I freeze up when the big traumas/CPRs come in

Altra, BSN, RN · Sep 11, 2005

Hey VS, I'm a new grad in a Level I ER too.

I believe I understand what you're saying. The only specific advice I can offer is to talk w/your preceptor AWAY from a trauma or code -- ask, what is the process, what is the "outline" for procedures for certain types of trauma, what equipment should I have ready, who does what, who is that resident that always comes down and asks for ______, what SPECIFICALLY was your preceptor looking for you to do during the last trauama/code that you didn't do ... are there videos you can watch, references you can read ahead of time, etc.

It is overwhelming. I'm about 1/2 way through my orientation & this week coming up I'll spend a significant amount of time w/my preceptor in the trauma bay. Yes, I have a knot in my stomach just thinking about it.

As for IVs ... don't you just hate struggling when it seems to be such a no-brainer for other nurses? :uhoh3: I firmly believe that it just takes practice - when you've done it a million times like other nurses you're working with, you'll be proficient too. Can you spend a 1/2 day or even a whole day w/a nurse from the IV team? Those nurses are AMAZING.

Believe me, I know, it's hard to be under such scrutiny ALL THE TIME. But we chose the ER for a reason, right? Let's hang in there - we'll get through this! :)

Editorial Team / Admin · Sep 11, 2005

I'm a new nurse in a level 1 trauma center, and I'm still with my preceptor. He doesn't talk to me during the traumas, he's busy doing his own thing...afterwards he yells at me for having just watched everything going on around me, but not doing anything. I've tried to tell him that I don't know WHAT I'm supposed to be doing, but he says (or yells) YES YOU DO, YOU KNOW WHAT TO DO, YOU JUST DON'T DO IT!!.
So here's the deal: I can handle the chest pains and abd pains and UTIs no problem. I know what to do, what to ask the patient, what to assess. I get them in a gown, put them on a cardiac monitor & pulse ox & O2 if I think they need it, start and IV and draw their blood. It's routine, no big deal. But then when a big trauma comes in, GSW to the head, they're doing CPR, or an unresponsive person, decreased LOC, that EMS is bagging as they come in....stuff like that. The BIG stuff, the ones where the docs and the nurses and the techs are all crowded into the room together, the docs start to intubate...the techs are still doing chest compressions...I just don't know what to do! I really don't! There are so many people in there, by the time I think "oh, I need to get a pulse ox on this guy" someone's already done it. And then I think "I need to get the cardiac monitor leads" someone's done that. And most of them come in with an IV, but in traumas, we always put in a second line...and the CPRs too...but I suck at my IVs still, I'm still missing 90% of them! So I don't do that...then the techs start cutting the clothes off, and I wonder if I"m supposed to be helping do that...my preceptor does. My preceptor's usually running around doing stuff...getting an IV going, or drawing the meds, the Vec or versed or whatever if they're going to intubate. AND I HONESTLY DON'T KNOW WHAT TO DO! Everyone around me is doing stuff, and by the time i think of it, it's done.
Often my preceptor will tell me to "start writing"...so that I can record the times that the intubation occurred, the times of all the meds, etc etc...and later i put it all in our computer charting system. But I want to DO SOMETHING, not just write it down. But I don't know what to do! I really don't!
I have been told "remember your ABCs"...and I KNOW THAT...but when it comes in the door, A-airway and B-breathing, it's covered...they're patent, they're being bagged and sometimes they're already intubated...or the docs are preparing to intubate...so then what? C=circulation...I've kind of decided "ok, I'll be the one to get that first blood pressure" or to check pulses...at least that gives me something to do.
This whole post just sounds so stupid....what I want is for my preceptor to talk me through this stuff, when the pt rolls through the door, I want him to say "ok, because the situation is "x", I'm thinking "y" and I'm going to do "z" first...and the "xx" can wait for now because .... you know? I want him to talk me through what he's thinking, what he's doing first, and why. And what MY role is...versus what the techs are doing and waht the docs are doing and what respiratory is doing. I know they say "A, B, C" but in reality, when there's a whole room full of people, you're really all working on the A's B's and C's all at the same time, not waiting for A, before going to B and C, you know?
Anyway...how do I stop just standing there and watching, and start DOING something? Has anyone ever felt like this?
VS

TAKE A BREATH!!!!

Hello, vampireslayer,

I remember what that felt like.

First of all, have you had ACLS?? If not, sign up tomorrow (or Monday).

Now, you need to go to your preceptor and have him/her give you 3 things that he/she wants you to do when the next full code comes in. I mean 3 BIG things.......airway/breathing...........chest compressions...........IV (you MUST try).

That will give you something to not only think about and be prepared for , but, know what you will do. If those things are being done, ask the compressor if you can do compressions. You know how to do them. TELL them you will do compressions now.

You said that the A-B-C-s have already been evaluated and no need to do them..........WRONG..........you must reassess these. So, you can check pulses with and without compressions. Slip a stethoscope on the chest and listen for breath sounds during ventilation with the bag-valve-mask before intubation.

Recording is a good thing to do. It is a must and very important. You learn much by doing this.

I think if you approach your preceptor about this now, before the next code comes in, you will feel much better about things.

Good luck!!

neneRN, BSN, RN · Sep 11, 2005

You're supposed to be scared when the sickest pts come in- you're new and it is scarey at first. Being comfortable with these pts comes with time and experience.

You sound like you know what you need to do, but the experienced nurses are one step ahead of you in actually doing it...I agree with siri- tell your preceptor to assign you a task each time one of these pts comes in, this time you do compressions, next time you get the line, next time you push meds, etc. I remember being in your position as a new grad- my preceptor would do his thing while I stood there and watched. Then one day we got a code in and another experienced nurse pulled me aside before it arrived and said "Take your pick, you can do compressions or push meds." This made all the difference in the world because I felt like I had an assigned role as part of the team- and I wouldn't be in the way. It's hard for the preceptor to try to teach/direct you once the action's going-there's just too much to be done and it needs to be done fast. That's why its important to have a plan going in. Then, once you've done everything at least once, you'll start to get a feel for the rhythym of the teamwork and be able to jump in and work the case without direction.

ClaireMacl · Sep 11, 2005

We have had a senior nurse who has never been involved in CPR, you never know if you will or you won't.

Personally, I, when I first started out got very freaked! I had a guy I was talking to who told me he had a major nose bleed the day before, his wife said it was everywhere, but didn't call an ambulance. He was GCS 15, completely oriented, talking about nonsense, then suddenly, his eyes went blank. I knew what had happened, i knew from the description that he'd had a massive GI bleed the day before, but I felt helpless. I screamed for help. Mananged to compose myself that it was a PEA and alert the medics, but as I had just been talking to him, I just couldn't comprehend. This was my first day in Resus. I don't think I was with it, but I just ended up writing "cpr commenced", IV adminstered etc and wrote the times. I was soooo scared. The man died, I composed myself and went to talk to the family, since I'd been with them for the hours before... they were so lovely, so understanding. I think my first experience of CPR meant I could move on in a good way, I can't imagine myself now, as a senior emergency nurse, not having experienced any CPR.

It takes time to get used to it. Your instructor forgot you were in shock. I was lucky to have a fabulous team around me. You'll be just fine in the future, as I am now.

It's a horrible thing to experience, but you have to work on automatic and that only happens with practice.

Best of luck!!!!

Billiegirl · Sep 11, 2005

I can definitely understand how you feel! I recently switched positions in my ER (new title, more hours, WAY more to do) and for some reason our code rooms and trauma rooms terrify me.

I can't tell you how to get over your fear because I'm still trying to do the same. I can tell you that I used to love those rooms and I know someday the fear will go away.

Talk with the staff, you'd be surprised how many of them had and still have the same feelings. They can offer you some good advice. They can and will tell you what to do, but it is up to you to jump in. That's what I'm working on.

Billie

chadash · Sep 11, 2005

Definitely take ACLS! Pick up the book they base the class on (the ACLS Provider Manual from the American Heart Association) and you can study up ahead. I can't imagine NOT being terrified in a new situation like that! You'll be fine!

twinmommy+2, ADN, BSN, MSN · Sep 11, 2005

Thank you so much for posting your fear here. I"m a senior student and took a job in a level 1 er that will start in Feb. I learn alot from reading all your posts. Thanks again!

ERERER · Sep 11, 2005

A few ideas:

---don't underestimate the learning tool of being the scribe. It gets you in the swing of things.....you learn everything that was done and the order in which it is done (usually all at once!!). Gets you in practice for drug dosages, drip rates, ET tube sizes, meds, rhythms, vital signs. If you take every opportunity to be scribe, you will see that most trauma codes follow the same script. This is the best way for someone new to learn trauma/codes, to get comfortable. Do it LOTS!!!

---in the rest of the ER, grab every opportunity to start IV's. practice is the way to learn. including children and babies. there was a great thread somewhere on this site about iv tips/techniques. Insert NG's, foleys, listen to chests and bellies, assess circulation, look at pupils, defibrillate. pretend every patient is lying in the trauma bay (if you have the time!!!)

----read read read.....even Nursing 2005 this month has a nice article on head injuries.

----the trauma centers that i have worked, at least the good ones, have a list of duties for all the participants. One nurse is in charge of Airway, airway, airway, monitors, stands at the top of the bed. The second nurse, is the "doer" does IV's, draws blood, foley, ng, meds (after #1 nurse prepares), the tech does compressions, cuts off clothing, etc. someone shows up to be communications: with family, with CT, with OR, all things telephone. everything is organized in the mass chaos that is trauma. all good trauma centers should have this system, instead of people just running around yelling.

---speaking of yelling, trauma surgeons and residents do this the best. don't let it rattle you, it's their way of talking in the stress.

---remember that all good trauma nurses were newbies at one point. they fumbled, stuttered, cried, but kept plugging away. we need good trauma nurses now and in the future.

---ACLS, TNCC, PALS, ENPC etc all are tools in your back pocket, not required cards in your wallet

---keep us posted of your progress. Personally i would rather see a nurse a little scared than a nurse that thinks she(he) knows it all!!!

vampireslayer · Sep 11, 2005

Thank you all for all your support! I'm feeling better already...course that could be because I don't go back to work for another 4 days!

I am scheduled for both ACLS and TNCC in October. I've already got the TNCC book, and I've been reading that. I also ordered the Kathy White book that I read about here on allnurses.com.

The last trauma I saw, I was on my way out the door at the end of my shift and decided to stick around for a few minutes just to watch. I tried very hard to ignore all the activity and focus JUST on the nurse and his nurse intern, and what they were doing. When I did that, I realized that it wasn't really as chaotic as I thought...

Next week I'll talk to my preceptor about giving me specific responsibilities when the pt rolls through the door...and I"ll try not to be disappointed if I get the "scribe" responsiblity again...I agree, it is a good learning opportunity, to see everything that gets done and in what order.

Oh, and regarding IVs...When I first started in the ED and couldn't seem to get my IVs, I came home with a bunch of 22g IV caths and my husband let me practice on him! I think I stuck him 6 times, and was successful 4 of those! I went back to work and was all of a sudden successful in 90% of my sticks! I think it's a confidence thing? Anyway, I got sick, really dizzy, lightheaded, weak, some kind of flu, and I think my reflexes were off...that day I missed all my IVs, and it's continued for 3 weeks now, missing about 90% of them...I think I lost my confidence...well, I KNOW I did! So yesterday I practiced again on my husband! I got 3 out of 4 (and the 4th one was a tiny little upper chest/shoulder one that you sometimes use on those realy obese people when you cant find anything else...so I'm not surprised I didn't get that one). Anyway, I feel more confident now, and I'm anxious to try again once I get back to work...I'm also going to try to sit down when I start my IVs. I did that with my husband and it seems so much easier, more stable, more comfortable.

Thanks all!

VS

jnette, ASN, EMT-I · Sep 11, 2005

You'll get there, VS, and I admire your grit and determination.

You'll make fabulous ER nurse, I just know it. You're asking all the right questions, motivated to get in and DO something, and WANTING guidance and direction. All excellent signs.

You'll be an asset to the team in due time. Yay for you. :balloons: :)

MissJoRN, RN · Sep 11, 2005

I admit it, I'm really sticking my nose where it doesn't belong- never was, never wanted to be, an ER nurse but...

I do like the idea of you having a task- how does everyone else know their role? I was an EMT and have seen the trauma codes- nothing like TV, huh? The call comes, report from the chopper, the team assembles, gowns up, and waits, quiet talk about what movie looks good for the weekend, the bay opens and everyone calmly, quietly, but quickly gets to work. Everyone already knew their exact role, and where "their own" equipment would be. No one's stepping over each other, no-one is doing a duplicate task, no task is neglected. Very cool. I admire you! Your preceptor needs to run you through this.\

As far as the IVs go- isn't it amazing how much easier something is to do once you know you can do it- "been there, done that" (Hey, the whole trauma code deal will work the same way I'm sure) I think what I would do is step up and try to get a line in, even if (or maybe especially if) someone else already is. You might get your while they miss or the other way around. Can't hurt to have an extra. Pt won't feel you anyway (sorry to be crass). You get the feel of starting IVs in the worst pts- hypovolemic, livid, etc.

Good luck- hey, you're way past me already :)

PS- I can't help but notice that you really know what's going on, needs to be done, etc. That's more than half the battle. Speed will come. In the meantime it sounds like you can mentally run the code. Keep thinking your way through the sequence- I did that early in my EMS life when I was nervous of codes and early in my nursing career (and every specialty switch) when worried about the "worst case scenarios" I'd make up a scenario to myself and mentally work my way through it. Great way to keep busy while waiting for a bank manager to talk to you, oil changed, etc :chuckle