As fate would have it

So we have been busy trying to clean out the trauma service since Thanksgiving and things were slowly but surely getting back to a good looking census. So when the cheif resident asked if I'd be okay with the intern having the weekend off I thought it might be okay. I figured better for him to get his days off now than over New Years, right? Well, I guess I still think that (because, really, how is New Years weekend going to be anything but complete craziness???) but I would feel better about it if we didn't have to get slammed this weekend. Ugh! Things weren't too bad on Saturday during the day, but then I came in on Sun and see my list 3 times as long. What the heck, people?

So there was good news and bad news in that. The good news was that most of them were "trauma specials." That means they'll get to go home. But also, therein lies the problem. Technically someone staying in the hospital is less work than dc'ing someone. So I had over 15 c-spines to clear, and of course you wait, wait, wait for final CT c-spine reads to come back...and then they all come in at once. And of course everybody wants the collar off since the second it was put on them (now probably 24 hrs later). But obviously I can't see all 15+ people at the same time, so people toward the back of the clearing list are even more cranky than they already were. Anyways, going around to a dozen different floors to get collars off is only half the battle. There's of course the infamous "paperwork" to actually dc them. No small feat there. Plus the pager going off non-stop about other issues, like true medical problems. So as you see, it turned out to be quite the day. But I'm sure I'll be happy when I have an intern to help see people come New Years. Lord knows I'll need it more then than I did this crazy weekend.

Foreign objects

The other day I was discussing with my colleagues the topic of foreign bodies. What have we seen over the years? Probably my most memorable foreign body was finding a koosh ball on a pelvic exam. And let me just say, it'd been there a while. Interesting, but I don't think I took the cake. My colleague had a patient that was "cooking naked" and fell on a can on cooking spray. Don't you hate it when that happens, especially when you relax your sphincters when falling? Fortunately the lid was conveniently duct taped on. Sadly, this is actually not the first time I have heard of a large can being found in lower GI tract. Really, you'd think that would be a unique find, but surprisingly no so unique.

A perfectly round object was seen on AP and lateral views of a pelvic x-ray of another patient. When questioned the patient casually replied, "Oh, my golf ball?" Oh, of course! Now why didn't I think of that? Just where I keep my golf balls. Apparently the patient was annoyed by diarrhea and felt a golf ball was a better choice than, perhaps, Imodium.


I have to say, I learned something in this conversation. I learned a new term "fisting." I'm not sure if I'm better or worse for knowing this information, but maybe somewhat enlightened on an apparently common [sexual] practice. Call me boring, but fists don't sound like a good time. Each to their own I suppose, but clearly even the name could suggest the potential for injury. The "foreign object" was of course not present on admission, but the fist had perforated the bowel.

Well, although some of these stories can be funny and strangely fascinating, they generally aren't so funny in the moment. They actually can be quite serious (like perforated bowel!) and often require surgery for removal or repair. And of course in the category of foreign bodies, often comes impalement. Hum, perhaps I should save impalement for another day.

Acute Care

I just got back from a meeting for Acute Care NPs at the American Nurses Credentialing Center to discuss boards. The meeting reminded me of certain nuances about being a trauma sub-specialty within the umbrella of Acute Care. I'll admit that there were times in grad school when I questioned if Acute Care was the right specialty. Being around a lot of people who love cardiology or neuro or some other system made me feel a little isolated when my thing was injuries. Sure, trauma affects systems, often multi-system, but it is very different then discussing heart failure. But what other specialty would a trauma person be, right?

As I might have mentioned before, I used to work in the ER prior to becoming an NP. For anyone who has worked in the ER before, or really even just in a hospital, you know the ER is a bit of its own entity. It's like being part of the hospital, but not quite. And the Trauma Center I work for now has the Trauma bay separate from the ER. Trauma resus patients come directly to the 2nd floor to the trauma bay, which is next to the OR suites, just in case. So I have nothing to do with even the patients in the ER in my current hospital.

Despite feeling a greatly outnumbered in school, and working in areas of the hospital that can feel a little removed, I do ultimately think Acute Care was the right specialty. It seems perfect now. But being at this recent meeting reminded me that even though we are all ACNPs, we all do very different things and like different areas within our specialty. I do feel like trauma is a somewhat underrepresented, so it was nice to have the opportunity to bring the trauma perspective to the meeting.

Tis the season... for ATV crashes

I see it has turned into ATV season again. We are seeing more ATV crash injuries coming into the hospital now that the weather has cooled off in the desert. Half of the trauma service is now ATV crashes. And as if riding an ATV weren't dangerous enough, people seem to invariably come in with an alcohol level and/or positive toxicology.

I suppose I can understand 20 or 30-somethings riding ATVs (sober, of course), but 80 year olds? Really? What's with the elderly riding ATVs? We even had a 92 year old. They seem to say, "Well, I've been riding ATVs for years. This has never happened." I'm all for being active in your old age, but I at some point you might need to re-evaluate your "activities."

I see ATV crashes commonly result in spine fractures. Head injuries are seen as well. And that is in younger folks. All of elderly that have come in lately did have spine fractures and and one with significant pelvic fractures also.

The hard part about elderly being injured with pelvic or back fractures is the toll immobility takes. When younger people are laying flat in bed for days waiting for a back brace and/or surgery, they can recover physical strength faster. Elderly lose their strength quickly and get it back slowly. This often results in a discharge to a skilled nursing facility, which doesn't always have the best rehab outcomes.

Personally, I've seen far too many devastating injuries from ATVs and would recommend just staying away from them. Since I know not everyone will, I then recommend being smart about it:

1. Don't drink or do drugs (ever, really, but in this case when planning on riding an ATV)
2. If you are over 55 years of age really consider it a sport not for you anymore (or maybe over 60 if you are really fit and super cautious)
3. Wear a helmet
4. Don't ride around like a maniac- use common sense.

I suppose if you stick to those recommendations you should fair much better than the people I see in the hospital.

NPs in ED

I just read a journal article that came out recently on patients' thoughts about being treated by an NP in the ED. They surveyed 190 patients being seen in the fast track area of the ED asking about 8 questions, with the crux of the questionnaire essentially being "Would you be willing to be treated by a nurse practitioner today?" I found the results interesting. Albeit the majority, 65% said yes (17% were unsure and 17% said no). To me, this is lower than I would like to see it and I think it stresses the fact that people need further education on the NP role.

Also, 56% stated they had previously been treated by an NP (with 22% saying no and 21% unsure). I would venture to say some of the patients that fell into the "no" or "unsure" category have actually been seen by an NP before. Quite often I am referred to as "doctor" even after I've introduced myself as a nurse practitioner. I can continue to repeat myself, and some folks will still stick with "doctor." Eventually I give up because ultimately it doesn't really matter; care and treatment will proceed the same regardless.

Perhaps I used to also be guilty of no delineation. Back when I worked in the ER as an RN I used to say, "...blah, blah, blah...the doctor will be in to see you." We had physicians, PAs, and NPs working in that ED so it really could be any one of them, but I generally didn't know which one would get that patient. So unless stated by the provider, it is largely assumed to be a physician.

I think this study really pointed out some things most of us already notice in practice. Since I noticed this knowledge gap, I have made great efforts in educating my patients, and others in general, about NPs and the role. Hence, the development of the www.worldofnursepractitioners.com website. The observation was actually the impetus behind that website, but of course it still takes many, many more health care workers educating patients/public.

By the way, the article is "A Patient Survey on Emergency Department Use of Nurse Practitioners" in Advanced Emergency Nursing Journal.

PhD

Oh dear, I've let time pass again. My apologies. I had been consumed by yet another standardized test in my life. But it is now behind me and I can move forward again.

As you might remember, I mentioned my debate about returning to school for a PhD. Well, the process is in full swing now. And through the process I have decided to open the application process to several schools, not just my alma mater. I think this is a wise decision. But, of course, for every school added, I see the amount of work to do multiply exponentially. I still think it's smart to cast a broader net, at least for comparison.

Part of the process is deciding what I really want to study for the next 4+ years. Trauma, of course, no doubt about that part. But I love so many things about trauma it's about committing to one aspect of trauma that I will want to research until I'm blue in the face. It appears things are settling down to two main camps: trauma in the elderly vs. violence (esp. intimate partner). My particular interest is in prevention and I am on the hunt for the right faculty to work with.

Right now each school is on it's own pace. While I am just starting to communicate with some schools, others are approaching their deadline as I type. The first application is due at the end of this month. I actually find this an exciting time. I will be sure to add updates about my progress intermingled in my blogs.

Pen in the eye

There are certain things you like and certain things not so much. I dig just about anything trauma related. But eye trauma is one of those things that I just find sort of creepy. Well, in a recent trauma lecture we had a great Head & Neck surgeon come and talk about facial trauma...which of course included eyes. It was great to learn the nitty gritty of Le Forte fractures, which we see quite often in facial fractures, but the orbital trauma makes me want to squirm.

Apparently jail inmates place an empty pen shell over a real pen. So what this means is when they stab someone, they pull the pen out and everyone thinks that what went in came out, but really the pen shell got pulled off and left behind. This matters anywhere a person is stabbed, really. But we saw video of a this being next to the eye. A patient stabbed to the eye complained of pain to the eye and initial providers sewed the lac without further imaging. There was some mild edema near the medial canthus, however no overt signs of a large foreign body. Yet once transferred, further imaging revealed a large portion of a pen, which was subsequently removed surgically.

It was quite interesting seeing howing eye trauma, and facial fractures, are repaired. An incision is made on the inside of the lower lid until the bone underneath is accessed. And then that opens a whole eyeball world. The topic was interesting and enlightening, although it still makes me squirm.