I think I may have mentioned this before, but I have a bad habit of staying up/out too late the night before something important is supposed to happen. I've always had difficulty initiating sleep, but some times it's more acute than others.
Two nights ago, I woke up at 6 in the evening. Realizing that in two days I would have to wake up early to drive to the temp job at the home improvement store, I decided to stay awake through the night, figuring I'd go to sleep early the night before the job and get a decent night's sleep.
Reality always has a funny way of intervening, sometimes there's a glimpse of intention behind the random events of my life.
Each time I felt tired and thought I'd throw in the towel and go home, something got in the way. Running into friends. Conversations with bandmates. The request of a pretty girl. Finally, by the time I got home, the final distraction. Left-over southern style ribs and grilled corn on the cob.
When the dust settled, I had three hours to sleep before my first paid gig as an RN.
Needless to say, I was pretty dysphoric when the alarm went off, but by the time I was halfway through my forty minute drive to Lowes I felt halfway competent, without coffee or anything.
The first thing that I thought was somewhat odd was that this building, once I found it, was HUGE. Take a super wal-mart and quadruple it. It was that big.
The second thing was that the parking lot with all the cars had a sign that said "employee and visitor parking". Hmm. That's strange. Calling your customers "visitors" and insisting they park in the same place as the employees.
The final oddness straw was the fence. It was tall and topped with barbed-wire, interrupted only by a guard outpost.
I walked into the guard building, through the door that said "truckers only". I didn't see any other door. Wearing brilliant blue scrubs, the woman behind the counter noticed me immediately and smiled at me past the truckers filling out some form or other.
"Can I help you?"
"Yes, I was trying to get to the front entrance of the store. Is this the right way?"
"Oh, no, sir, this isn't a store, it's a distribution center. Would you like directions to the nearest store?" Her response was smooth and practiced, with a Corporate accent. My sleep-deprived brain took a moment to adjust.
"Uhhh...erm....no, I'm working here today as a Registered Nurse."
"Oh!" Her polite smile had turned into a cheery grin. "You must be filling in for Shelly. Just head right through there and you can sign in".
After a short trip through a metal detector I'm on my way into the actual building with a temporary badge around my neck. I find the reception area, just past a sign that proudly proclaimed "002 DAYS SINCE THE LAST REPORTABLE INCIDENT! 022 DAYS IS THE CURRENT RECORD! SAFETY IS NO ACCIDENT!". Niiiice. I would have liked to see the -average-, not the high score.
After introducing myself around to the friendly office staff, they summon someone with a key to the area I would be working in.
There was a moment of panic, as my sleep deprived brain tried to assimilate the fact that THIS was where I was working.
The nurse I was covering for is a board certified APRN and family NP! I'm a new grad from a 2-year RN program (but the temp agency told me not to tell -them- that because it would make them nervous)!
I calmed down a bit when I remembered that the temp agency said all I would be expected to do is provide first aid and activate EMS in case of an emergency.
"I can open everything but the drug and filing cabinets" the employee told me.
I glanced up at the cabinets, labeled with their contents. Pretty run of the mill stuff. Acetaminophen, diphenhydramine, epinepherine, aspirin, albuterol, stuff like that. The fridge was full of ointments and influenza vaccines. Oddly (to me), no Insulin to be found.
"Hey, maybe I'll come back later and you can give me a breathing treatment"
I laughed, I thought he was joking. I looked up at him and saw he was serious and gesturing to the nebulizer. I opened the housing and found an incentive spirometer and instructions.
"Oh yeah, I know how to use one of these.." I muttered to myself absent-mindedly. I knew these devices well, as I child I regularly depended on them for bronchodilation. The employee wished me luck and left.
I rifled through the emergency supplies and found that they were armed for Bear. The big orange bag you can see in the picture is apparently something similar to what Paramedics take with them (it was emblazoned with the paramedic symbol on the front). Most of the advanced cardiac life support meds I learned about in critical care, a glucometer, glucose paste and glucagon, IV kits, protective gear, a self-contained pulse oximeter, sphygmomanometer, you name it. The AED hung on a hook next to the bag, along with 3 tanks of oxygen. Except for the ACLS medications and vein access gear, I was confident I could use all of it in an emergency (I'm not ACLS certified and I've never performed venipuncture).
I got lost in the supply closet for a while, marveling at the fact that it had pretty much everything I would have found in the clean utility rooms on any of the med/surg units I had served on, just in smaller quantities. Bags of lactated ringer's solution, IV gear, a plethora of bandages and gauze, suture kits, etc.
When I finally emerged I noticed that there was an entire additional room in the Health Center I was to occupy for the day. I walked through it on my way in but was distracted by the exam room. The office had a desk, a few chairs, a filing cabinet and a computer. I called the off-duty APRN to see if I could get the password to the computer, but, alas, I could not.
On the desk was a small packet of printed instructions for Per Diem nurses. Apparently the company that is contracted by the home improvement company to provide health services occasionally deploys per diem nurses when the APRN is off-duty. I idly wondered why I was placed there by a temp agency instead of one of the company's own per diem nurses.
The instructions were pretty clear and I got oriented to the documentation routine right away. I inventoried the emergency medical supplies, noted the expiration dates of the ACLS meds and antidiabetic agents, examined the epi pen, checked the battery on the automatic external defibrilator and made sure all of it's supplies were there. This took me several trips walking back and forth between the desk where I had set out the documentation and the closet in the exam room, but I figured the motion of walking back and forth would help perfuse my abused, sleepy vasculature. I recorded the ambient room temperature and the temperature in the refrigerator. Last was the calibration of the glucometer, a process I was thankfully familiar with after all those shifts in med/surg.
I reviewed all of the emergency procedures and administrative protocols, and completed all of the required non-care documentation. The office was still quiet and there was nothing to do, so I set out some things I thought I might need later (alcohol wipes, tape, gauze, penlight, all the things I would fill my pockets with on med/surg) and gently cleaned the earpieces of the stethoscope with an alcohol wipe (hey, you never know).
The clock by the door indicated that it was only 1 hour into my 8 hour shift. I was sorely missing the internet, now that I was out of things to do. I tried to convince the IT department I needed internet access in case I needed to google something, but they apologized and told me that wasn't possible. Oh well, worth a try.
Nothing left to do but sit and wait for patients! I settled into the uncomfortable chair at the desk as well as I could and started reading "Principals of Emergency Medicine" by various authors (it was a good read, contained a condensed version of basically everything we had learned about every body system in nursing school, plus some juicy clinical pearls I resolved to save for later in my cranial vault. By the end of the day I had read all 798 pages, skimming past some of the review material I was already familiar with).
My first patient encounter happened around Noon. An older man with thick glasses and a grizzly beard shuffled into the room, wielding an inventory-control gun. The coffee I had acquired in the cafeteria was starting to kick in, so I snapped into assessment mode immediately. Shuffling gait, favoring one of the lower extremities. He sat down heavily in the chair opposite mine and told me that he had pain in his leg.
I sat forward in my chair, squaring my shoulders off with his and making eye contact.
"Go on," I said "what's up with your leg?"
He pulled up his pant-leg to reveal a tightly wrapped elastic bandage.
"I got these ulcers on my leg 'cause of the diabetus. It's 'out of control' 'cause I don't do anything about it. I just came back to work today after two months, 'cause my doc said to stay off it for a couple months. I used up all my PTO (paid time off), so here I am. Doc sez I should only do half-days at first, but the boss says no. I can't work with my cane and we don't have sit-down jobs here."
My mental data collection continued. Assessments stacked up in my mind until nursing diagnoses and probable comorbidities emerged like a crystalline fungus in an alien compost heap. Peripheral vascular disease. Non-compliant with therapeutic regimen. Betcha anything he's hypertensive, too. Clear speech, positive affect, appears euthymic. I'm always suprised and amused when people come right out and say that they're not attempting to manage their serious medical condition, but I don't let it show.
"Well," I say cautiously, "I'd think your employer could accommodate you somehow, seeing how you have a condition and all that."
"Hah! Not at this place." Ah, the time-honored tradition of insulting your employer behind his back. It's universal. "I'm going to see my doc tonight, but I just don't think I can work the rest of the day, you know?"
I nodded sympathetically. "Why don't you hop on the exam table so I can take a look at that leg?" I was eager to get more objective assessment data, and I figured the time we spent in an examination would give him more time to rest his leg.
"Oh, no, you don't need to do that, I want to keep the bandage on. It hurt like this while I was taking my time off, like when I went grocery shopping with my wife, I just need to rest it for a while, rest and tylenol, that always did the trick."
I nodded again, in a way I thought might be interpreted as supportive. "I'd say rest is probably the best thing for you." I was glancing at his chart now, noting his antihypertensive medications and previous records of diabetes management, trying not get the info I needed without seeming like I was ignoring him.
"Soooo..." I figured it was time to rephrase and regroup. "You're going to see your doctor tonight, we just need to figure out what we're going to do for the rest of this shift. What do you think we should do? I don't work for your company, I cant exactly tell your supervisor what to do, you know?"
He threw up his hands. "I have no idea!" He seemed to get a little agitated, maybe that was a misstep on my part.
"How about this," I said as soothingly as I could, "I definately think it's in your best interest to rest that leg for a while if it will relieve your pain. If you want me to explain that to your supervisor, I would be more than happy, just have him call me or stop by. I'll be here all day. I'd give you tylenol if I could, but unfortunately I don't have a doctor's order for it (I had searched everywhere for standing orders for PRNs but they were nowhere to be found). The nurse I'm covering for can prescribe medications, but she's more advanced than I am I'm afraid." I smiled weakly.
He nodded, thanked me, and shuffled out of the room. I didn't hear anything else from him or his supervisor for the rest of the day. I charted everything I thought was salient in SOAP format (a requirement of this particular company), and made sure to include that he declined an assessment, would follow up with his PCP and returned to work.
The hours stretched on, then a bunch of people stopped by right in a row towards the end of the shift. One man just wanted to weigh himself to see which of his buddies was winning the "who could lose the most weight" game, I praised his weight reduction efforts and gave him some diet/exercise tips. Another man came in looking for the regular nurse to update her on what was going on with his upper-extremity paresthesia, which his PCP thinks might be the result of a stroke. He asked me what I thought it was and I politely and cheerfully reminded him that I was not a physician and could not give him medical advice.
Another man stopped by and asked for something for heartburn. I didn't think there was any antacids in the exam room and was still not too keen on the idea of administering ANY substance to ANYONE while I was there (since I'm just supposed to be doing first aid and I couldn't find any orders), so I invited him to sit and tell me about his heartburn. He was a younger guy, around my age.
He said it would be brought on by eating certain foods, and that once it happened it would last for "like a month". I asked him if he had seen his regular doctor about it and he said no. I counseled him that he should as soon as possible, since it might be something serious and relying on antacids all the time can cause other health problems.
Looking back on the day, there was so much that I was paranoid about. I walked away from the health center feeling energized about the experience, finally getting a small, limited taste of the experiences like the ones I'd pour over in blogs like "What school doesn't teach you about being a nurse practitioner" and "The nurse practitioner's place"...but then I started thinking...what if that diabetic guy was forming a deep-veinous thrombosis? I should have insisted that I took that bandage off even though he said he didn't want me to! What about that guy with heartburn...what if it was something more serious!? I should have at least auscultated him..hell, I could have even hooked him up to the EKG (never done that before but there's a first time for everything)!
I'm just there for first aid, I kept telling myself. The best thing for those guys is to go to their doctors, and they said they would. I'm only there for work-related injuries. Still, I'm an RN, though, and I should be applying the full spectrum of my abilities that my scope of practice allows, shouldn't I?
Anyway, as boring as the day was, all in all, it's an awesome thing these NPs do, even when it's in a sterile corporate/industrial environment. An awesome thing that I am totally not yet qualified for.
It was nice to keep the seat warm for a day, though.