I will freely admit that I am bitterly cynical and despairing of seeing much good in most of mankind. But I am neither heartless nor hopeless. My night nurse job in the emergency vet clinic has shown me that again and again.
With only two people awake most of the night (the vet is usually asleep upstairs), we two nurses keep constant track of each other. The clinic is a large one and just about any kind of random shit could happen, from something as trivial as needing help holding a cat to get a temperature to a 9-1-1 call to the police to deal with a belligerent and possibly drug-addled client threatening physical violence to us. In other words, I know far too much about my colleague's bathroom habits ("gotta pee, be right back"). Still, most of the time the silence and the darkened rooms can easily lead you to feel that you are completely alone.
As a result, I am often caught by my co-workers chirping silly nonsense to animals as I perform this or that procedure: "okay, little bit, let's get this catheter sorted so we can go out for a walk"; "sorry, honey bunny, I've got to poke you in the bum"; "hold still, you crazed beast, I've got to shove this down your throat". I keep telling them, tease me as much as you want, I'm not going to stop. So, not heartless. We do the best we can for the weakest amongst us. And if silly chatter gets me there, well, piss off with the teasing.
The night nurse supervisor is scheduled to leave an hour before I do, so I bridge the gap between the night and the day ICU staff. Once the night supervisor rounds the day ICU supervisor on current patients, which also happens about the same time that the vet comes back downstairs, I alternate my focus between the day ICU nurse and the doctor.
It's my personal practice to complete pre-assigned patient care tasks first, then ask the day nurse or doctor how I can help them. I explicitly say, what can I do for you? They never turn this offer down. There is always something that needs to be done, some changes in treatment plans that need to be recorded and implemented, new blood to be drawn, additional drugs to be given. So, not hopeless. I know that they are going to have the best interests of the animal and client in mind. We are a team trying to make our tiny corner of the world a little better. If there is something I can do, then I need to do it.
In short, despite my personal curmudgeonly perspective, I try my best to support my team and to care for the animals in equal measure.
The clinic I work for is large and has many employees. The management of the clinic provides these slips of papers called "cookies". You can fill them out for any employee, describing some special thing that they did that you want to call special attention to. I have done so several times for one nurse in particular that has spent a lot of time training me. I thought we were supposed to slip them into the locked box labeled "cookies", which is what I did. Turns out another common practice is to give the filled-out slips to that employee, who can choose to put them in the locked box or not.
Here's a cookie recently given to me by a day ICU nurse whom I respect:
Okay, I have to admit, I'm a sucker for this. Of course more money in my paycheck would be better than a slip of paper. But to know directly from my co-worker that she finds me helpful certainly makes me feel invested and rewarded.
In other news, the other night I finally achieved my first successful hind-leg blood draw from the saphenous vein (scroll down for pics of the saphenous vein; the cephalic vein is usually where the IV catheter is placed). If you have a short-coated dog, you can see the saphenous vein crossing the outside of their hind leg just above their ankle (it's also there in cats, but harder to see unless you hold the vein off). Okay, it was a relatively calm Doberman bitch, so it wasn't like I could miss the damned thing. Still, I had tried this blood draw on three other dogs and failed. She was standing so the angle for the needle was a bit funky. Still, I got it in one poke! I was so pleased. Blood, beautiful venous blood!
One of my goals this summer is to learn how to set a catheter in an animal. Since I am at the mercy of the emergencies that come in, I may not achieve this goal. By that I mean that the physical condition and size of the animals that arrive at the clinic at night entirely dictate whether my experienced co-workers need to set the catheter while I hold the animal. I don't have the luxury of poking any animal in my attempts to learn. And that ideal animal or two might not walk in the door between now and the end of September.
Getting the catheter in the vein is only a small part of the process. I could write an entire post about all the things that can go wrong, and right, with this. But the catheter then has to be taped in place in such a way that it is secured to the animal's leg but the tape is not so tight that it constricts return blood flow from the limb (which leads to "mega-paw" when the paw swells up because the venous blood can't return and collects in it).
So I decided to start my learning process with the taping part. And I decided to practice on a banana. Laugh all you want, but it turned out to be a pretty good learning tool.
Here's a picture of my third taping effort:
Not great, but not horrible! We re-used the same catheter and T-port many times since there was not a concern about keeping things sterile--we were sticking it in a banana after all--and I just cut off the tape from previous attempts and started over. And over.
There are four pieces of tape on that banana. The first is the minimum point of attachment of the catheter to the limb. The second securely attaches it. The third is what my co-worker calls the "bra": it secures the T-port (the green thing sticking out is one of the ends of the T-port; it is inserted directly into the catheter). And the fourth creates a stress loop for the short T-port line that you can see looping over the top of the tape, so that if the animal pulls on its line, the stress loop should prevent it from pulling the T-port out entirely (the IV line will attach to the clear end of the T-port that you can see on the right). But as you learned from the previous post, this can happen even if the tape job is perfect but the animal is thrashing around with unusual vigor.
Not all clinics put a T-port in the catheter. You can hook the IV line directly into it. But this clinic puts T-ports in all catheters so that determines how I am learning to tape.
Taping a catheter has some basic rules and requirements but there are quite a few acceptable, and safe, individual variations. And as my co-worker pointed out, a giant wad of tape over the thing would probably work but it is not pretty or the best solution. Learning how to tape the catheter efficiently and with consistency means that even if you are no longer at work, the current animal care team knows what to expect.
I taped the catheter into the banana four times tonight. It was a mess. Tape sticking to me, to itself, to wrong parts of the banana. Fingers fumbling--do I use my left hand or my right hand for this? Oh, that piece is too short to wrap around like I intended. It was frustrating but I kept reminding myself, there will be a living creature on the other end of this. You need to learn how to do this right.
Sure, a banana is not close to the real thing, an animal that feels pain, that bleeds, that has hair (more things for the tape to stick to), that doesn't want to hold still. But if I can get even a little bit more comfortable with the taping part, then I will be ready when and if that perfect animal comes in the door.
In case you were wondering, I tossed the banana in the trash when I clocked out. Ew.
My apologies to the Fab Four.
WARNING: There are some upsetting photos at the end of this post. I am going to put them below a fold. But if you click through, you will be exposed to them.
My job as a night vet tech in the big ER vet clinic is proving to be challenging and rewarding in almost equal measures. Blood, feces, urine, vomit, survival, recovery, death, birth--it's a hell of a tapestry. I used to suffer from insomnia. Not this summer! I am asleep as soon as I become horizontal, sometimes even before then: the other afternoon I nodded off while playing a last game of baby with the dogs before we went to bed--they were not amused.
But don't let my whining mislead you--I am learning so many valuable things! Every night I am confronted with situations that require me to step up to the plate, that require me to act with compassion and confidence. Every night I get a little more confident that I can do that.
After
trying three times during the past several weeks to get blood from a
rear leg vein on three different dogs, and worrying that I had lost my
blood-drawing mojo, I did a jugular blood draw today on a small white
dog. One poke, pulled 2 mls, no hematoma, no bleeding afterwards. Little
white dog was sent back into his owners with only the faint whiff of
alcohol as evidence that anything happened.
Why would I mention the color of the dog? There is a commonly held "truth" in vet care that white dogs will inevitably be bleeders. Poke them and blood goes everywhere. I suspect it is nothing more than memory bias--even a tiny bit of blood can cover an amazingly large area in the right circumstances. It looks gory, really isn't. Plus the additional time spent in cleaning the dog up cements the memory. A smear of blood on a dark haired dog wouldn't even be noticed, thus not remembered.
It is absolutely true that
successful blood draws depend heavily on the skills of the person
holding the dog. The nurse I worked with tonight is experienced and
patient. She didn't rush me as I held off the vein then released the
pressure a couple of times to make absolutely sure I was going to poke
the right thing. Ninety-pound calves have jugulars the diameters of
pencils. Little white dogs have little jugular veins that are maybe 2-3 mm
in diameter. The vet hovering over my shoulder said, remember, all the
nerves are in the skin and muscles. Don't hesitate when you are ready!
Commit! And so I did. I think he was impressed.
One of the job hazards of working with animals is injury. We had a monthly nurse meeting this morning and I was looking around the room at all of the bruises and scratches and scrapes on everyone. I am not at all implying that my co-workers and I are careless. Quite the opposite. We learn to use a large number of techniques to restrain animals so that they aren't harmed but their teeth and claws are safely out of the way. Experience helps but it is no guarantee. Shit still happens even when everyone is prepared and doing all the right things.
On Monday night, I was helping a very experienced nurse get a temperature on a fractious little dog. She had a good hold on him, so I gently lifted his tail, said "poking!"(it's a courtesy to your colleague to let them know you are inserting a needle or thermometer or some other intrusive thing into the animal they are restraining; you never assume they can see what you are doing) and slipped the thermometer into his bum. He exploded, raking his rear claws down her arm. Blood was dripping off her elbow but she still didn't let go of him (very impressive). We put some gauze and vet wrap on her (works for dogs, works for us too), then she said to me, time for pup to get a nail trim. He was a little black dog and all his nails were black. Fortunately, trimming nails holds no mysteries for me. I clipped them all, including dewclaws, without a single bleeder.
I work in a place where it is not uncommon for the police to drop by without warning--bringing to the clinic dogs that were hit by cars and abandoned, still alive, by the road. Maybe the cop witnessed the incident, or saw the dog afterwards. It doesn't matter, really. We have stretchers hanging by the main exit doors for this purpose.
It certainly gives one pause to see a fully kitted-out policeman ringing the front door buzzer at 2am. There is almost never a happy ending to that story.
Tonight, we had two dogs hit by cars that were brought to us by the police. One will survive and will find a new home. The other, well, his back was broken and he had to be euthanized.
He had been knocked into a ditch and was wet, covered in moss and algae slime. He was cold and in shock. And despite the fact that we were preparing to euthanize him, my colleague got a large fleece blanket to cover him up for those 15 minutes it took to get everything ready.
If you were deeply cynical, you might say, why bother getting another blanket dirty for this dog. But if you work long enough with the folks who take care of our animal companions, you will see that this small act was not small at all. There were many layers of meaning to it: respect for the diminished and fading spark of life the dog still had, sadness at the way this dog had to end his run on this earth, a ritual acknowledgement of our role in the euthanasia, an action that might help reduce his pain and fright.
The other dog? Her owner was eventually found, and when he found out that she had already undergone treatment (she'd been hit by a car), he accused us of "ruining" his dog (Warning! Black humor ahead: 24-hour emergency clinic business plan: buy car, hit dog, have dog undergo many unnecessary procedures, make money! Yeah, I don't think so.). The Humane Society took legal ownership of her, covered all costs of her treatment, and she will be re-homed with someone who will love her.
Moral of both stories: my faith in humanity remains generally dim but I am honored to work with so many true-hearted people.
As I fumble about learning new skills at the vet clinic, I make mistakes. Thankfully, none of them so far have been irreversible.
I hold bottles of drugs up next to doctor instructions, double checking the name (I have to learn the drug name, the commercial name, and the shorthand name because different doctors and nurses use different names). I double check the amount I need to pull, pull it into a syringe, then double check that ("measure twice, cut once" applies here). Many of the injectable drugs that we regularly use for pain relief or sedation can kill an animal just as well as they relieve pain or sedate if given in the wrong dose. When I have to calculate the milliliters of drug that I need, I write the calculation on the back of the care flow sheet so that if questions come up later, I can "show my work." Mistakes in these tasks would not be irreversible.
The night nurses have to round with the day nurses at the shift change (7am). Almost every morning, the day nurse calls me out on something I did during the night but didn't record properly on the flow sheet, or points out that I failed to complete something that needed to be done, like get a couple of blood pressure readings or weigh the animal.
Part of learning is making mistakes. I learn quickly, I learn best by doing, not watching. And I own my mistakes. I apologize if that is necessary, correct the problem if I can, but always, always, I admit that I made an error. I also say, it won't happen again, and I make sure that it doesn't.
In fact, I turned my learning curve into a bit of a running joke: if something goes afoul, I'm almost certainly responsible for it. That sort of backfired because then I started getting blamed for all kinds of canine flatulence and dead batteries and paper cuts and other random things. It was all in jest, and I'm glad my co-workers think it's okay to tease me, but the jokes increased my worry that I was hindering more than helping.
To my complete surprise, the nurse that I've worked with the longest told me tonight that she really enjoys working with me, and that while I say that I know nothing, she thinks that I actually do know a lot. I found myself almost getting teary. I thanked her for telling me, told her that it meant a lot to me that she said that, and continued loading more piss-soaked and bloody towels into the washing machine (I wear gloves when handling the laundry).
