Terra Beek

Navigating the Psych ER as a New Grad Nurse

by Terra Beek | Oct 31, 2016 | Blog, Career Advice | 0 comments

I sighed and looked up, the light turned green. Green means go, right? I advance on the pedal, and drive through the intersection. Only, I didn’t make it through. CRASH! I remember the event like it was yesterday. It seemed as though time stopped. Glass shattered on my clothes, my dress, through my hair…I heard the crunch and screeching of tires. The car door started jetting into my leg from the brute force of the oncoming car. I let out a blood-curdling scream.

Time immediately stopped. “Oh my God.” I thought. “This is it. This is how I am going to die.” It is true. You kind of think of everything in those milliseconds. “I should have told my parents I love them tonight. I should have told my friends how much they mean to me. I should have…” So many should haves…

The car came screeching to a halt. Was I dead? [et_bloom_inline optin_id=optin_21]

My car was facing the other way. I had been T-boned, driver’s side, by a man running a red light. They estimated his speed was at least 60 mph. Two ambulances, police officers, and many deep breaths later, I’ll never forget the police officer’s face as he looked at my mangled car, my shocked tearful face, and said, “I have no idea how you walked out of that car alive.” With that, he put his hat on, turned on his heel, and walked away.

That night, I ended up being the patient in an ED. It was eye-opening, to say the least, that the affect this reversal had on me.

Fast forward to now, and I still drive through that intersection, although now a shiver runs down my spine sometimes as I do. What is that red light runner doing now? I wonder this sometimes. How did it affect him? You see, it is this “how does the other person feel” perspective that I try and think of now when given the psychiatric rotation in the ED.

I have stared in the face of the “truly mad, or truly crazy” person. How do I know? Believe me, you know. As an ED nurse one can tell the difference between the “fake crazy” and “real crazy.” I have never been more terrified than standing face-to-face with “real crazy.” Respectfully, I try, as with the red-light runner, to understand what they must be feeling.

I was given the psychiatric assignment just the other day. As an ED nurse, it is pivotal in our department we do not let homicidal or suicidal patients leave. They are a danger to themselves and others. Sometimes I am still reminded of my parents’ drawing in our house from Alice in Wonderland—the one where the Cheshire Cat exclaims, “We’re all mad here.” “How do you know I’m mad?” said Alice. “You must be,” said the Cat, “or you wouldn’t have come here.”

Sometimes, when I am dealing with psychiatric patients I will admit I think of this drawing. Am I mad for being here? How can I care for these patients when I have no idea what on Earth they are going through?

It is then I just think of humanity’s basic principle: help one another when in need. Perhaps I cannot understand what they are seeing or hearing, but I can at least be present. And this is the fundamental advice I have for nurses with psychiatric patients: just be present. Sit there, listen. Yes, it feels uncomfortable. Despite having a black belt in Taekwondo, multiple degrees, certifications, and a license telling me I can deal with this stuff, I still feel pretty useless and helpless when confronted with mental illness. Your presence and physical company can be instrumental when no else dares to do so. Now, obviously if a patient is acting out and belligerent, then yes, due caution is in order.

Speaking of, as a new grad nurse, I have not been immune to psychiatric patients acting out. I have seen a patient spit and stood in front of a patient at arm’s length as she shouted obscenities: “YOU ARE THE DEVIL INCARNATE. YOU ARE A VICTORIA’S SECRET WHORE!” Once a patient even reached for my neck, her far-away look belying her violent mannerism. I, thankfully, acted quickly and maneuvered away.

I have been kicked in the ribs by a teen thinking I was an angel from Hell. I know a nurse who had to lock herself in a supply closet to keep from being hit, and I also know a nurse who had his ribs broken by a patient. I have assisted in numerous patients being restrained in four-points, and as a new grad nurse I have been the one shoving a needle in a psychiatric patient’s thigh—hoping against hope that the police officers can restrain the patient long enough for the medicine to take effect and knowing it is down to me to accurately and quickly sedate the violent patient.

And I’ve come out the other side. Sometimes I battle what I think is right versus what medicine dictates. And I am often reminded of Jung’s saying, “Show me a sane man and I will cure him for you.” Having attained a minor in philosophy, I often find I think of this.

Despite all—literally—bruising moments, I try to always think of what the patient feels, what the patient thinks. Will I ever really know, or understand? Probably not. But, as a new graduate ED nurse, I find I am just finding my footing, and I reflect on the Kate Millett oddity that “[t]he involuntary character of psychiatric treatment is at odds with the spirit and ethics of medicine itself.” As a new graduate nurse in the ED, here are four things I have learned when dealing with the psychiatric patient.

1. Be present.

Sometimes the best medicine is doing nothing, just being present for someone else during his or her crisis. I have heard many a patient’s plea for death, and many more regrets. Sometimes, I think it truly is beneficial to be a comforting presence.

2. Listen.

As with number one, I find silence is something I am still quite uncomfortable with. I am a nurse; I am trained to intervene, to DO something. Sometimes, however, so much more can be accomplished by just listening.

3. Stay safe.

As a new grad nurse, I find in the ED I am always watching my surroundings—one eye and one ear out, looking, listening around me. Besides observing for potential code situations, I always make sure I have an escape plan if a psychiatric patient ever does get violent. Further, I have seen psychiatric patients bolt like lightning down hallways, once time in nothing more than his skivvies (which at best were barely hanging on). It is always best to be proactive rather than reactive—a good rule for the ED in general.

4. Stay calm.

Above all, I feel patients can sense when a health care professional is anxious or nervous. Staying calm around someone who is completely unpredictable is hard—especially if the triage note says something like “homicidal ideation, tried to kill sister with a knife today”—but it is imperative.

As for me, I have been trying to see the other side since my fateful crash. Maybe I don’t always understand the psychiatric patient’s mentality, or even want to understand it, but I can care the best way I know how, one shift at a time.

I think it is important to note that not all psychiatric experiences are negative; in my day I have met many the sweet, kind, elderly—but politely—confused patient. “Dear, I cannot seem to make my sheets like I like them.” She looked at me, smiled, and beckoned me over. “I just can’t get these sheets right,” as she attempted to smile. We walked arm in arm, but I noted that she started tearing up. “Okay, we can do this. How about we try together?” I asked, smiling and offering some consolation. “Yes, yes. We will try again. I am just so confused!” She put her hands up in the air, exasperated. As I stared at this woman, I felt empathy. Okay, I thought, time to initiate some first-class bedside manner—GO!

And thus I sat down on the bed beside said confused patient and we talked, even shared a laugh. And though, bless her heart, I know she will not remember our conversation, by the end of it she looked at me with blue eyes and stated a simple but powerful “Thank you.” Then she reached up and hugged me. An actual, genuine, heartfelt, gracious hug. Is getting a hug from a psychiatric patient cause for concern? Well, it depends on the situation, and perhaps the general answer would be “yes.” But not this time. That shift, we made her bed a total of 5 times, and I don’t regret a single one. I learned having patience with patients is instrumental in their care. I gotta tell you, the way she looked into my eyes and uttered those two monumental words that every nurse longs to hear—I’ll never forget it. And it was then I understood how a patient can leave a lasting impression and teach just as much as nurses care for, teach, and affect patients. Maybe it is this reciprocity that is the gem of nursing. And my treasure chest is becoming quite full these days.

Room 20: Trauma in the ER as a New Grad Nurse

by Terra Beek | Oct 14, 2016 | Blog, Career Advice, Coronavirus, Emergency | 0 comments

“Are you crazy?” This was the response—replete with an equally stunned face—I got when telling people that I was thinking of taking a new graduate emergency department nurse residency. “Um, I guess so,” was my pathetic shy response. Inevitably, second guessing ensued.

Nothing about the ER is easy. Now, I would venture to say nothing about any kind of department or nursing is easy. I remember watching the TV show ER as a kid. I always kind of imagined the TV show…“ER.” Cue theme music. Cue fast screens of each actor looking serious, looking concerned, looking medical-ly. Wait. Where is sexy George Clooney with medication on hand, and that stethoscope placed precariously, but oh so perfectly around his neck? Nope. Not here. I’ve looked. No Clooney, no Noah Wyle. [et_bloom_inline optin_id=optin_21]

I can remember it vividly. The moment I decided to tackle nursing. I had been sitting next to an elderly blind woman. I was a volunteer in the ED, the lowest on the food chain, and unbearably shy and awkward. I was asked to help feed this woman her meal. I approached the curtain, and with a feeble, “hello?” I walked in with trepidation. The woman was as sweet as she could be, with a southern accent and manners to match. She asked, “Well, hello there…Do ya have my Jello?” With this I felt at ease, and with a smile I sat down next to her and proceeded to have a long conversation about Jello, Southern food, and the smooth moves of James Brown.

I would not change my choice for the world, and working in the emergency department has been the most rewarding, challenging, and enlightening experience of my life. And, without a doubt, I have learned some of the most about nursing and myself during trying times and harrowing situations.

This brings me to Room 20.

We have all heard it. The stories, those patients that stay with you the rest of your career. The ones you never forget…you can be anywhere, doing anything, and BAM! An immediate recollection of the event. It is like a memory frozen in time that is destined to stay with you the rest of your life. I must admit I had not had mine yet. As a busy, task-oriented new graduate nurse with spankin’ new scrubs on (and a shiny pen light to boot) I was unaware of the fateful day I would encounter my moment. But then again, who is really ready when that moment strikes?

I was on top of things this day, I had my rooms prepped, my monitors ready for whatever may befall me. I looked over to the charge nurse desk, and saw a patient on a stretcher. Oh lord, I thought to myself, this one looks like a challenge. He was talking, more mumbling, and at first glance anyone could have mistaken him for just another guy who had had too good a time out on the town. Boy, was I wrong. “Put him in that room, room 20.” They were pointing to my assigned room. My breath quickened, I picked up my pace, and I steadied myself for my new patient.

“He’s responding, but just barely.” I looked at him; he looked like someone in crisis, not at all as he first appeared by the charge nurse desk. And I knew then we had to work quickly before he deteriorated even more. “I’m starting IV access.” My hands fumbling, shaking, I tried to keep his hand steady. I missed. The other nurse missed. Another nurse and a nursing assistant were getting the patient on the monitor and performing all other duties. I called for the code cart. “We need IV access…And quick.”

“I know,” I exclaimed, attempting to keep my calm despite a steady surge of butterflies and terror creeping up on me.

“Hey,” the other nurse looked me squarely in the eye and said one of the most haunting things I have ever heard. It was not so much what he said, but the way in which he said it that really struck home. “This guy is going to die.” I swallowed hard. This stirred in me more fight than anything. The attending physician and respiratory therapy were at bedside as we furiously wheeled him into the trauma bay. Multiple rounds of epinephrine, a failed pericardiocentesis, a chest tube, you name it. We couldn’t save him. In the end, we all settled on a brain bleed. The ultimate diagnosis: fatal and sudden bursting bilateral cerebral aneurysms.

Despite knowing we did everything we could—we worked as a team, we poured sweat and tears into this case—it was not enough. Perhaps his fate was sealed before he entered our ER. But, I still recall staring at his lifeless hands, hands that one time held coffee, high-fived a friend. He was in his 20s. I cried all the way home. Like a baby. The stress of the whole day just releasing into my steering wheel.

As a new graduate nurse in such a demanding environment, with equally demanding patients and tasks, I learned I can never get used to seeing a dead body. But I also learned I never want to get used to it. I try and treat every patient with as much respect and dignity as possible, and more often than not I choose to not know the backstory unless necessary. Death in an emergent setting can be harrowing, but there can also be moments of calm sadness, if not even serenity.

What Can a New Grad Do?

1. Breathe. My biggest advice: BREATHE. Really, you would be amazed at what an inhale and exhale can do for one’s nerves and clarity of thought. In retrospect, I know that as a new graduate nurse just the simple task of breathing in such stressful situations is immeasurably beneficial.

2. Decompress. Does nursing school prepare you for all of this? No. I say a silent prayer for each zipping of a body bag. It is hard to tell others of such morbidity, and to this end, self-care and decompression at the end of the day is both healthy and necessary.

3. Reflect. I think back to that situation often, and realize, more than anything, the worth of reflection in clinical practice—for improvement, for your own sanity. I personally like fitness or long walks, but it should be something fulfilling for both your body and soul.

4. Forgive Yourself. Fast, critical thinking is needed, split-second task performance, and impeccable teamwork. Will this always happen? Hopefully so, but honestly and unfortunately, it isn’t always possible. If this is the case, then learn to forgive yourself, and know that all your heart, effort, and knowledge were put into the case. After all, nursing is both an art and a science. And taking care of others is one of the most beautiful of arts.

And still, at the end of the day, I make sure to always try and reflect on two pivotal questions: Am I happy? Am I a good person? What are your answers? I know that as a nurse I am happy, and I know that I strive every day to be the best person I can be—for my patients, for their families, for my coworkers. As for the art that keeps on giving? Maybe it can be said that nurses are medicine’s Monets.