lxpatterson

melena stool is pretty bad, that and fresh clotting blood....maybe it's because those smells are always associated with very stressful situations.

Very sad! I had an injection drug user being treated for recurrent endocarditis that he gave himself...man, you're 35 with a prosthetic valve, don't you get it? He would disappear for half a day and miss a bunch of his ABX drips because of "errands" (which got more and more far fetched) and come back high as a kite.

You use the public bathrooms? I've been indoctrinated by colleagues to use only staff bathroom, which is unisex (but essentially a women's bathroom with a supply of feminine products, face cream, etc).

Male RN here. Didn't realize underwear would cause discomfort. Will remember to wear pants under my gown the next time I'm a patient! Oh, and funny story about gowns. I was in a bicycle accident on my way to work and I didn't have any clothes on me besides the bicycle clothes I was wearing, which was essentially lycra race wear like you see in the Tour de France. You're essentially bare skin under the lycra (in order to pass sweat). The paramedics who picked me up cut these clothes off me because they were pretty much shredded and blood-soaked, leaving me with nothing but a gown and a sheet in the ER for the rest of the day. Every time I got out of the stretcher to have a pee or go for imaging the staff would do a double take because I was bare ass with nothing but gown and socks on.

I started my career in a rural acute care hospital, rotating between inpatient acute medicine and ER. I think it's a great first job because medical staff and senior nurses are usually fairly invested in getting you, a new grad, up to speed. Compared to a city hospital, where the pool of nurses is much larger, the smaller pool of nurses in a rural center requires nurses to be competent in many roles. Therefore, staff will put more into teaching and mentoring because no one wants to be stuck with an incompetent colleague overnight when there will only 3 RNs in the building. But as you pointed out, you probably will not have much sexy stuff like thoracics with multiple chest tubes or central lines with pacemaker wires, etc. In your first year you should probably be more concerned about building basic competency like getting your ACS response and ECG interpretations down, having the ACLS algorithm memorized cold, foleys, NGs, basic ADL care, etc. I think once you are confident in your practice, you will be less concerned about how an teaching hospital ICU might view your resume and more likely to have actual experiences to impress an interviewer.

"Several lessons to be taken away: (1) Don't hand over controlled meds to students, even mature ones whom you trust, (2) Don't carry controlled meds around in your pocket, and (3) Treat your classmates well... you never know when or how they might bail you out or stab you in the kidney." Yeah, don't carry meds around period! I walked around with a syringe of fentanyl all day after a rapid sequence intubation and only found out at the end of the day when the supervisor was trying to reconcile the narc count. Man, did I get (rightfully) chewed out!

I'm glad to be Canadian! I've never had to submit to the indignity of a drug test, nor am I aware of any clinicians at hospitals here being required to do so routinely (unless reported for a specific drug-related issue). I think if I was registered with the Louisiana BON I would advocate for changes in those rules, which seem unusually harsh. Do MDs or PTs have to send in a urine routinely? Do they have their practice and reputation jeopardized over a bit of weed? And honestly, if Louisiana is a place which such an awful drug problem that people have to be constantly tested then I would consider moving to another state.

That's why you always need one female in the headcount. Best ER shift: 1 male RN student, 2 male RN, 1 female MD.

I look at some of the young RNs (1st career, post-BSN, 22 yr old) that started at my current job with me and I think that older grads have maturity and interpersonal finesse that helps avoid a lot of useless BS with patients and staff -you know, the kind that could potentially snowball into a malpractice or disciplinary thing.

I've done enough schooling to realize that you're just a number to the school: you present a prior GPA and a sum of money and they produce grades for you to take on to your next stage in life. By the second month of school I always have my student number memorized because that's really the only number that matters to administration and faculty. Your dick (whether you have one or not) does not figure into the entire equation. Strictly a numbers game.

Someone mentioned that legally, an AMA signed by a competent patient is sufficient protection for your licence. Personally, I would document as well that I discussed death and morbidity with the patient. To me what is interesting is the discussion of moral obligations, beyond wwhat is the minimal legal requirement. Obviously this is a big part of the discussion because most of us are uneasy with the scenario even when the legality of it is clear. The question I ponder is what is the difference between a pt who threatening suicide and the septic pt going AMA home to a certain death. Ultimately, both will die without intervention, but only one is routinely placed on an involuntary hold. Why is that?

That's ridiculous. If we are simply dispensing medications because patients want them then we might as well give them a key to the pyxis and let them help themselves. The reason we don't do that is NOT just because of overdose, it's because like all medications, analgesics have a slew of other unintended effects, many of them unhelpful. In this milleu of "client-centered care" we might hesitate to practice "paternalism", but we are really not benefiting patients if we are not providing them with judgement and guidance. If I have a patient who is a nurse struggling with bone mets, I'm going to give her the full menu of palliation options and she can tell me exactly what she wants and when she wants it. If I have a 16-year old patient with cholecystitis who is chatting with a friend in the room with no diaphoresis or physical signs of stress telling me she has 10/10 pain and wants medication for that, I'm going to inquire further. I wouldn't say this person is drug-seeker, but more likely she isn't communicating her discomfort well and it's to her benefit that I find out what she is really feeling rather than shoving hydromorph in her vein. That's common sense.

Float nursing, if you can find a program that will hire new grads, is a great opportunity. Many of the Toronto area hospitals are putting their new grads through a float program. I declined a float position in the city and chose a rural hospital because it has many of the aspects of float (I do ER, peds, psyc, cardiac/tele, ortho, MS) without having to deal with the interpersonal issues involved with being thrown from unit to unit.

Haha, exactly! I haven't had run ins like that with my medical staff, but that's exactly what I would say to an uppity locum. I stuff order sheets and things like that on a slow night shift as a courtesy, but it's not my job.

Of course you have to figure out what the patient's preferences are, without assuming they are ok with stuff because they are from a certain culture. But once you have established that someone is ok with a family member making decisions for them and having access to their information, it's a matter of documenting it well. It's that documentation that protects you. Secondly, it's mostly people from an older generation that prefers heavy family involvement. And it is very unlikely that an 80 year old Chinese granny with minimal cultural fluency and English competency, uninterested in learning about the intricacies of CHF pathology and treatment, is going to sue you; much more likely it is the scenario where the children of the granny, who may be well-off professionals, are going to sue you if they feel mistreated. I worked in the medicolegal field writing briefs for malpractice and casualty before becoming a nurse. I have never seen a malpractice or privacy case that was the result of cultural misunderstanding (although I'm sure it is a possibility), however I have seen many cases where personal dislike/animosity between patient and clinician, in combination with a minor or even questionable medical error, snowballed into a full blown malpractice case.

I am a Chinese-Canadian and I have had many asian patients in an urban acute care setting. There are certainly some unique food and lifestyle preferences based on culture, but I have to say one of the biggest differences may be the approach to autonomy. In contemporary North American clinical practice and in our nursing education there is a strong emphasis on individual autonomy (eg. privacy, medical paternalism v. patient's right to choose, conflict of interests and individual consent, etc). However, many Asian cultures believe that the sick person ought to be "protected" from many of the decisions involved in care because having to deal with these decisions might be a stressor that will make them worse. This may manifest itself in outright paternalism, as described by the above poster, or in other ways like multiple family members (including a clinician in the family) being fairly aggressive in seeking patient information. Therefore, the family may need to be accommodated in treatment planning. The most important thing to remember is not to assume, because every family is different. Many people who identify as Chinese, such as myself, have grown up in North America and may not feel the same way. In addition, there are many Chinese diaspora communities that have varying cultural beliefs. It is still important to find out what each patient prefers and is comfortable with.

Being respected and appreciated by colleagues, medical and allied staff (and reciprocating that feeling). That might include bringing in a silly joke gift that is part of an inside joke on the unit; being thanked for doing a good job; receiving informative feedback or education when you've missed something.

I work in a rural hospital and the differential is on the order of a dollar or two, but nurses are forced to rotate as charge after 2 years of experience at the hospital. Obviously the level of responsibility is not commensurate with the pay or prestige and everyone hates doing it. But because everyone has to do it, we don't let anyone 'hang' in a pinch and can look like charge-by-committee.

I have a background in research with chronic pain and psychophysics prior to entering clinical practice as a nurse. Many of you, from your clinical experience, astutely picked out the fact that all of us rate and communicate pain experiences differently depending on our past experiences with pain. While wise nurses have probably known this for as long as the profession has existed, academic psychologists have only started looking deeply into this phenomenon within the last 20-30 years. They like to describe it in these terms: every person has a different "sensory world". Here is a well-written and concise article looking at the question of how to rate pain (Elsevier). The most important takeaway for clinicians that I can emphasize is that you must anchor the "10" for patients with the phrase "worst IMAGINABLE pain or sensation". The key being that the my "worst imaginable" pain is probably somewhat similar to your "worst imaginable" pain; my "worst experienced" pain is unlikely the same as your "worst experienced" pain. Doing this will bring you closer to some kind of absolute measure of pain that is comparable between patients, where you can say, "hmm 7 is pretty bad, maybe we can consider Dilaudid..." But as you can know, it's never that easy clinically, and we all know that pain is not only physical (ie. noicioceptive) but also has a other components like psychological, existential, etc. Even with the best pain scales we still have narc seekers and "tough guy" patients who refuse to complain of pain. That's why our best pain assessment is still our clinical judgement, to look for physiological signs like diaphoresis and behavioural signs like agitation and guarding. And that's why nursing can never be replaced by webMD or some other automated process.

any crossover between human pathology and plant pathology?

I actually changed careers from an introverted field (research) to nursing. One reason I got into acute care and emerg is because of the challenges of working closely with many people and being able to develop rapport with patients. I truly see it as a challenge, every day at work is a learning experience and developing a proficiency that doesn't come naturally. But I think one common thread that most posters have highlighted it is that the social aspect of working is quite exhausting for most introverts, and there's a cost to friends and family. I like what someone said about being picked out to be management. Some of the best nursing managers I've had are introverts, and I find a surprising number of people considered "opinion leaders" or "mentors" are introverted. I feel like it's because we are very objective and focused when it comes to workplace relationships: it is a means to get the job done. Therefore, many introverts will not bother to retaliate when there is some snide rumor about them going around, and will not feel guilty "faking" a bit of camaraderie with someone they're going to be partnered with for several weeks. We spend our limited "social energy" on the political games that matter and ignore the ones that don't, that's why many of us may be picked for leadership.

biochem

Very true! You have to be flexible and eager to take on shifts and be willing to move to underserviced areas. I am a 2 years out from RN school and i chose to move out to a rural hospital from Toronto, but I have to say I love the lifestyle and the work experience I've gained here. I have to say that in a small community institution staff are more invested in mentoring and taking care of junior staff than in the larger institutions I've worked at -which is great for recent grads. Having to be flexible is no different than any other industry. My cousin is an engineer with a masters in chemical eng and he had to leave a consulting job in Vancouver to Nfld to further his career.

With that kind of attitude, you better hope the nursing schools keep pumping out graduates to maintain the current employer's market. Hospitals and units can develop bad reputations, and once this nursing glut is over, people will vote with their feet. One of the major children's hospitals in Canada (non-unionized) has a reputation for treating their staff like crap, but also having the highest CEO pay of almost any hospital in the area. The new nurses I know go in there eyes open, most of them plan to go in for 2-5 years for the experience and education and then take off to grad school or another hospital. Retention is obviously a problem, but management won't pay attention until they lose too many senior staff and the whole place is staffed with smart but inexperienced new nurses, creating an unsafe environment. I currently work in a small rural hospital and that kind of problem is already becoming evident. The province pays good bonuses and other inducements to attract young staff out into under-serviced rural areas, so having enough staff is not an issue. Since there are enough bodies, management feels like they have the upper hand, but that's not the case. Recently a spate of senior nurses have taken early retirement or are leaving because of issues with management, leaving the staff pool with a large proportion of inexperienced staff. That's unsafe. I hate working a shift with no >5 year nurse in the hospital. I am a new nurse, and I am smart enough to recognize the value in experience and knowledge my senior colleagues bring, why doesn't management? And this same phenomena is occurring with the medical staff also. These kind of retention issues will only get worse until administration start respecting clinical staff.

Very true! I have a male PT colleague who always has a scoop on the latest. However, I feel like as a man you're not expected to. Like I can ignore all the gossip without being considered aloof and 'unsocial'. Also, guys may pass along rumors and gossip to kill time, but we're really not invested in making any kind of judgments based on it. As far as most male clinicians are concerned, if what is being said doesn't affect the status of my patient, my salary/schedule, and doesn't affect risk/liability, we could really care less. As far as I'm concerned my manager can sleep with a bear, a hare, a maiden fair -I don't care. But that's just the sample I've been exposed to, I'm sure there are guys who feel different.