You might not (or, might, given my propensity to speak directly out of my ass) know that I've only been a nurse for three years.
Over the course of those three years I have learned many many things. Some good and uplifting, some awful. Some useful, some trivial. But everything I've learned has brought me to where I am today.
That's the first thing I've learned. Hold on to your butts. I'm about to get all Baz Luhrman on you.
1. Every experience you have in this field is meant to teach you something. Figuring out what you're supposed to learn from any given situation is probably the most important skill you'll learn-- besides how to prime IV tubing so that your pump doesn't alarm every five fucking seconds.
2. If you set the volume to be infused equal to the rate of your insulin drip, you'll never be late for your q1h accu-checks. 5 units per hour for a 1unit/ml bag of insulin? Set your volume to 5ml. It'll beep in an hour and you know it's time for YET ANOTHER fingerstick.
3. It's ok if things don't get done in your shift. Even if the oncoming nurse is hella bitchy about it, even if you feel hopelessly inadequate because you forgot things or didn't have time to finish up all that tasky bullshit you encounter in a shift because you got busy or sidetracked or people coded or whatever, remember to tell yourself that there's a reason hospitals are open 24 hours a day.
4. ER nurses are fucking busy. You never know what's going on down there. They turn and burn rooms faster than chicks at a busy Nevada cat-house and rarely have time to breathe or pee, let alone hang that K replacement. You never know if they just unsuccessfully coded a baby, or were assaulted by a psych patient, or all four of their rooms were sick as shit and they got busy with other, higher priority things or their charge was on their ass to move that patient-- YOUR patient-- because the waiting room is full of level 2 acuity patients with a 6 hour average wait time. So, go easy on them. See item #3.
5. ER nurses: remember that we're busy on the floor too. That is all. Carry on.
6. DKA patients need at least 2 IVs: one for the insulin and liters and liters and liters of IV fluids, one for adds and other shit. So do GI bleeders. They're going to probably get protonix and octreotide drips and those aren't compatible with each other.
7. It's important to learn the habits and personalities of people around you. This may be difficult for some people to do. It was really hard for me. This may seem really shallow or like I'm advising you to put on affectations when dealing with people, but this is what has provided me with the most success in getting what I want and or need. Granted, there was a lot of trial and error, but I learned which doc likes witty banter and which one wants only the facts. Which doc wants to hear your suggestions and which one flat out doesn't give two fucks what you think. Which doc is willing to teach you things, and which one to avoid speaking with at all costs. I learned which nurse hates long reports, which nurse wants to know every minute detail, which tech will do anything you ask if you buy them a cup of coffee every once in a while. If you learn how to talk to people, you can always get what you want.
8. Twitter is an invaluable resource. Follow a shit ton of other docs and nurses on Twitter. It's like you're part of a worldwide all-encompassing compendium of medical knowledge, all at your fingertips. See: @Mojo_RN
9. You really are NOT as horrible-- or as great-- as you think you are.
10. It's okay to make mistakes as long as you OWN them. Be accountable. Never, ever, ever, ever try to hide or gloss over the fact that you fucked up. Number one, if people find you out your credibility will never recover. Number two, even if you get in trouble, remember that experience and true knowledge never really comes from doing things right. It comes from fucking up.
11. If you're in ICU? Learn your vent settings for christ's sake. That's not just RT's job, it's yours too.
12. Be fearless in pursuing your dreams and goals. I've learned in my short three years that people are never going to outright give you anything, especially their knowledge. Especially in nursing. Actively seek out new information and new experiences. Take classes, go to seminars and conferences, ask to observe whatever bedside procedure is going down in your room-- or, shit, if you can, if something cool is going down in someone else's room ask if you can watch that shit, too. I remember seeing my first chest tube insertion and it wasn't even my patient. It was cool as hell. And, knowing that the doc who was putting it in was the type of doc who looooooooooved imparting knowledge on his people (see #7), I learned a lot of cool stuff. Ask a million questions-- it's okay if people think you're annoying. Fuck them, you're trying to learn. Don't allow yourself to stagnate.
Also? Google everything.
What's a loculated pleural effusion? Google it.
What's the difference between SVT and Afib with RVR? Google it.
How do you tell and upper from a lower GI Bleed? Google it.
Google School of Nursing Alumni, Unite!
13. Apparently, you can give adenosine to patients who are in afib with RVR. I used to think that you couldn't, but THANKS TO TWITTER I learned that it can be a useful diagnostic tool with regard to cardiac issues.
14. If you're ever going to ask anyone for help-- turning, cleaning, bathing, drug calculations, witnessing your insulin, whatever-- be prepared to help out in return. People resent and despise that nurse who sits charting while everyone else is running their asses off. If you help out consistently and there's one night when you're just like ...fuck this shit I'm tired, people are 1000% more willing to cut you a break than if you're always that schlub who charts and texts while everyone else is running a code. (yes, that is a scientifically derived statistic. 1000% more willing. Look it up. On Google.)
15. Always have another bag of IVF in your room-- pursuant to your hospital policy, of course. But having another bag of fluids in your room will not only save you a shit ton of time, but if another nurse checks your beeping IV pump while you're in an isolation room cleaning up the 50th c. diff shit of the night, they are 1000% more likely (again, scientifically valid) to spike that bag for you rather than just adding volume and walking out.
16. Your patients are your patients. But so are everyone else's. Your patients are theirs, and theirs are yours. What?!!?!!!!! That's insanity!! you might be saying to yourself. No, I mean it. "It's not my patient" amounts for shit with regard to monitor alarms, IV pumps, call lights, ventilators, and the GODDAMN TELEPHONE. ANSWER THE GODDAMN TELEPHONE.
17. Your patients trust you with their lives. Be worthy of that trust.
18. There is a huge difference between being assertive and being aggressive. Learn this. I have not yet learned this. When you figure it out, email me at firstname.lastname@example.org. Thanks.
19. Don't take anything personally. Don't take that asschewing from Doctor I-Never-Want-To-Hear-Your-Opinion-Because-I-Am-God-And-Therefore-Infallible to heart. Don't be disheartened when you hear you've been written up, or that other nurses are talking shit. This is the HARDEST thing I've had to learn and I still struggle with it every day. But the fact of the matter is, people are going to talk shit about you for whatever reason: You're new. You know more. You're cuter. Your scrubs are too tight. You called in sick the past two days. You hit the keys too loud when you type. Your hair is a weird shade of brown. This happens. Let it roll off your back, be secure in what you know and what you don't, what you're comfortable with and what you aren't, and learn how to assertively (not aggressively) advocate for yourself. Other people's opinions of you not a reflection of you, but of them.
20. If you dangle your patient's arm over the side of the bed, it's easier to start an IV. But don't just go by sight, learn how to feel those suckers out with your finger. A vein feels springy, like a trampoline, when you push on it. Skin feels mushy. Tendons and ligaments feel hard like a cable. Practice feeling the veins on your arm and the arms of others close to you. NOT strangers.
Do try to start your IVs in places where your AOx4 patient is going to be able to move their arm easily and not occlude the damn thing every time they reach up to wipe their nose. But if you MUST go in the AC, a rolled up kerlix helps keep the patient from bending their arm all the way, thus pinching off the catheter. Take it out of the package and lay it longways across the crook of a patient's arm. Secure with tape or other kerlix and presto: no beeping IV pumps.
21. There is going to be shit that haunts you in this job. Literally haunts you. I remember witnessing my first peds code-- a boy who looked so much like my son I cried the whole time. I still see his face, and his little hand hanging lifeless off the gurney jerking with each desperate chest compression. And the screams of his father who lost his only son and wasn't there when he died. You will have your moments too. They will be hard to deal with. They will cause you to doubt why you even chose this bullshit profession in the first place. They will make you cry, scream, throw shit, and crush you beneath their weight if you let them.
It is imperative to have two things if you're going to last in this profession. The first is someone you can talk to who absolutely understands (without a shit ton of explanation) what you are talking about.
Listen up, spouses of nurses: if you're a florist or a long-distance truck driver you won't understand what your husband or wife is talking about when he or she goes on about the patient being maxed out on pressors and still hypotensive, or needing 30cm of PEEP because ARDS, or VFib or PEA or any of it. Regardless of how you try to understand and how willing you are to just sit and listen, sometimes (at least for me) it makes the situation more frustrating when you have to explain what the fuck you're talking about because the person doesn't understand. I just want to vent, not give you a pharm lesson. And, sometimes, our jokes and funny observations can seem to the layman like we're being insensitive or fucking gross or crass or hateful. Don't be insulted or jealous when your spouse finds someone insular to this profession that they confide in. And nurses: FIND THAT PERSON who understands that you're not being insensitive when you talk about how the patient farted every time you compressed her chest. I'm lucky that my hubs knows enough about this shit that I can babble on and on and he gets it without stopping every five minutes asking "What's Neo? Wait, what do you mean FIO2? What's a lactate?"
The second is good, healthy coping mechanisms. This is not going to the bar and tying one on. This is not avoidance. This is not compulsive shopping. Use your employee assistance program if you have to. But if you can't cope the right way and process this shit properly, this job will eat you alive-- and sometimes at the expense of your health, your sanity, and even your family.
LAST BUT NOT LEAST in this TL;DR "remember to wear sunscreen" bullshit post:
22. You can do it.
No, seriously, you can.
I mean it.
You will not hear this nearly as much as you want to in this profession. Nurses historically have a very poor track record of encouraging other nurses to be great. But believe me, you can do it. Tell yourself that in the car on the way home from a rotten fucking shift where everything went wrong and you're ready to quit nursing altogether and go back to waiting tables at the Waffle House. Tell yourself that when you walk back in from your break to your cursing, spitting ETOHer in four-points and your GI bleeder who needs 4 more units of packed cells, FFPs, and cryo. Tell yourself that after a shift where you've executed it perfectly AND stuck the landing. Tell yourself that often, but more importantly, BELIEVE it when you say it.
You aren't saying you're perfect.
You aren't saying you'll get it right every time.
You aren't saying you're better than everyone else.
All you're saying is, you can do this. Because you can.
PS No I'm not fired.