andSicker

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2012-01-18T19:15:00.001-05:00

Core Course

2011-11-23T20:56:00.001-05:00

We had our "Core Course" last month, nurses and nursing students from all over came to our office to hear us lecture on various topics. I attended the core course as an audience member last year, as a new hire, and now I'm presenting every six months! Here's my first attempt, a lecture on pain and symptom management:

The presenter immediately before me was one of my heroes, an inspiring nurse who got me interested in Hospice care when she came to the nursing home I was working at as a consultant. Here's her presentation:

One of the best things about working for this agency is the chance to work alongside nurses who have inspired me early in my career. I'm proud to follow in her footsteps.

HEENT partial exam

2011-11-19T11:10:00.000-05:00

2011-10-29T13:03:00.001-04:00

Still kickin

2011-10-26T00:28:00.001-04:00

2011-10-09T00:35:00.002-04:00

After Work

2011-09-23T15:07:00.001-04:00

17-18

2011-08-06T01:08:00.000-04:00

After Work 5-10

2011-07-24T15:55:00.000-04:00

After Work episode 4

2011-06-27T12:13:00.001-04:00

After Work, episodes 1-3

2011-06-27T10:57:00.000-04:00

Fun with distance learning

2011-04-22T20:27:00.000-04:00

Classes haven't started yet, but they've opened up the discussion forums so we can practice posting threads, introducing ourselves and asking simple questions. I've put way more thought into this than I need to, because..well, for no reason, I just felt like typing a lot. Very rapidly. Here's one of my posts, in the response to a question (which I'm paraphrasing) "How do you find good sources for your papers?"

Ah, an interesting question. Whom to believe? Wikipedia is too malleable to be used for anything but a tertiary resource (even though it's more accurate than most encyclopedias and is a useful jumping-off point for research). Some meta-researchers contend that a high percentage of peer-reviewed scientific journals are bunk, and a computer science student even procedurally generated a fake article that passed the peer-review process. The peer-review process is often used as a cudgel for political or monetary gain, sacrificing accuracy for profit. There are inklings of a successor to the peer-review process, however the current system is so established it's only fraying at the edges instead of imploding. There's no incentive to change the system if it means a drug company can bribe their way into scientific "fact" through the peer review process.

Ok, so I'm ranting a little. Back to the question: Whom do you trust? It's not clear that there is any source that is authoritative, only sources that are commonly agreed upon: The "True Enough", as Wittgenstein was fond of saying to his students. It seems as though Meta-analysis is increasingly necessary to determine the quality of the information we consume. A simple fact presented to us may be checked and cross-checked, however the possibility always remains that the original source was wrong to begin with, and the other sources are merely repeating the error. Teasing apart this tangled web of intention and meaning often requires collaboration, and "the more, the merrier". Through discussion and collaborative comparison of sources we can often expose ourselves to understanding that's off the beaten path.

I humbly offer these options as possible starting-points for where that collaborative process is taking place on the Web (in no particular order - not an exhaustive list - please consult your dermatologist).

PloS one

Metafilter

Atmospheric Chemistry and Physics

arXiv

media commons

Back to School

2011-03-28T15:32:00.003-04:00

Well, here I am, 2+ years into my career, and I'm back to school!

I've just been accepted to Sacred Heart University, where I plan to obtain an MSN with focus in Clinical Nursing Leadership. It's an online degree program, which should help with balancing school and work. My classes start at the end of April. I considered University of Phoenix online, but they didn't have the degree program I wanted. I liked the 5-week classes and no multiple choice testing they offered, but when it came down to it, SHU had the degree I wanted and U of P didn't.

I decided on the Clinical Nursing Leadership track partially by process of elimination. My goal is to generalize while advancing my education, a goal that many elder nurses advised me is too difficult to do in this profession. Fortunately, I'm stubborn.

I considered the APRN track, but with the entry-to-practice being raised to the Doctoral level, the CNL track will give me a solid basis for Doctoral study while opening up new roles and new challenges.

I considered the Nursing Informatics track that was suggested to me by my clinical faculty during my RN training, but I'm firmly rooted in patient care. I ran away running and screaming from software development when I abandoned Computer Science Engineering. I may come back to this one later.

All the MSN tracks enable me to teach nursing at a University, something I'm interested in doing farther down the line.

Clinical Nurse Specialist appeals to me, however my mind balks at the thought of specializing in something. The Clinical Nursing Leadership is a good compromise where I obtain a Masters level preparation in general bedside care. Rock. The novelty of the role (only developed 5 or 6 years ago by the AACN) played a factor as well, it's exciting to think I'll be helping shape a new Nursing role.

Once I've finished the CNL track, it'll be interesting to see where my interests lie for the next degree acquisition. DNP is the obvious choice, and the one I'll most likely go for first. SHU also offers an interesting online degree in Applied Psychology with a focus in Organizational/Institutional psychology which is also worth considering. Doubling-back post-grad and scooping up a Nursing Informatics degree might be fun, too. My CSE background would definitely come in handy, and it's quite a rare specialization.

I spoke with my academic advisor for the first time today, and it's the first time I spoke to a PhD Nurse. It was a delightful conversation in which we discussed philosophy and nursing practice, and sketched out a plan of study. We connected over the fact that we've both worked in home Hospice, which I found encouraging. I plan on doubling up on some of the easier classes, and my prior academic excursions knocked out a good chunk of the required classes already. No Math, Writing, Public Speaking, Social "Sciences", Bioethics, History or Humanities for this non-traditional student. I'm amused that I'll be required to take classes on Religion ("particularly the Catholic Intellectual Tradition" pops up a few times in the course descriptions). I briefly considered trying to get out of it by mentioning that I'm an ordained minister of the Universal Life Church, but I decided not to tempt fate.

I banked enough money working overtime to take it easy this past month, picking up a Hospice shift here or there but not stressing myself out with crisis or office politics. One of the bands I'm in, Above/Below is up for a Whalie award! The awards show is in May, the day before my Birthday. You can vote for us at WailingCity.com, vote for us! We'll be playing at the awards show and at the afterparty at my favorite pub. If you're curious, check us out on bandcamp, where we briefly topped the charts for Hip-Hop (think The Roots).

Aside from Music I've been slowly getting back into Aikido, which I had to briefly abandon because of working so much overtime. I got one of my friends hooked on it, and he graciously got ME back into it after being away from the dojo for months. My re-entry to the traditional combination of Zazen, Body arts, Iaido (traditional japanese sword-drawing, striking, cleaning and resheathing) and organic farming (yes, you read that right) started with a wonderful seminar that featured senseis from all over the country. Here's a sample video:

Time Off

2011-01-21T17:26:00.000-05:00

Learning how to say "no" to extra shifts when you're already overworked is a skill that I'm still developing. Currently, my limit seems to be 13 days in a row. It's difficult when the job is perceived to be my activity of choice, favored above most other activities. The joy of working masks the insidious creep of fatigue into nursing practice.

Today is my second day off in a row, the first two days I've had off since I returned from Paris. Oh, by the way, I went to Paris, here's a pic of me at the Eiffel Tower:

Public pics Here, Here, Here, and the Louvre Here and Here.

I also took some videos:

The day I got off the plane, I spent the next 14 days in a row at the nursing home. From now on, I'm going to try to stop at 13.

I never know what to do with myself on my days off, hopefully I'll eventually have a regular work schedule (after two years of practicing) which should help that somewhat.

So, here are some of the things I've been doing on my down-time:

Music is usually Number One, even though I rarely listen to or keep up with music nowadays (same with movies, a spiritual sacrifice to mirror a greater loss). One of the bands I'm involved with, Above/Below, just finished recording an EP, and a music video is in the works, due to be finished by the end of this month. You can check out our album on Bandcamp, where we briefly -TOPPED- the hip-hop charts. Obligatory Facebook Link.

Shooting the music video was lots of fun, since the band members are scattered across the country until summertime, we shot footage from our respective locations (including some video of me in Paris). I'm excited to see how it'll turn out.

Video games are still a major passtime for me, after shunning them almost completely during nursing school. Starcraft 2 is still currently my major time-sink.

Riveting, I know.

The only thing I haven't caught up with yet that I'm planning on is Aikido. Working unpredictable shifts and staying late at work make a regular 3 days/week training cycle difficult to work out, especially when you're expected to "call out" of a training session as you would a work shift. I put a good 1.5-2 years into it and plan to continue, but not until I can devote regular time to it.

So how to make the best use of my time off? Sometimes I feel as though I should just do nothing at all. Inactivity is the best salve for a busy week, maybe.

On the other hand, the clock is ticking, and I want to get started on my Master of Nursing Science degree. Picking through the different specialties is tricky, though. Nursing Informatics is an obvious fit, and more attractive because of the low number of people holding that degree in the states, but this would take me farther away from patient care. APRN sounds like fun, but now that they've bumped up the entry-to-practice to the DNP degree, that sounds more like something to pursue -after- getting my Masters. Going to school online has some obvious advantages, but the online programs don't always have the specialties I want. I'd much rather -generalize-, but you know how that is.

My recent 1.5 week stint in Paris has made me resolve to travel more often, maybe twice a year. It was the first time I'd been out of the country in about 3 years, I could do with another vacation like that twice a year. Where to next? Arizona? The Netherlands? New Zealand? I dunno. Doesn't really matter.

Paris

2010-12-25T20:33:00.003-05:00

My room is full of backpacks, messenger bags, duffel bags, matching luggage, tote bags and cases and pouches for things. This has nothing to do with the fact that I'm getting on a plane tomorrow, they've been there for ages. Two of the bags have my travel things, selected from the heap mostly on the basis of current level of cleanliness, memetic or otherwise. The rest are sometimes full, mostly empty, like burned out shells of previous trips.

It'll be weird to not work for so long, probably the most time I've taken off at once since I got my Nursing license. Even during vacation I'm sure I won't be able to help calling in once or twice to see how everyone's doing.

Work has long been my favorite place to be, as surprising as that might sound. With two options for picking up shifts (Hospice in addition to supervising in a nursing home) i've been able to get lots of hours in consistently.

After two years, working as an RN still seems more fun to me than any of the other things around me to do. Maybe fun is the wrong word...it's tolerable. More tolerable to me than the times when I'm not at work. That might sound pathological to some people but to me it just feels like being home.

Home used to be a person, to me..now it's a whole host of people. It's as if years of isolation, estrangement, misunderstanding and doubt were stripped away in the swirling chaos of The Job. The never ending drama of life and death, catastrophe and resolution. Integrity and Despair.

The Job is nearly impossible unless you consider the situation from the patient's point of view. When there's nearly 40 of them you have to consider, no amount of three ring binders or photocopies are going to help you actually understand what's going on with those people. The barriers that people face in their illness or decline can't always be "care-planned" for. Just the simple logistics of the basic care needs for these 40 people is a worthy game in itself, and then the efforts and behavior of subordinates come into play. Complexity upon complexity. Attempting to see one facility simultaneously from the point of view of scores of people sounds like an insane thing to attempt but it's fairly easy to do with the appropriate training. It's hard to do -all- the time, of course, but it's an endeavor that seems like more play than work.

The information involved with The Job could easily fill thousands of 8 1/2"x11" pieces of paper, even more of the documentation is electronic. Every assessment, action, observation, measurement and notation expand exponentially, warped through the lens of billing and insurance. Sometimes it's like some kind of dante's inferno for clerical workers. Keep up with your paperwork while someone's (your, our) grandmother or grandfather is dying in the next room.

To fulfill obscene documentation requirements AND take what you would professionally call "good care" of someone, it's easy to imagine that the job involves a lot of hurry and rushing around. Oddly enough sometimes just offering your time to one of the patients and really talking to them can save you HOURS of work in the coming months. A little planning, care, and thinking ahead (creatively) can save you -effort- as well as time. When it gets to the point where you're -really- on top of things the experience is almost serene, the inevitable emergencies and dilemmas are easy to deal with when everything -else- is in order. One of my mentors back in school told me a story about working on a psych nursing unit, where there would be one person in particular that would rile everyone else up, unless this nurse took an hour out of her busy day to take him aside into a therapy room where he could shout and hit the table all he wanted to, and then the rest of the day was more manageable. Psych's a different milieu, of course, but the idea still holds.

I probably never would have just decided to nip off and flee the continent for a few weeks on my own, but it's probably for the best that I am. Best cure for the holiday blues, surely, is to pack up and exhaust the mind and body with travel. Drown out the memories of holidays past, letters you keep meaning to write, a glimpse of a familiar face walking down the street. Travelling is often fun in the same way Nursing is fun, it's a suitable challenge to the info-maniac pattern-matcher who's bored with anything that can be easily explained or summarized. A perfect distraction for the chronically distracted. In both, sometimes there are quiet moments when there's nothing possible that you can do, and all that's left is to sit and watch. Bask in the sheer improbability of a passing tide of travelers, what a privilege it is to witness this one unique slice on their march towards entropy. A people-watcher's paradise, whether you're watching many people briefly or watching a few very closely and bringing all of your powers of observation to bear in order to make accurate assessments. On a day when everything goes well, everyone works hard and it all falls into place, sometimes there's nothing left for me to do during those last few minutes of my shift. No forms to fill out, no ambulances to greet, just a quiet sit at the nurse's station, staring silently through the front door, listening to the discordant chimes of tragically meaningless alarms. In situations like these I'd only be getting in the staff's way if I hurried around poking my nose in everything. Everyone looks good, all the work is done, all that's left is to greet the next shift when they walk through the door.

Whether I'm home, or travelling, or at work, the place is always the same. Semi-unpacked from a return trip never made. Always at home, and home always slightly out of reach. My aim is the same as it had been, all those years ago, even as far away as it is now. Maybe over the years, they say, and it's too long still, for lives so short and fragile.

Maybe the forces that fling us across continents and augment our memories with overlays and storage devices will somehow let us meet again.

wildlife

2010-12-05T23:04:00.001-05:00

On Sun, Dec 5, 2010 at 11:01 PM, Mail Delivery Subsystem wrote:
> Delivery to the following recipient failed permanently:
>
> google@google.com
>
> Technical details of permanent failure:
> Google tried to deliver your message, but it was rejected by the recipient domain. We recommend contacting the other email provider for further information about the cause of this error. The error that the other server returned was: 550 550 5.2.1 ... Mailbox disabled for this recipient (state 14).
>
> ----- Original message -----
>
> MIME-Version: 1.0
> Received: by 10.151.38.9 with SMTP id q9mr8463566ybj.222.1291608102668; Sun,
> 05 Dec 2010 20:01:42 -0800 (PST)
> Received: by 10.236.109.164 with HTTP; Sun, 5 Dec 2010 20:01:42 -0800 (PST)
> Date: Sun, 5 Dec 2010 23:01:42 -0500
> Message-ID:
> Subject: wildlife
> From: Patrick Murphy
> To: google@google.com
> Content-Type: text/plain; charset=ISO-8859-1
>
> you are breeding totally rad wildlife. I can't wait to see what it can do.
>

Last regrets

2010-08-29T19:36:00.004-04:00

In desperate hope I go and search for her in all the
corners of my room; I find her not.
My house is small and what once has gone from it
can never be regained.
But infinite is thy mansion, my lord, and seeking her
I have come to thy door.
I stand under the golden canopy of thine evening sky
and I lift my eager eyes to thy face.
I have come to the brink of eternity from which
nothing can vanish-no hope, no happiness, no vision
of a face seen through tears.
Oh, dip my emptied life into the ocean, plunge it
into the deepest fullness. Let me for once feel that lost
sweet touch in the allness of the universe.
Tagore, from Gitanjali, LXXXVII

I recently took a second job as a Hospice RN. It's a relief to have a proper orientation finally, skills are reviewed, discussions are scheduled with members of the interdisciplinary team. The quote above is from Dr. Elisabeth Kubler-Ross' book "On Death and Dying". An ancient, battered copy was brought to me by one of the administrators after I mentioned trying to borrow a copy from a friend, which then been lost in a move or something.

A lot of my time now is spent following established Hospice nurses on routine and initial visits during the day, while maintaining my Charge Nurse position at the nursing home. I've had many sixteen-hour days in the past week between the two jobs, but the sustained activity is easy to bear when the work is intellectually stimulating and meaningful.

When I tell people in conversation that I've begun working as a Hospice nurse, there have been basically two types of reactions. Often, people immediately begin sharing their own experiences with death and dying. Some people talk about how great the care provided for their loved ones were, or how beautiful the facility was. Some stories relate experiences of caring for a loved one at home. In almost all cases, the story ends with what was most helpful in achieving acceptance or closure.

Alternately, many people react with a darkened expression and something like "I could never do that" or "People must get burned-out fast from that" or "what a depressing job".

Although I'm still getting to know my new colleagues, it already seems as though nothing could be further from the truth. True, it's work that involves a fair bit of crisis, but the same could be said for my nursing home work. The folks I've started to get to know through Hospice are some of the most well-adjusted, philosophical and peer-supportive Nurses I've met in my career so far. This was one of the major factors in deciding to apply where I did, I met some of the Hospice Nurses that would come into our nursing home to consult on some of our residents, many of whom I had developed an appreciation of/closeness to.

The few shadowing experiences I've had so far have bolstered my confidence. Support from social workers, clergy and fellow RNs is never farther than a phone-call away, and the solid skills I've developed in the nursing home give me confidence that I can walk into any situation and provide whatever care is necessary in the moment, be it a foley catheter, incontinence care or a total bed change for a bedridden patient. A quiet presence or a detailed explanation as the needs of patients and families dictate.

Careful management of nursing home residents has taught me to assess people thoroughly and systematically. A lack of pre-established routines or protocols (or orientation or structured training) forced me to develop my own habits and techniques and critically analyze them later. This probably isn't a mode that is well-suited to all new RNs, and it certainly had it's drawbacks, but after two years of developing my Nursing practice and then stepping into a totally different setting, I have the feeling that I'm no longer a Beginner. Perhaps a decade or more away from being able to call myself an "expert", but a Beginner no more.

Knowledge of and comfort with specific procedures is important, of course, a practiced hand can make the difference between incontinence care and a total bed-change being either a great relief or vastly unpleasant. Beyond the simple neuromuscular familiarity with the tasks, however, lies a much deeper and interesting competency to attain. Learning to evaluate situations holistically and coming up with therapeutic responses to suffering or anxiety is a major part of what I see as the real "core" of nursing practice. The "little extra things" aren't little, or extra, or even things, but rather key elements in delivering care therapeutically. It's necessary to be present. It's the simplest thing in the world, and so often absent in the care of the infirm or seriously ill.

When people comment on how depressing they perceive my jobs to be, I often compare End of Life care to Labor and Delivery. I was pleasantly surprised to see this position expounded in great detail in Kubler-Ross' book. It first came to me that folks with dementia seem to step backwards (in order) through previous developmental stages and polarities, until a time is reached where nothing is expected of the person, and everything they need is provided to them (hopefully).

Care for people who are in this condition provides a special challenge to new and experienced Nurses alike. On the most basic level, in the absence of the ability to communicate functionally, competent care for the patient relies heavily on assessment and observation skills as well as a level of critical thinking that may not be routinely employed in the case of someone who can share with you the location and quality of their pain or how their stomach's feeling. The real challenge, however, involves compassion and the preservation of dignity. This is the area in which the Nurse's role of Advocate is all-important, a subtle mode that is usually instantly perceivable to family members but even more important in the care of someone with no family and no visitors.

My only regret, perhaps the last regret I'll ever have, is that I didn't reach this level of awareness three years sooner.

esprit de escalier

2010-06-17T22:39:00.003-04:00

The title is French for "spirit of the staircase" or "staircase wit", an idiom for the experience of suddenly realizing what the best thing to say/do was, after the event had already happened.

I experience this a lot after work, and even more frequently when I'm working long hours and/or having my sleep cycle disrupted. The solutions to many of the unsolved mysteries or loose ends from the shift all drift into focus after a couple of hours to decompress and unwind. The best thing to have said in this situation, the technique I should have used for that, and maybe 5-10 things to follow up on and re-evaluate the next day. I had good luck with carrying a small moleskin notebook and jotting down things I have to keep track of. I've never taken notes in my life before this job. Middle-school, high-school, engineering school and nursing school. I graduated from three of those. Nothing about the act of taking a class really required me to write down the things on the power-point slides or the passage read to me from something. That information is in your hand-out, ma'am. Do you want me to read your hand-out or pay attention to your presentation?

I write this stuff down, though. It's actually stretched the limit of how many things I can keep track of at once, an experience I've always associated more with video games than employment. The pages of these little black books get plastered with sticky-notes, nure-to-nurse reports from hospitals, lists of issues to bring up with the MD, particular risk areas or factors, things to follow up on, etc. I've lost three or four of the notebooks in the space of a couple of months. At least one was the victim of our ravenous black lab puppy, Jenny. The rest are probably hidden under some hidden cache of laundry somewhere in this room.

Today I went without the notebook, instead opting for the nursing report sheet. Stapled-together 8.5x11" pieces of paper just aren't quite as portable as a little notebook, maybe I just need bigger pockets.

The fact that the information is so holistic and varied is what makes it interesting to me. Information about skin integrity and GI/GU status just as important as subtle interpersonal relationships between patients, family and staff. Expectation management. Closing. Interdepartmental communication. See, you can even leverage commissioned sales and engineering into a nursing career! You should really consider it, we could use all we can get.

Anyway, the notebook also was used to jot down those ideas that came after work was through, I probably used it that way more than any other if you don't count the disproportional amount of space sticky-notes take up.

I bought notebooks for years without ever writing anything in them. It's probably an appalling habit if you think about it. Lots of different notebooks in different shapes and sizes, different style covers. A considerable amount of money was probably spent, all on notebooks that I'd never use more than a page or three out of. A full notebook seems to have no value to me, since you can't add to it anymore. Reference, what's that?

Lots of the things I jotted down I'll still remember days or even weeks later, not a mean feat for someone who usually has trouble keeping track of what day or time it is. The actual writing is just a back-up, the act of writing, I suppose, is the key.

My hand-writing is hilariously bad. I think I'm more readable than people who scribble in cursive, but more often than not my spidery, frenetic block-printing reminds people of their children and leaves them scratching their heads. Spending so much of my life in front of a keyboard and then suddenly being forced to manually write LOTS of IMPORTANT THINGS nearly ALL THE TIME is an amusing switch. My signature has warped delightfully over the years, many of those years not having signed anything at all.

I guess I found a job that just seems easy, even when it's difficult. Remembering the families and medical conditions of dozens of people sounds absurd unless you consider the effect of actually being interested in them and caring about them. This is actually a pretty easy thing for anyone to convince themselves of, with a little practice. After all, who controls what's important to you? Is it you or some movie you watched? Your bad day? Your car problems?

The ability to be present in our profession seems so fundamental but can also be a challenge to maintain in the face of such a complex data set. Intuition becomes a vital necessity, even though it takes years to develop in these settings. I enjoy the interrelationship between rational and intuitive that this profession has presented me with.

I've been on the staircase, but I'm walking slow, listening for you.

Nursing homes are interesting, after all.

2010-04-26T10:10:00.004-04:00

BRIDGEPORT, Conn. (AP) The former chief executive of a Connecticut nursing home has been sentenced to a year in prison for using money intended for the homes to buy real estate.
Raymond Termini, former CEO of Haven Health, was sentenced Tuesday to 12 months and a day in prison and a $6,000 fine. Prosecutors say he also has to forfeit $500,000.

Wow. Nursing homes can be pretty exciting places, huh?

The intrigue. The politics! The ever-present human drama unfolding. The unending labor, whether laboring for breath or laboring for pay.

Fortunately, the inevitable chaos of a busy nursing unit is finally starting to make sense to me. Something that can be controlled, or at least surfed.

It's a lot to keep track of at once. I can't go to sleep right after a shift, because there's too much to process. Even now, I've just worked a 12 hour shift that lasted about 14 hours, and I'm still fighting the urge to call back and add some random piece of info I suddenly thought might be useful.

At times like this I have to remind myself that we work in shifts for a reason. The next shift coming on can handle whatever happens next.

The main bottleneck seems to come down to how information is stored and retrieved. It sounds like such a ludicrous problem to have, to spend hours producing or reproducing minuscule amounts of data. Let's call it 8-64 bits per second. Copying down intake and output into multiple redundant binders, writing terse nursing notes, signing your initials hundreds of times. Let's say between the actual writing and checking the things you're writing from and to, I'm going to guess a bits-per-second rate of 8 to 64 (a bit is a 1 or a 0, and 8 bits make up one letter like "Y" or "s" or "." ).

Verbal report sounds like it contains about 16 thousand bits-per-second worth of info.

My internet connection is somewhere around 6.76 million bits-per-second.

I suppose the bandwidth isn't as important as how the data is related to itself and it's owners. Oh, how I yearn for a relational database! A touch of SQL or even Access.

No matter how faithfully and reproducibly information is stored and retrieved, however, the human element is most important. The right way to calm down an anxious co-worker or resident isn't always easily explained or reproduced.

The things that can't be easily explained, however, we still manage to communicate. We are, after all, Nurses.

and we work in shifts.

Informatics of Nursing Education

2010-04-17T03:55:00.003-04:00

Instead of raising your hand to ask a lecturer a question, why not press a button?

Why not put a screen on that button so it tells you how many people pressed their buttons first? Say you had only four people sharing one of these buttons. Two people might press the button one after another, then two numbers would be displayed. Add a second button to cancel the most recent button-press. Put microphones in all the buttons so everyone can be heard.

That would have been a nice lecture to have.

The anachronism that is Paper Charting continues to gnaw at me. The more I understand what's going on around me in a paper charting environment, the clearer it is to me that huge swaths of our time is being wasted in fools' errands. The worst part about it, to me, is that the charting isn't even fulfilling it's purpose. Conveying information. The charting of most healthcare institutions I've seen is more concerned with how to get reimbursements than conveying information in a useful and meaningful way.

I daydream, sometimes, about what an electronic charting tool for CNAs, LPNs and RNs in a skilled nursing facility might look like on a spiffy linux based tablet like the german-engineered wepad.

Nurses seem to be a pretty technophobic bunch, but many of them deftly use facebook, for example.

User Interface Design seems like a wholly foreign concept to the developers of most of the information technology I've seen in educational and healthcare institutions. Menus made up of laundry lists of nonsense and irrational depth, unintuitive layouts, it's like they aren't trying. Your fancy multi-million dollar computerized charting system is worthless if it's unintuitive and frustrating. More frustrating than, say, a piece of paper and a pen.

I struggle on with paper charting, since I'm not too optimistic that whatever electronic charting tool I'm handed will fail to infuriate me.

We have a computer at our desk, that's the thing that kills me the most. A computer none of us use. It's not that great, but even a low-end computer from a few years ago is light-years beyond what the old room-sized punch-card computers could do.

I'm not trying to crack the atom here, this is really simple.

For each person:
-What went into them?
-What came out of them?
-How are they feeling?
-What can they do?
-What did you do for them?

The CNA interface could just be icons. Tasks can be organized and presented for quick reference, signed by the person that completed them. Punch in that 120ml glass of water on the spot, no need to remember or "guestimate" what percentage of their meal so-and-so ate. Just tap it in while you're there. Signing off on when different types of care are performed also provides valuable information to anyone interested in bowl-and-bladder issues, sleep&rest, etc.

The floor nurse's view contains all the CNA info along with med-administration and treatment info. Instead of a huge 3-ring binder of flip-cards to initial, why not just a list of what needs to be done, and when it needs to be done by? Add to it a feed of the CNA's activities and the floor nurse knows right away if someone's been using the bathroom more often than usual or is suddenly incontinent when they weren't before. While they're at it, they can add the 120ml of water THEY gave the resident along with their meds. Info goes to the same place. Most importantly, maybe, current orders regarding activity and precaution are presented uniformly, universally, and changes are instantaneous. Better still, recent labs, consult reports and therapy progress notes could be referred to at any time. Medication orders would update automatically, without errors in transcription or comprehension.

The nursing supervisor would have all of the same info as the first two views, but with expanded options for managing workflow and staff scheduling, as well as a running list of all issues everyone in the unit is currently having, and what kind of help people need. Let's say someone gets tied up in an emergency, and hasn't gotten around to getting someone's blood-sugar or giving them their IV antibiotic. If there's already crap going on, who has time to run around looking for help?

There's an easier way, and we could probably put it together from scrap parts cheaper than our pulse oximeter.

This issue may be central to the future of the nursing profession. If we can't organize ourselves well enough to train new nurses quickly enough, more and more of the functions of the nursing profession will be ceded to unlicensed technicians with specialized functions.

I say specialization is for insects!

The Killing Spree that Wasn't

2010-04-12T22:20:00.003-04:00

A Dutch nurse given life for murdering seven people in a killing spree that never happened will hear about her appeal on Wednesday.

Moral of the story: Don't multiply your p-values.

The statistical analysis is a rather interesting read, even though the math's a little over my head. Basically, a Dutch nurse got convicted for killing patients just because a lot of deaths happened while they were working. From the paper:

4 Appendix: extended discussion of hetero-
geneity
4.1 Preliminary remarks
The null-hypothesis tested by the court statistician H. El ers in the case of Lucia de
Berk is supposed to mean that incidents on a ward, and shifts of a particular nurse,
are independent of one another. In the minds of lawyers or medical specialists, as in
that of the man in the street, independence means: lack of causality. Causality can
be \measured" by performing the thought experiment: suppose that Lucia worked
on a particular shift, and that an incident occurred: would the same incident have
happened if Lucia had been magically exchanged for another nurse? The idea in
this thought experiment is that \everything else that might be relevant is kept
the same", so that we compare strictly comparable situations: with and without
Lucia, everything else being unaltered. In a randomized double-blind clinical trial
we do keep everything relevant the same, by randomization. In observational
studies we are unable to do this, so instead we are forced to take explicit account
of anything which could be relevant, in one way or another, if we want to conclude
causality. This requires prior knowledge concerning the mechanisms underlying
the phenomenon under study.
4.2 Are nurses interchangeable?
According to many medical specialists we have spoken to, nurses are indeed com-
pletely interchangeable with respect to the occurrence of medical emergencies
among their patients: nurses merely carry out the instructions given to them
by the medical sta , and they do this according to standard practices of proper
care, so it can make no di erence at all to replace one nurse by another. However
according to nursing sta we have consulted, this is not the case at all. Di erent
nurses have di erent styles and di erent personalities, and this can and does have
a medical impact on the state of their patients. Especially regarding care of the
dying, it is folk knowledge that terminally ill persons tend to die preferentially
on the shifts of those nurses with whom they feel more comfortable. (This might
apply to the Red Cross Hospital, where Lucia worked on two adjacent wards for
terminally ill aged patients). As far as we know there has been no statistical
research on this phenomenon.
4.3 De nition of incidents
There is another respect in which nurses can have an impact on \incidents". In
the Lucia case, incidents were never formally de ned. However, if medical doctors
were expressly called to the bed of the patient by nursing staff , then that soon
quali ed as an incident, especially if Lucia was somehow involved. Who decides if
the doctors should be alerted? The nurses on duty, themselves, of course. It seems
that several of Lucia's incidents were created by herself in situations where she was
uneasy about the patient who appeared to be developing some new and, to her,
alarming symptoms. The nurse who keeps a closer eye on her patients, and who is
less prepared to take risks, will generate in this way incidents on her shift, which
otherwise might be postponed to the next shift or even fail to materialise at all.
According to medical specialists, nurses do not have a choice in such situations:
they have been trained to make the right decision and every nurse in the same
situation will make the same decision. According to nurses however, this is just
not true. Nurses do have to make their own decisions and though they should
always be able to justify their choices, this does not mean that every individual
will make the same choice in the same circumstances.

Wow, statistics is some heavy stuff, huh? Almost makes me excited to study it again in grad school (almost).

Even the Dutch state prosecution now accepts Lucia should be acquitted and there was no evidence of any unnatural deaths, though her convictions for stealing two books from the hospital library – a charge she denies – will be upheld. Now living with her partner while awaiting judgment, Lucia is penniless, denied benefits, and paralysed down one side following a stroke she had in 2006 in the week she was told her conviction would be upheld.

All because of a math error.

You might remember the Cat who predicted deaths in an RI nursing home. I haven't heard anyone seriously suggest the cat was killing the patients.

Work last week was full of action and excitement! It was one of the busiest weeks I'd seen in a while, and I was filling in for the day-shift supervisor. It was the kind of challenge I enjoy, lots of things to do and keep track of. Around 30 elders to keep track of, with two hip-height racks of charts to manage. MD appointments, changes in condition, changes in skin, changes in wounds, sudden changes of vertical status (if we're unlucky), charts to audit, phone-tag with various MDs, labs pouring off the fax machine, face-time with family members, staff issues to work out..there's no time to be bored! Thankfully the staff I work with are all great. Those of us that are left have been through a lot with each-other and I always look forward to seeing them, even the ones I don't always agree with.

Even better, the student nurses were there for two days out of the week. Having them around has been lots of fun and has given me plenty of opportunities to reflect on my own practice as a Nurse. It's also loads of fun having extra people around to help me look stuff up and collect samples, as well as ambulating and transferring people. The sheer logistics involved in moving what seems like a small number of bodies around can get pretty intense.

I had so much fun last week that the prospect of taking this next week off is daunting. I probably should have planned a trip or something, but I couldn't think of anywhere to go.

In my idleness I've been pondering my options for grad-school. The more I work in an environment without electronic charting the more interested I am in Nursing Informatics, especially considering the extremely small number of RNs who currently hold that degree. I've been prototyping in my head what I would want an electronic charting tool for a nursing home to look like, tablet PCs with icon interfaces to add I/Os, vitals and med administration, different views for CNAs, Floor nurses and nursing supervisors, integrated inventory management, etc. I think I may save that for post-grad, though, I'm more interested in bedside nursing at the moment.

I'm browsing through the list of masters degrees in nursing offered at University of Phoenix. Strangely enough they've reversed which courses appear on the Masters of Health Care Administration and Masters of Science in Nursing pages, but I figured it out after clicking around a little bit. The graduate degree I was looking for wasn't in the list (Clinical Nurse Leadership), but Nursing Informatics is. Also, staggeringly, a dual MSN/MBA program. The also have Family Nurse Practitioner up there, but I'm not sure I like the idea of working in a doctor's office. The fluorescent lighting gets to me. Anyway, I sent off a request for some info, We'll see where it leads.

It would be nice to take classes with names like "creating change in institutions" and "Management of pediatric and adolescent populations" for a change.

After the Flood

2010-03-31T23:25:00.003-04:00

Yes, my nursing adventures continue. My absence from blogging has been the first in about ten years (I'm not about to check to see exactly how long), for comparison I've been an RN for I 22 months. I can't really imagine any other vocation for myself. It hasn't been an easy process, certainly. Sacrifices had to be made, trials were endured, things had to be confronted, not an activity recommended for people sensitive to fluctuations of blood pressure.

When I decided to pursue a degree in nursing, I knew the process would change me fundamentally. I had planned on this. It was a change I had already identified and accepted. Funnily enough, it was a change that seemed most compatible with how I already was. I like to keep things simple that way.

I still work at that same skilled nursing facility I've worked at for 16 months. It feels like home, more home-like than my actual home, really. Nursing home work was the last thing I wanted to do as a student, I had my heart set on either emergency or med-surg.

Working at a skilled nursing facility has been way much more fun than I thought it would be. The learning-curve was VERY steep, since there isn't as much on-the-job training as there is in hospitals, but this is the sort of challenge that I enjoy, chalk it up to stereotypical male risk-seeking behaviors.

Say what you will, supervising a nursing home is EXCITING. Nursing home residents are at the cutting edge of gerontology. Sure, people are "medically stable", but how medically stable can someone be when they've survived heart failure for a decade because of a drug that's only been out for a decade?

The really engaging challenge, of course, isn't clinical or mathematic or even purely scientific. The challenge to preserve the dignity of people who have lost their independence is much more. Maybe not the challenge..the privilege.. to encounter the worst and offer the best. Buddhists in the audience may harmonize with the ideal of alleviating suffering. What better way to alleviate your own?

Skilled nursing facilities are at the forefront of this challenge. It's true that only a small percentage of elders can't live independently, but that small percentage means that it's feasible to provide all of them with Care. Nursing homes and Family caregivers are the vanguard of this issue. Another interesting thing to consider is the mutually beneficial relationship between Nursing and Social Work.

Even though I harbor a deep suspicion that death will be abolished by the time I'm that age, there's still the strong possibility that I will occupy a bed somewhere, some day, where I'm dependent on Nursing Care for my health and well-being. Before I get there, why not contribute as much as possible to the art and science of taking care of people in those situations?

I'm reminded of this as I work alongside the student nurses on their rotation through our facility. Many of them are older than me, of course, but all of their enthusiasm and intelligence bolsters me when things get tough. A partner and I did a bit of research into the system-wide advantages welcoming students into a facility provide, and I have to say I've experienced every one of them and more in just a few shifts.

My short time in the career so far has been bombarded by intrigue, office politics and the rest of the nastiness you would expect, but my enthusiasm for the endeavor remains unbridled.

In truth, It's my best escape from the things that gnaw at me when I'm not at work. A lost Love, missed opportunities, things left unsaid, all of these things can take a back seat when you're making sure some brilliant elderly scientist is allowed to die with dignity. At least, they can take a back-seat until It's my turn...

This is still something I hold out hope for an alternative to. I think we're really close, however you slice it. Resolution of non-destructive brain-scanning, the exponentially increasing curve of technology..if we don't reach immortality than we'll have at least given it a good shot.

Whatever lies ahead, applying all the cleverness and ingenuity I possess to alleviating the suffering of some of the cleverest and ingenious people of our grandparent's generation is an endeavor worthy enough to distract me from my own suffering.

I knew, when I started down this path, that it would probably result in the loss of everyone I loved....

..but then, they were all going to die anyway.

unless...

The First Game

2009-10-15T01:45:00.002-04:00

Let's say one military is sending a signal but doesn't want the other military to intercept it. Information and security are intricately linked. You want your friends to know stuff, but not your enemies, or random (previously) disinterested third parties.

The simplest solution, at first, is to only communicate when necessary. This just makes it easier for the "enemy" to determine who is communicating and devising ways to eavesdrop on that communication.

Next, you start to communicate more and more so there's noise, but then you encrypt the signals that are important to protect them against the "other". This makes the encrypted signals more interesting.

Then people formulate new ways to make and break encryption and intercept signals ad infinitum.

Go (called Wei qi, baduk or Igo in other countries), the other game I take pretty seriously, is the perfect example of this infinite simultaneous arms race.

There's a contest, it takes place on the board. One player moves, then another.

The moves aren't secret, you can see them right away. You pick the best response out of a huge number of possible lines of play.

I'm getting ahead of myself.

The game is usually played on a 19x19 grid, although beginners do better on 9x9. One player puts a black stone on an empty intersection. Another player puts a white stone on an empty intersection. If a move results in an absence of empty intersections for a stone or group of stones, it's removed. The color that surrounds the most empty space wins. You can't repeat a board position.

That's it. The rules in a nutshell, for a game that is infinitely deeper than chess. People go to school to learn this game, just in the hopes of playing it professionally. I hear the exams are brutal.

So, the thing about this game is that it's a signal/security dilemma that you can replicate anywhere. The funny thing is that there's no way to hide your moves from the other player. They're all visible, there's no way to "fool" or "trick" your opponent from the standpoint of where the actual stones are placed. You can't move them once you place them. Each one is a decision.

The modern solution to the signal/security dilemma is to forget about encrypting or protecting or limiting or obfuscating your signal.

If you have the best signal, it shouldn't matter who's listening in. Let them listen. If you're a better strategist, you already anticipated that they might know your move.

When one entity contests another, both in this metaphor and in the game, you start out operating on one of three basic assumptions:

"This opponent is weaker, I'll win easily and don't have to worry or think too much."

"This opponent is stronger, I'll play cautiously and plan for the worst, and not expect to win."

"This opponent is near my strength, this should get interesting."

Of course, sometimes you know for sure who's the better player, sometimes you don't. You'd have to play to find out.

Supposedly there was some clinical research done in China that suggested that playing Go was good for stroke rehab, and generally strengthened reasoning and judgment skills. I'd buy that.

There are few experiences that match the gravity and seriousness of a Go match. It's more similar to a martial art than a game, requiring both training and study. There is even a concept within the game called "life and death".

Anyway, enough rambling. Check out some links about Go (link, link, link)

Here are some Go pictures.

Strike the Earth!

2009-09-24T01:28:00.004-04:00

There are only two games that I play with any "seriousness". Since I haven't had the time or inclination to blog lately, I thought I would rant and ramble about them, mostly because I'm a little sleep-deprived. Work provides endless layers of complexity and occupies most of my thoughts, but when I have time to myself, I shift that level of focus to a "game" that's self-directed and employs that same level of complexity.

The first game I want to talk about is a computer game called Dwarf Fortress, availible for mac, PC and linux 32&64.

There are lots of different styles of games, action, adventure, strategy, role-playing, chance, etc. These are all roads well-traveled and familiar to anyone who has seen, say, a game of chess and a game of mario brothers.

Dwarf Fortress is something that people tend to classify as a management game. It's an unfinished product, still in development, but profound nonetheless. It's a simple game that creates complexity by randomly generating parts of the game. Ms. Pacman was considered an advancement over regular pacman because the "ghosts" that chase the character around the screen had an element of unpredictability thrown in to them, while the original Pacman had the ghosts traveling the same paths over and over, leaving to the player to figure out how to avoid them and clear the level.

Enough about Pacman, back to Dwarf Fortress.

At first you're presented with a list of variables involved in randomly generating the world. The degree to which different x and y axis are correlated with more or less volcanism, savagery, temperature, rainfall, etc can be fiddled with to produce unpredictable results.

After this, history is randomly generated including high levels of detail down to individual people and battles and dragon attacks or anything else you would expect to happen in some random fantasy setting.

Next, it's time to choose the area in this world you plan to play the game in. Proximity to settlements from other civilizations have to be considered for hostility and caravan access, you want to pick a site that's likely to have fresh water or magma or whatever else you think is important. Caves maybe.

Next, you select the skills, abilities, and starting equipment of seven dwarves (yes, seven dwarves, try not to laugh). You can select their degree of skill among well over 30 different jobs, everything from mining to farming to soap-making, tanning, butchering, hunting, trapping, soldiering, weaponsmithing, lye-making, siege engineering, mechanics, and that's just off the top of my head. You start off with a certain amount of money you can use to buy wood, work animals, weapons, mechanisms or anything else you can think of that will help those seven dwarves survive.

Then it's time to embark! Your Seven dwarves relocate to the site of your new fortress, and it's time to get to work.

"Work" is accomplished not by telling any individual dwarf what to do, rather you give them all permission to work some of these specific jobs, then you plan out and designate what kinds of work has to be done (mining, farming, etc). The dwarves will then go about their business, working in time to eat, sleep, play, have kids, throw tantrums, etc, all without you being able to directly control all of it.

So, you have to plan. How far away is the primary food stockpile from the kitchen? Do we have enough people available for cleaning and refuse hauling? How's that military coming along? Are the fortifications ready? do we have enough crafted stone flutes to meet the demand of the next caravan? The dwarves will mostly do what you tell them to, but they also have their own agendas and can not be 100% relied upon, even though they can be 99% relied upon.

You have to create a system that is tolerant of those occasional glitches and faults, and sometimes even the best planning only results in more complex glitches and faults...all because of the emergent properties of the complex system you are attempting to manage.

"Best Practices" come into play. "Hey, if you're going to try to pump water out of that river, let's build in a shut-off switch in case we start a flood"

Simple things like that, all products of "lessons learned".

The motto in dwarf fortress is "losing is fun!". A failure that wipes out days of hard work gives you simultaneously the satisfaction of watching a large complex construction collapse with people running around in terror or slowly starving to death, it also gives you a better idea how to prevent that from happening at the future. You have to review.

In those moments before you trash a fortress and whip up a new one, there's a flash of insight. "Well, this would have worked better if I had done this instead."

Since the game is always random, there is never a specific order of steps that can be learned to be effective, there must be analysis of the local situation and appropriate delegation of the correct jobs to the right people to survive those circumstances.

People will write, at length, beautiful novellas about individual games they've played on the Forums for this game. The level of detail simulated borders on absurd (down to the degree of injury to individual toes, dwarves paying rent, breaking the law, throwing parties and fighting each other.

In addition to the "fortress" mode of the game, there's "adventure" mode. Instead of managing a population, you control a single individual and explore the remnants of old fortresses you previously created, seeing how the events that happened in the game changed the simulated history, inspired different themes in the artwork and statuary, things like that. You can wander from town to town taking on quests or hunting jackrabbits or trying to build a huge pile of mushrooms and then set it on fire, whatever.

This gives you the opportunity to explore the game you just played in a different way...as one of the uncontrollable individuals from the management-game. Maybe a hallway and dining-room seem a lot different when you're designing one versus when you're running through it.

One final mode simply allows you to browse the simulated history for the world you've generated.

The graphical representation of this detailed simulation is entirely minimalist and old-school. The graphical representation is more like the old terminal games from the early 80's like Rogue or Nethack.

The game is displayed with simple computer characters. % is a piece of food. ^ is a trap. @ might be a guard and $ might be money. a strip of floor with a stairway at the end of it might look like .,.,,,...,,,.> or ++++++X depending on if you were looking at a dirt floor with an up-staircase or a polished stone floor with an up/down staircase at the end of it.

Despite the simplicity of the graphical interface (which is all manipulated by keyboard, with some recent limited mouse additions added in), this game runs on almost any computer, but requires a powerful computer to play deeply.

The challenges are immense, which is why I'm so astounded that this seems to be mostly the product of one primary developer. The game seems simple enough, but when you have to keep track of up to 200 dwarves, all with clothing, jobs, spouses, toes, food, money, workplaces, preferences and desires, things get a little complicated. Just figuring out where everything's GOING gets complicated. Once you throw in realistic fluid dynamics (water will seek to find it's natural level, spreading and exerting pressure, just in real-life), weather and economics, you're asking a LOT of your computer.

I've let my computer slide in the past couple years. Nursing school and starting my career caused keeping my computer hardware up-to-date to take a back-seat. Now that I'm more settled into my job, I've decided it's time to upgrade mostly so I can play dwarf fortress longer. Things start to slow down to the 10 frames-per-second range (30 or even 20 would be great) once the population of my fortress hits 90 or so. My computer was pretty beefy when I put it together, but I've let it slide for too long.

I've got half the parts delivered already for the new one, I look forward to putting it together, mostly so I can extend my discovery of this game to the next level of managing populations over 150 entities. Watching some of the video tutorials has been instructive.

Anyway, back to the game. The level of randomly-generated (what's properly called "procedurally generated", since it's not "truly" random I guess) detail is staggering, and it's actually too much to keep track of. Oh, sure, in an ideal world you'd make sure that the one dwarf assigned to fishing doesn't mind being out in the sun, but if your fisherdwarf really hates the sun, do you spend the time training a replacement or do you build them a hut to fish under? Maybe you just stick it out and risk a tantrum while you make other arrangements?

Each dwarf has it's own thoughts and preferences, and it's reflections on it's short-term and long-term experience are immediately available. Oh, this one really hates goats but loves silver, raspberries and statues made of granite.

Well, that's nice, but we all have to get along in an environment that is NOT tailored to suit your exact tastes.

You can set your dwarves up to succeed, or you can set them up to fail.

Both are fun, both are educational, but why are you playing?

Letter to the Editor

2009-08-17T17:17:00.003-04:00

I found Rex Reed's brutal miscategorizations and stereotypes about people with Asperger's syndrome in his recent review of the movie "Adam" published on 7/28 extremely offensive.

His comments, while ignorant and hurtful to those of us who are not "neurologically typical", speak more to his difficulty coping with people who are different in a way he doesn't understand.

Even still, this kind of hateful misrepresentation of people with Asperger's presented as -entertainment- can and will be bad for your business.

Those of us who act and think differently than most may be a minority, but we struggle for our rights and dignity just as hard as any other minority. There's a lot of misunderstanding about mental illness and developmental disorders out there, and people who contribute to those misunderstandings risk alienating them from a small but unique and exceptional group of people. It wouldn't be acceptable to smear people with bipolar disorder as "untrustworthy" any more than it is acceptable than to smear people with Asperger's as unloving or incapable of putting other people's needs above their own.