Emergency Room

I was in my usual Saturday clinical rotation with Batch 5 at a community hospital in east Los Angeles on this very hot October Saturday. 

I convened with my students at our usual corner in the hospital's cafeteria and briefly discussed with them our objectives for the day then I carefully handed their assignment sheet for their assigned unit.

I also gave them a little brush-up recall on how to calculate Pediatric doses and reminded them of some few new regulations issued by the charge nurses of the different units I met early that week.

I have twelve students that day so I evenly distributed them to three places. Some students went to Couplet Care Unit (which is comprised of Labor and Delivery, Post-partum, and Nursery), Emergency Room and Pediatrics. But most of the time I stayed in the Emergency Room because some of my students do a lot of medication administration and surgical procedures in ER.

It was a very hectic day in ER that day and my students were pretty much exhausted with the rapid flow and turnover of patients coming in and out of the unit. But they were very ecstatic and excited because they had learned a lot that very day.

Some of them had assisted several patients with wounds and cuts, sutured by the in-house physician. They also assisted the doctor in the suturing process. I carefully told and encouraged them to anticipate whenever they received patients with open wounds and to assess the patient first, cater with them by cleaning the wound carefully, and apply their knowledge and skills they have learned from the class and the clinical rotation. So I let them prepare the needed supplies and equipment for the suturing procedure and each and every one of them were so eager to prepare everything.

We encountered a lot of cuts ranging from lacerations, abrasions, open and close wounds, gaping wounds and minor scratches, even self-inflicted wounds, you name it you'll see it there.

But there's this one wound I can't forget from this very cute handsome Latino guy who apparently told us that he made it by putting a regular marble down his penis' prepuce. He specifically told me that he made a cut and inserted a marble in the cut and sutured it by himself. Then after a week it got badly infected so he went to the emergency room to seek for professional help. When I get to see the cut, it looks so gross that even the skin appears so swollen and red, already developing a very bad cellulitis and having some yellowish drainage.

I grabbed two of my male students and assisted them how to dressed the wound as per physician's order, applied an antibiotic ointment, and told them to make a care plan for it. Then we gave the discharge instructions to the patient and some directions on how to take care of the wound itself.

We also had this one teenager who had a right side pneumothorax. Upon confirming from the x-rays that it was a pneumothorax I immediately gathered my students around the patient and carefully coached them on what to prepare and assist, as each one of them take turns auscultating the patient for an absent breath sounds on the right side.

Then we prepared the equipments needed in anticipation for the needle aspiration had the mother signed the consent for the procedure. When the in-house doctor did the procedure they were in awe watching the air bursting out and making bubbles in a bottle of normal saline and confirming from the chest x-ray that the right lung had expanded back to normal position after the needle aspiration procedure.

They were telling me that it was cool for them to have witnessed a rare procedure like that. They almost had witnessed a thoracotomy with chest tube insertion had that lung didn't expanded back to normal position. So I explained to them the rationale of the needle aspiration and the need for chest tube placement had the situation called for it.

There's this female teenager whom my students had catered because she had a threatened abortion the night before. She was on her fourth month of pregnancy and all of a sudden last night she had an unexplained contractions while she was sleeping and had a miscarraige.

She even brought the four-month-old fetus and the placenta carefully wrapped in a paper towel zipped in a big Ziploc bag and was placed in a very attractive paper bag with printed angels on it. It was a horrible sight to see the hapless fetus lying lifeless inside that plastic bag.

My students felt so sad about what they had seen and they told me that it was the first time they saw a little lifeless fetus. I told them that it was a good experience for them to see one and they agreed. They then assisted the mom as the doctor checked her for an internal examination checking if there is still some remnants of pregnancy because of the fact that she was still bleeding vaginally. We also catheterized her for a urine and drug study as per doctor's order.

We then soaked the fetus and the placenta in formaldehyde and send it to laboratory for a pathology study and for more studies. Then some of the students stayed with the mom to comfort her.

We also had an eleven-month-old female infant who came in with suprasternal and intercostal retractions, tachycardia, and tachypnea with a moderate hypoxemia as noted with the oxygen saturation of 89%. In short, she has a respiratory distress with no apparent respiratory failure. We assisted the baby and the parents on the gurney, connected her to the monitor, attached her to an oxygen via a simple mask and gave her bronchodilator breathing treatment via that mask as ordered by the ER doctor.

I told my students what to look for and assess had they receive such patient with respiratory distress and carefully assisted them on what to prepare had the doctor ordered laboratories and intravenous infusion.

They were so eagerly pumped-up when they heard that the doctor needed urinalysis and basic metabolic panels for the infant. So I asked some of them to attach a urinary bag to the patient and prepare necessary equipment for lab draw as I prepared myself to draw and collect the blood specimen coaching them to assist me in inserting the intravenous catheter and collect the specimen from the catheter so that I can only poke the poor baby once. I can really see in their eyes how excited they were watching me doing the procedure.

We had also received from an outside transport a fifty-one-year-old diabetic male patient with severe hypoglycemia having a blood sugar of 25 mg/dl as called by the coming ambulance crew from the phone.

So, while waiting for the patient to come in, I gathered my students and instructed them what to prepare and anticipate like the gurney to receive him, an intravenous set infusion for the dextrose 50, and the glucose monitoring system, as well as the oxygen had we need it. I also assigned them roles to do when the patient comes in.

When the patient came, we instructed the EMT guys to place him in the gurney and my students with their assigned roles crammed around the patient and do their respective responsibilities. We immediately removed the patient's habiliments and placed a hospital gown, attached him to the monitor while taking the vital signs.

Noting that the saturation was low we immediately placed a non-rebreather mask and gave him 100% of oxygen, then one of my student took the blood sugar which came back 35 mg/dl so I immediately started an intravenous line and obtained an order for an IV bolus of dextrose 50 as ordered by the doctor. One of my student took the temperature which came back below normal so I instructed them to get a warmed blanket in the warmer and cover the patient while I instructed one of them to pick-up the Bare-Hugger at the central supply.

The ER doctor commended us for our presence-of-mind, alertness,  and help and even congratulated me for a job well done in teaching my students to be a more responsive, quick, and smart thinking nurses. It felt so good to hear such appreciation and praises which I myself didn't expect.

And as we convened for our post-conference I also praised my students for a job well done while we carefully evaluated every scenario we had that day. We reviewed what we had experienced for the whole day and I appreciate their being so cooperative and responsive in any stressful situations. And they were so thankful that I was always there to help them out and for being there all the time to assist them.

I went home very relieved that my students had learned so much that day and hopefully will learn more when we come back in that little community hospital which really welcomed us with open arms to learn there during my students formative times of their nursing career.

Hopefully, more difficult and interesting cases will await for us there for the coming weeks.