from maintaining her airway, until IV access was achieved. Somehow, she had a decent blood pressure and heart rate. Then finally, a working IO was established.
The doctors ordered a head CT and we raced down the hall to the imaging department. While the patient was in the scanner, I stepped out into the hallway to contact my unit and gave report to the nurse I left in charge asking her to get a bed ready. At that moment, the scan was over and we raced to get the patient to our PICU taking the same long, arduous journey I took to get there. Seconds seemed like minutes and minutes like hours. All you can do is breath, stay focused in the moment and try not to trip. Watch out for that bump on the floor. Grab that IV tubing about to get caught in the gurney wheels. Careful! An elderly patient is ahead walking the hall with his IV pole in tow. As I looked around, I noticed the same paramedics who brought her in were still with us. Hmm?...I thought, that is unusual, and we continued down the hall.
Finally, we were in the PICU, my comfort zone. My co-workers, our attending physician, the neurosurgeon on call, the house supervisor, and several police officers were there. I felt some relief. It was almost the end of the shift and there were a few nurses straggling in for the next and one "extra" nurse who came in early waiting for us when we arrived. As I turned her over to our staff and gave report as best I could, I realized I didn't even know her name. I saw the police detectives sitting outside her room and approached them. I introduced myself and asked them to tell me what they could. "Well, we are not sure of her name. This is what we know. The father went on a rampage and shot everyone in the home and then himself. There were several children, visiting relatives, and a couple others unidentified. The mother and this child are the only survivors at this time."
As their words flowed in attempts to answer my questions, they relived the scene in recollection. They described what they saw upon entering the home. They looked toward each other for confirmation as they recounted..."Oh yeah and there was that adolescent draped over the chair and down the hall is where the two year old was found." Then, all of a sudden my attention was drawn towards the patient. She was coding.
When I entered the room to assist, I saw my colleagues hand's shaking as they drew up the Epi. I saw the same two paramedics still there helping as they could. I saw the neurosurgeon who was in the process of inserting an EVD move away from the bed to make way for our attending who had tears streaming down his cheek. In spite of shaking hands and tears, I saw the team working in unison with multiple parts functioning as they should like a well-oiled machine. Everyone was focused at their task at hand doing what we are trained to do. The crash cart was in the perfect position. There was plenty of room for everyone to work. The Respiratory therapist was bagging her little body with perfect rhythm in precise flow. As I stood at attention, ready to jump in when needed, I noticed something very different in this resuscitation scene than what I had witnessed in the past. No one was edgy. No one was impatient. It flowed so kindly. There was palpable kindness flowing through that room. But then, within a few more minutes the attending "called it" and we let he go.
You see, she had been shot in the head. There was brain matter exposed. The CT scan showed her injury to be "inconsistent with life." She had been down for periods of time off and on while with us and possibly before she was found in her home. I didn't know the results of the CT scan or how much time had passed before the paramedics could care for her until that moment. I barely knew anything factual about her throughout the entire time I was involved in her care. I simply functioned in the moment, moving from one responsibility to the next while I contained my thoughts and steadied my own shaking hands. It was now a few hours past the end of my shift.
That didn't matter. I had to complete a pile of charting, as accurately as possible, to document the care I provided over several hours starting in the ER, to CT and then finally in my unit. I don't remember how many forms I completed or even if I completed all I should have completed. I did my best in that moment. It was time for me to leave.
As I entered my car for the hour long drive home in the wee hours of the morning, I began to cry. And then, just as the tears began to flow, I had to shut them off. I had to focus on getting myself home safely. It was as if I was two people at the same time. The one who just experienced one of the most horrific things a nurse can experience and was about to fall apart, and the one who had to hold it all together as if nothing happened for just one more hour until safely home where I didn't have to make important decisions with rapid fire speed that could effect a person's life. Once I got there, my family safe and sound, I began to recount. The more I recounted, the more questions I had and none of them could be answered. They were the philosophical types of questions like, "What am I here (on earth) for?" The analytical type like, "How on earth did she maintain a blood pressure and heart rate?" My mind went in circles. I finally fell asleep.
The next day I awoke and immediately remembered what happened the night before. I sobbed and sobbed and sobbed. I couldn't even have verbalized why I was crying...not in any sort of organized, "this is what the problem is" kind of way. I knew we all did all we could do. I knew I had functioned well in her care. I knew there was no satisfying answer to why people do the things her father had done, but the thought of returning to work terrified me. As the day went on, and the next passed by and the next, I realized I needed help and got in touch with the EAP folks at work. I learned I was traumatized and was told I had PTSD. PTSD, really? From there I received therapy, and it took the better part of a month to recover enough to return to work. I learned that it is not always the one incident that causes a PTSD reaction and that it often is a culmination of things over time that leads to that final straw. To be sure, this was, in deed, one of the worst situations I had ever experienced as a nurse. I have been a part of many tragic and sad situations as most nurses, paramedics, and doctors have experienced in their practice. What was different now? Why now? I began to analyze.
First, there was the call from the ER which had me scared. Could I measure up in this unfamiliar environment? In Critical Care units we receive the patients pretty much cleaned up, IVs started, ventilators running. In the ER that night when they first brought in the mother, she came in with a bang, quickly tossed onto the gurney, still in her underwear with her body covered in blood, and dirt as she had crawled out of her home, dragging herself through her yard and bushes as she attempted to escape, and get help. I hadn't even processed that when the baby came in. And then for her, everything we attempted to do to help her failed. Hours went by furiously working with not much more than a breath in between the changes and then we lost her. In addition to the to the gunshot wound in her head, she had a through and through wound to her forearm. Apparently, she had attempted to shield her face when she was about to be shot in the head.
These images tormented me. Pretty much, the entire night was not the usual sequence of events we see in the PICU. Yes, we have police officers from time to time investigating crimes, but I never heard one describe a scene such as what the officers did that night - lifeless, bloodied bodies strewn all over that home. I paused thinking how brave they are and was amazed at their strength. They were very respectful to us and quite patient while waiting for us to give them the information they needed and that took several hours. Then there were the original paramedics who stood by us the entire night and were very kind and helpful. They did not have to do that. Watching my colleagues pick up from where I left off with such competence and skill made me proud. Seeing the humanity in all who were involved and how well we all worked together - many had never met each other before and yet we functioned so well it was almost "textbook". Everyone was kind to one another and just a bit more patient with each other than what I usually had seen in these situations. There was emotion at every turn, both negative and positive. The compassion and sheer determination everyone involved had in order to try and save this child was powerful and had me awestruck.
We are trained to contain our emotions and personal opinions while caring for our patients. Most do. I did. However, this doesn't mean that we don't still feel emotion or have opinions. We are human beings and it is normal and natural to experience a multitude of emotions as we care for people who trigger things in us whether they are deep seated or on the surface. We are bombarded with tragic, sad stories, wonderful, almost miraculous stories, and to a degree, even the mundane. I now know, that when we get to the point of feeling like someone's appendectomy or broken femur is mundane, then it is time to pause. When we start to crave and feel excitement over only the biggest catastrophic, most ridiculously crazy train wrecks of patient situations, then we are starting to loose who we are as normal human beings. Having said that, to some degree it is also normal to loose a little sensitivity and even required to do so in order to survive and continue do the work we do. This is only my opinion based upon my experience, but I learned that it is important to take stock of ourselves from time to time and "check in" if you will, to make sure we are still "okay". It is important in order to stay healthy and strong in so far as if we want to keep going, do well and be happy as healthcare providers, then we must allow ourselves to feel once in awhile and retain as much of the "normal" as we can. If you "check in" and everything is okay, then you are okay.
All I am asking is that you all please just remember to take the time to care for yourselves, and blow off some steam when needed. It's okay to vent and even whine on occasion. Don't let your nurse back be broken. That back brace of cynicism, harshness and critical judgement of one another, perfectionism and self medication will fall apart one day. Added to the day to day experiences, the responsibility, the need for constant updating of knowledge and the scrutiny we experience from managers, and the public, it's no wonder there are so many nurses with broken backs. Literally and figuratively. Take care of yourselves, and please take care of and be kind to one another.
You scream at the TV "Pull the d@mned side rails up!" every time a hospital scene is played.
Exactly right, the elephant is in the room because nobody wants to do anything about it. Safety will increase with better and APPROPRIATE ratios (Ex. ICU RN's have 2 patients, but do not give me the two sickest patients, both on life support with pressures in the crapper while on multiple pressors, family issues, etc., which giving the other nurse 1 ICU patient who is on no pressors or life support and being downgraded in an hour) I recently improved our safety in our unit by not scheduling people for mandatory overtime anymore. Management breathing down my neck because we did not have enough staff on the unit and I bargained with people to work overtime in exchange for future time off and the schedule they wanted. Well that went on for about 6 months and they still hadn't even hired anybody or interviewed! I stopped doing the overtime and people of course were not coming in when staffing calling about extra shifts because of burn out or wanting personal time off. We had to start turning patients away because of not enough staff. Well, guess what there went $$ out of the door and sure enough, new staff members hired the next week. You must acknowledge the elephant yourself and do something about it!
The moment that healthcare started referring to patients as "clients" is to understand how modern healthcare is evolving. Its about dollars and how quickly you can get them in and out the door. Look at bundled payments that rolled out for CMS. You get a set amount that covers X surgery and stay. Typically total joints stayed around 2 days, now they are pushing for them to be done as outpatients with < 24 hours in the hospital. I never did an evidence search to see if this was effective but from the experience side, its not really a great idea for the patient or nursing. What it is good for is making money. The shorter the stay, the more money kept in the coffers. I really dislike where healthcare is heading but its not up to me, were just pawns in a much larger game dictated by insurance and health laws.
I was just on a case for work and let me tell you, if myself and the other nurses had only charted by exception we would have been up that proverbial creek. Our charting was raked over the coals. We were all consistent in what we saw but slight differences in verbiage is what they went after. BE Consistent! And chart defensively, especially with electronic charting..it becomes very easy to click boxes and not explain what is abnormal. If there is an order make sure it is done, doesn't matter if the 4 people before you didn't so it. Always perform your own head to toe assessment, don't rely on the person before you.
That charting was ... just not intelligent. I understand that in LTC settings a full set of vitals including SpO2 may not be obtained every day, let alone every shift. But if there is a physician order specifically to obtain SpO2 daily ... what other evidence can be offered that the order was implemented if no O2 sat is documented? Duh.
There are too many good reasons to lie about adverse events for the truth to always come out.
Best McGyver moment in LTC - cutting the end off oxygen tubing to insert into a gtube that had a broken seam on the cap which would leak during feedings. Best funnel I've every seen!
I have worked LTC for 29 years. A few times I have tried to get out of the LTC grind-house, by trying to get into Acute Care hospitals or Home Health. Each time you meet the same barrier - many do not see or accept the experience and years put in doing long term care. For a lot of the Nursing/Medical employment LTC is looked down upon.
A typical day/shift has the nurse coming into the building already *Drowning* lately. You either have work thrown on the next shift by the prior shift, or by the Nursing Managers, or simply because the day itself has been a mad house. Lately it is the 2nd shift ( 2-10pm or 3 -11pm) that can get hair pulling crazy. Yet - understand, this is only via my personal experience. On the evening shift you get Admissions which can come in any time during your shift - up to the time your shift ends, you have doctors/FNPs coming in during the evening and writing orders, you have family members underfoot. Then you also have the support leaving you after 5 -6pm ( ie; Managers, etc). Some will see their staff struggling and stay alittle longer to aid you if able. Sadly though many notice and just walk right out the door.
Toward family members many are actually very nice and caring toward the LTC staff. Still it is the one or two that come in, believing NOTHING you do is good enough, that can break the work day. And though you want to just tell them to take their family member home sometimes inside....you put on that warm caring smile, bite your tongue and again try to appease that family.
Then in the past several years you notice CNAs you are getting want the paycheck but try to do as little as possible, so you have to play Warden....having to chase them continually to get things done. Then you have Managers telling the nurse "You need to really stay on top of your aides," when you are already doing the best you can.
When you finally get done at the end of your shift, a day that was so busy you could not take a break, had to sign out for supper but had work through it to get done on time, you now have to wait on your relief nurse. It is now 30 minutes after your end time, no call or anything, and your relief saunters in late habitually. So you know the next day you will get called in to the office for working late because at your facility *There is NO excuse for working late accepted*.
And at least where I work LTC.....this is considered a GOOD day ( LOL).
Not every long-term care nurse chooses LTC as a profession. Sometimes, it chooses us.
But no matter how you've arrived at your first job in a nursing facility, there are challenges awaiting you that you didn't anticipate, especially if you're coming from acute care or another environment where even chaotic conditions have some form of logic to them. Here are a few things you should expect as a new long-term care nurse:
Expect to chase after supplies.
I have never worked in a nursing home where they kept everything in one place. You'd think they would put all the catheter supplies together, but no---whenever I had to change a catheter, I had to go to three different storage areas to obtain the necessary items. Even house stock meds were kept in different cabinets: vitamins and supplements at the nurse's station, OTC pain relievers and bowel care meds in the medical records office. I never did understand the reasoning behind this, so I lobbied administration to change the layout of the supply closets so we didn't have to waste time running all over the facility. Of course, they never did.
Expect to become the nursing version of McGyver.
LTC nurses need to be creative in order to solve the problems that frequently arise in a facility which always seems to be short of supplies and slow to make necessary repairs. You'll use washcloths or foam pipe insulation to wrap around the arms of wheelchairs when the vinyl gets torn up and causes skin tears. You'll utilize foam tape to "Nerf" splintered doorframes and the sharp corners of nightstands to prevent injury. Sometimes you may even have to use a Foley catheters as a G-tube because nobody ever remembers to order the insertion kits.
Expect to be challenged by a wide variety of situations.
Contrary to popular opinion, LTC is NOT boring. Yes, you will have routine tasks such as med passes and fingersticks on your 17 diabetics, but no two days are the same, especially if you work on a skilled unit, which is like a hospital only without the staffing and the equipment. Unfortunately, SNF patients are sometimes transported from the hospital in unstable condition---in fact, I've sent patients right back to the hospital without allowing them to be transferred from the stretcher. But even on the custodial care unit, you'll deal with a host of problems: falls, dementia, hovercraft families, scabies outbreaks, diabetic crises, psychiatric issues, and fights between residents.....to name a few.
Expect to become a diplomat.
It is difficult to hold your tongue when a resident's family member chews you out for the umpteenth time today because "Mom" isn't drinking enough fluids or eating enough or getting out of bed every day or having her 20-minute dental routine followed to the letter. It is beyond tempting to tell them to take her home with them if they feel they can take better care of her. But as you become more experienced, you learn how to let their constant complaints and demands roll off your back, and how to de-escalate a crisis situation by "killing them with kindness".
Expect to be looked down upon by other healthcare professionals; but remember, you are the expert on your residents.
Regrettably, long-term care is still regarded as the bottom of the barrel by many nurses in other specialties, as well as administrators, doctors, therapists, and even EMTs. I can't count the number of times I called the ER to give report on a resident I was sending out and was asked if I'd taken vitals! It's as if they think LTC nurses don't have the sense to do the basics before calling in the cavalry. And if I had a dollar for every time I tangled with EMTs over their reluctance to transport a resident because of insurance issues or "she looks OK to me", I'd be a rich woman today. But there is no need to let the idiots get you down.....when it comes to your people, YOU know best.
Expect to be chronically understaffed.
This is an issue everywhere, even in the best facilities. Granted, you can have days when there could be 15 staff on the floor for 30 residents and it still wouldn't be enough, but even on a good 3-11 shift, 3 CNAs and one nurse for those same 30 residents is pathetic. And when you complain, the general response will more than likely be "Suck it up, Buttercup" and that you should be grateful because XYZ Nursing Home's staffing is better than what the state requires.
Expect to fall in love.
LTC nurses don't do what we do for the money (it's also one of the most poorly paid specialties). We do it because we find so much to love in the wizened faces of our elderly, the funny things they say, the way they hold our hands in a tender moment. No matter how demented or ill, they will provide you with wisdom gleaned from their eight or nine decades of life, as well as a million and one laughs! I'll never forget the resident who once asked me, when I knocked over a couple of Jevity cans in the next cubicle, if I was the cat. Knowing that despite her dementia she had a wicked sense of humor, I said, "Yes, Elaine. MEOW!" To which she replied, "Oh, OK, thanks for letting me know," and promptly went back to sleep.
The hardest part of these special relationships is that sooner or later, your residents will break your heart by leaving you.....and every loss will change you. Some deaths will hit you harder than others, but eventually you'll learn that good-byes are not always the worst thing that can happen.
Loved this article! I started out as a CNA in 1980-1981 and was laid off a year later because CNA's were no longer permitted to work in a hospital. The skill mix went to LPN/RN only.
1984: Obtained my LPN because of wait listing to an RN program. I worked as an LPN for 4 yrs in a hospital and LTC per diem. Around the early 90's, the LPN were being slowly phased out of hospitals and going to a strict RN skill mix. Still no CNA. Mid 90's, I saw the LPN phased completely out in my area and an RN/CNA mix back in style. LPN's were left to work in LTC.
This has seemed to stay this way with select few hospitals retaining LPN's, but the vast require RN or CNA.
So, just when we think we have it figured out, hospitals throw in the mix the ADN vs BSN controversy.
I feel as though my life has been a pig pile of nursing degrees. I initially started out as a CNA, then obtained my LPN, because CNA work was becoming increasingly rare in hospitals. Once an LPN, I was relegated to the bottom of the heap, because the LPN wasn't good enough, so I went back to school to earn my ADN. The safety net of the RN started becoming full of holes, because even though I had my ADN, I still was at the bottom of the pile. I realized to get to the top of the pile a BSN was necessary. I went back to school and achieved my BSN. For now I feel safe, but if someone even mentions needing an MSN at bedside I'm going to hurt them.
I, and others, have said this earlier in the thread but apparently it bears repeating: You do not have to provide any sort of excuse or justification for calling in. PTO is earned. It's part of an employee's compensation. By definition, I am indeed entitled to it.
All facilities have policy regarding how often emplyees can call off in a given time frame. If I violate said policy by all means, punish me accordingly. If I am not in violation of any such policy, well, then kindly mind your own business. I have never provided a song and dance as to why I called in and I never will.
Isn't this profession already plagued enough by martyrs?
I just prefer if people don't tell me. it's none of my business...if there is an issue the manager can talk with them. I once had someone call in and tell me they "have the runs" then she got all descriptive. Yea, even though im a nurse I prefer not to hear about my coworkers "runs."
just say your calling in and if there are issues manager can call you. I don't care.
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