Raspberry Blase

Merry Christmas!

noreply@blogger.com (Jacob) — Tue, 10 Mar 2009 09:10:00 +0000

This fits well with work tonight:

Making the Best of the Holidays

by James Tate

Justine called on Christmas day to say she
was thinking of killing herself. I said, "We're
in the middle of opening presents, Justine. Could
you possibly call back later, that is, if you're
still alive." She was furious with me and called
me all sorts of names which I refuse to dignify
by repeating them. I hung up on her and returned
to the joyful task of opening presents. Everyone
seemed delighted with what they got, and that
definitely included me. I placed a few more logs
on the fire, and then the phone rang again. This
time it was Hugh and he had just taken all of his
pills and washed them down with a quart of gin.
"Sleep it off, Hugh," I said, "I can barely under-
stand you, you're slurring so badly. Call me
tomorrow, Hugh, and Merry Christmas." The roast
in the oven smelled delicious. The kids were playing
with their new toys. Loni was giving me a big
Christmas kiss when the phone rang again. It was
Debbie. "I hate you," she said. "You're the most
disgusting human being on the planet." "You're
absolutely right," I said, "and I've always been
aware of this. Nonetheless, Merry Christmas, Debbie."
Halfway through dinner the phone rang again, but
this time Loni answered it. When she came back
to the table she looked pale. "Who was it?" I
asked. "It was my mother," she said. "And what
did she say?" I asked. "She said she wasn't my
mother," she said.

From the March 10, 2009 Writer's Almanac.

The Dreaded Newborn Fever

noreply@blogger.com (Jacob) — Tue, 18 Nov 2008 10:18:00 +0000

Saw this article in the NY Times this morning and it got me thinking about the infants that come into our ED with fevers. WebMD has an article for parents on the same topic. If you're a parent and found this post because your infant has a fever, call your doctor to decide what to do.

If you read the article, you'll get the basic idea of if and how we decide to treat a 1-3 month old infant with fevers. If you didn't read the article, here's how things go at our institution:

- <1> 38 C (100.4 F): CBC, blood culture, cath urinalysis, cath culture, and CSF studies. An IV is placed and heplocked, unless the baby has been vomiting or "diarrhea-ing" - then they get IV fluids. As soon as all cultures have been obtained, the infant is started on IV antibiotics (generally ampicillin and cefotaxime, and if maternal history of herpes, Acyclovir). A chest x-ray is often ordered. The infant is then admitted to the floor for scheduled IV antibiotics and observation, regardless of lab results.

- >1 month old and <3>1 month old and <3 size="4">Helpful Tips!
One of the most common patient transfers we get is infants with fever. The outlying hospital is often unable to place the IV, obtain CSF, and/or obtain urine and blood. I thought I might offer a few tips for those adult people out there who hate taking care of kids.

Pain control: We use Sweet-Ease (a very, very, very sweet sugar water that works by blocking the pain receptors) to ease the pain associated with venipuncture, catheterization, and spinal tap. Just dip the pacifier into the liquid and let the baby suck on it. If they aren't sucking well, you can use a 1cc syringe (without needle - duh) to drip the liquid into the babies mouth. Sweet-Ease is supposed to work up to 6 months of age, but seems to work best in the younger ones. I've used it and the baby did not cry once for the IV placement, blood draws, or urine catheterization. Other times it doesn't seem to help at all.

Parents: Explain to the parents what you are doing. This is a very traumatic experience - if your hospital allows them to stay in the room, give them the option to stay. Also, be sure to let them know it is OK for them to leave the room if they would rather not watch. Tell them if you'll be using Sweet-Ease (or substitute) to help with the pain.

Yourself: Don't be too proud to not stick. If you don't feel comfortable, don't do it. You could ask for a NICU nurse to come help. Or, have your local pediatric hospital take the patient. Save the baby and the parents the trauma of multiple sticks (plus, it makes you look bad when you try 18 times for an IV, then send the baby to the children's hospital and we get it first try). Unless the baby is in distress, an hour or two is not going to make a huge difference in their recovery.

Urine: Get urine first - if the baby hasn't been feeding well, you don't want to lose the urine when they pee while you're sticking them with needles. Use a 5 French catheter. Little boys are fairly easy, you just have to work a bit to get past the prostate sometimes. It helps to pull the penis towards the ceiling while you're inserting the catheter. Little girls are slightly more difficult. Newborn females have anatomy that is a little (OK, a lot) different than older females. Have your holder hold the baby's legs spread and up (think lithotomy position). With your non-dominant hand spread the labia, then pull them up to expose the urethra. When you're cleaning the area, look for the "wink" - the urethra will open up and close when you touch it with your swabs. Aim for that wink, and go for it.

IV: Look around! Don't automatically think AC (think about it: infants are always waving their arms around - not being able to bend the elbow is a pain). The pudgier the infant, the more difficult to find an AC, in most cases. Infants often have good hand/wrist veins, but try to avoid those very superficial, skinny veins. The saphenous vein tends to be a good place as well - even if you can't see it, it's there (just anterior to the medial malleolus - see the picture). Scalp veins are amazingly easy to put an IV into, but are a little freaky looking for the parents. It takes a little extra work to secure the IV as well. Finally, if your institution has a NICU, ask one of their nurses to come help you out - they're wizards with baby IVs.

Blood: If the IV is bleeding well, go ahead and get your CBC from that - about 0.5 cc is all that is necessary. The blood culture should be obtained via a separate stick than the IV to avoid contamination. Look wherever your IV isn't - hands, AC, feet, ankles, etc. I personally have a harder time drawing labs than placing IVs, so if I don't find a promising vein, I'll have someone else draw.

CSF: The physician or physican's assistant will perform the tap - a lot of our docs like to have the baby in a sitting position. If your hands are big enough, you can pull down on the baby's shoulders with your thumbs and push their abdomen with your fingers to flex their spine. It looks uncomfortable, but it makes the vertebrae open up nicely. Don't forget to use Sweet-Ease - you may need one other person to dip and hold the pacifier for the baby.

I hope this has been helpful. I may try to post more pediatric tips in the future. Do you have any tips or stories about taking care of babies with fevers in the hospital (or as a parent)?

Regarding older kids with fevers, Ian at ImpactEDNurse has a much more well written post, if you're interested.

Depressing week

noreply@blogger.com (Jacob) — Wed, 12 Nov 2008 10:38:00 +0000

Multiple child abuse cases, MVC patient whose family was killed, coworkers losing loved ones to cancer...

Bleah.

Tis the season.

Evil is Alive and Well

noreply@blogger.com (Jacob) — Sat, 25 Oct 2008 15:46:00 +0000

It doesn't always have a shape
Almost never does it have a name
It maybe has a pitchfork maybe has a tail
But evil is alive and well
It might walk upright from out of the inferno
May be coming horseback through deep snow
It's ragged and fat hungry as hell

Evil is alive and well
Evil is alive
Evil is well
Evil is alive
Evil is well
On your feet to the tower and yell
Evil is alive and well

May be too humble to want to speak
May have a blood soaked bird in it's teeth
Smoked filled skies and bees in the well
Evil is alive and well
Maybe in a palace it may be in the streets
May be here among us on a crowded beach
May be asleep in a roadside motel
But evil is alive and well

Evil is alive
Evil is well
Evil is alive
Evil is well
On your feet to the tower and yell
Evil is alive and well

It's well
Down in every ditch
Up on every hill
It's well
I've got my radio on
Drowning the bells

When midnight's done and the day won't start
And All I ever gave you was a broken heart
It's hard to admit but it's easy to tell
That evil is alive and well

Spend a few hours in our ED and you will see that evil is alive and well:

Beaten babies, raped teens, psychotic kids.

Parents that don't give a shit.

A system that can't do enough.

And we smile through it all.

(song by Jakob Dylan)

Unpleasant Things I Do To Children

noreply@blogger.com (Jacob) — Mon, 13 Oct 2008 09:40:00 +0000

- Suck snot out of their noses and pharynx with tubes
- Poke them with needles
- Stick thermometers in their rectums
- Drain urine from their bladders with tubes
- Swab their throats
- Swab their rectums

and finally,

- Hold them down while someone else pokes them with needles, resets their fractured bones, sticks tubes into/swabs their various body cavities, etc.

Update: 100 Push Ups

noreply@blogger.com (Jacob) — Mon, 13 Oct 2008 09:28:00 +0000

Week 3's push ups didn't go so well. In fact, they didn't go at all.

I've got a couple of good excuses though!

1) Worked 3 12 hour shifts in a row over the weekend
2) Got a cold
3) I'm lazy
4) The assigned amount of push ups nearly doubles

All of those combined to make me not do them, so I'll probably repeat week 2 this week then continue on with week 3 after.

The second week's push ups went as follows:

Day 1: 9 + 8 + 6 + 4 + 11.5

Day 2: 11 + 9 + 7 + 7 + 21

Day 3: 10 + 10 + 8 + 8 + 21

Update: 100 Push Ups

noreply@blogger.com (Jacob) — Tue, 30 Sep 2008 01:25:00 +0000

Well, a week has gone by in the 100 Push Ups attempt.

If you've looked at the 100 Push Ups plan, you'll see a general idea of what the first week consisted of (my plan is a little different because I'm using the "old-fashioned" plan).

For your reading pleasure, I'll give you my stats:

September 19 (Pre-test): 11 push ups

September 22 (Day 1): 7 + 7 + 5 + 4 + 7

September 24 (Day 2): 9 + 8 + 6 + 5 + 7

September 27 (Day 3): 10 + 8 + 8 + 5 + 14

The pre-test entailed that I do as many push ups as I was physically able to perform (sad, isn't it?). That number determined which track I will follow for the rest of the 6 weeks.

I rested 60 seconds between the day 1 sets, 90 seconds between the day 2 sets, and 120 seconds between the day 3 sets. The last number on each day was a max to failure. I doubled my maximum, even after doing more push ups, on day 3. We'll see if the results continue to be as impressive.

I had to take an extra day of rest between day 2 and 3 because my arms and pecs were extremely sore. A nasty side effect of these sore arms was a continual fine tremor for a day or two after the first 2 days of push ups (which made placing IVs and catheters extremely difficult...).

I'll be doing another set this evening. Wish me luck!

P.s. It turns out my brother has been doing the 100 Push Ups program for a few weeks now - show him some Twitter love.

100 Push Ups

noreply@blogger.com (Jacob) — Mon, 22 Sep 2008 12:07:00 +0000

I heard about the one hundred push ups website a while ago, but never had the gumption to start the program. I decided recently to start - today marks the first day of my first week - so I'm going to try to keep a log of my attempt on my blog in the hopes that a little accountability will help me out.

Part of the impetus behind this is that I've recently lost about 15-20 of the 30-40 pounds which have been hanging on me since I graduated from high school. Now that I'm a little lighter push ups should be a little easier, right?

Also, even though I work with kids, every once in awhile we get large patients. I've never had very good upper body strength, and push ups might help me out a little bit in the obese, unconscious patient department.

Wish me luck and bug me about keeping up on this program, please.

A Sad Day

noreply@blogger.com (Jacob) — Sun, 14 Sep 2008 20:43:00 +0000

It's been a very windy day here in Yellow Springs. Unfortunately, a recent casualty was the tree that provided shade and extra privacy to our apartment.

See a few more pictures here.

Wife

noreply@blogger.com (Jacob) — Sun, 14 Sep 2008 12:12:00 +0000

My wife Renae recently started a blog. She's an excellent writer, so you should all check her out.

Plus, she makes excellent pizza!

Hoarse.

noreply@blogger.com (Jacob) — Sat, 30 Aug 2008 13:26:00 +0000

I never realized how hard it would be to not be able to talk. For the past two nights, my voice has been getting consistently hoarser. Last night, I was barely able to speak at all - if I tried to modulate my tone in the slightest way, my voice would disappear. I think I scared a lot of kids (and probably some parents too) with my very rough, very strange sounding voice. I wish I could record it and post it on here...

According to the docs and nurses where I work, I have croup.

Did you know that when you've had a cold and your voice gets all rough and hoarse, you have croup? Croup is basically an inflammation of the airway, namely affecting the larynx, trachea, and bronchi (hence it's more technical name acute laryngotracheobronchitis). Since kids have smaller airways than adults, the inflammation makes it difficult for them to breathe. They gasp and cough and generally sound like they're dying (which can happen if their airway totally closes down).

Luckily, croup is treated fairly easily and tends to resolve on its own. Cool, humidified air helps alleviate the swelling, so sticking a kids head in the freezer can help a lot. Keeping the kid calm will also work wonders in improving their airway. And a trip to the local ED will get you a breathing treatment and anti-inflammatory medication.

Apparently, developing croup is one of the many perils I will face while working in a pediatric ED. Other nurses have told me I'll be sick almost the entire first year since we come in contact with so many kids with colds. If that's the case, it is going to be a long year.

Hopefully with this night off my voice will heal enough for me to be able to speak again by Sunday. *crosses fingers*

Change of Shift!

noreply@blogger.com (Jacob) — Fri, 22 Aug 2008 13:16:00 +0000

Change of Shift is up.

Check it out.

Zingo!

noreply@blogger.com (Jacob) — Thu, 21 Aug 2008 04:57:00 +0000

According to Anesiva, IV starts are one of the most painful/traumatic procedures children undergo in the hospital. They claim that using Zingo will significantly reduce those traumatic events.

The ED I work at recently started using Zingo for IV starts and lab draws. All of us nurses used it for a few weeks and gave our feedback to management. They've decided to let us keep using it permanently.

Zingo is a fast-acting topical anesthetic. It numbs an inch or so diameter of skin in 1-3 minutes. The approximately 8 inch long device works by blowing powdered lidocaine into the skin. It doesn't hurt at all, but it does make a loud noise when it's applied. It's approved for use on kids 3-18 years old. According to studies done by the manufacturer, it significantly improved patient's pain ratings after venipuncture versus a placebo (see the data here).

There have been mixed feelings regarding Zingo's use in our ED. In fact, very few people like it or use it. In my own personal experience, I've found it to be helpful with older kids (say, 7 or 8 and up). Younger kids are really freaking out most of the time anyways, and Zingo doesn't have any anxiolytic effects, unfortunately...

My favorite part about using Zingo is walking into a patient's room and explaining to them that we are going to start an IV. They start to look a little crestfallen, and I tell them that we have this new thing called Zingo! And it helps the IV to not hurt! A lot of the time they're still nervous, but they seem to do much better emotionally after hearing that news.

I'm still deciding whether or not I think it's absolutely worthwhile in the younger kids, who can't understand that we're helping them. To them, Zingo is probably just one more agonizing thing we have to hold them down for. It almost seems better to me to just place the IV quickly.

And one of the best things about Zingo is that parents absolutely love it when we tell them we'll numb their kids arm or hand before we stick them. Nearly every single one has asked if we can do that for them should they ever need an IV.

If you're interested in managing IV pain for kids (if you don't click, you should feel very guilty ;D), go here. It has some useful tips for nurses who may have to start IVs or obtain blood from kids).

So, what do you all think about topical anesthetics for IV starts? Or, do you have any tips for starting IVs to make it less painful?

Nurses on Twitter

noreply@blogger.com (Jacob) — Wed, 20 Aug 2008 00:06:00 +0000

PixelRN has been doing a tremendous job keeping nurses connected online with Orientedx3. Now, she has a nice list of nurses who Twitter on her blog.

You can follow me on Twitter, if you like (although I'm pretty boring).

New Intramuscular Recommendations?

noreply@blogger.com (Jacob) — Fri, 15 Aug 2008 15:07:00 +0000

I hate giving IM injections. In nursing school, they made us memorize this whole chart of sites and needle gauges and lengths. Now, my brain cannot remember any of that - in fact, I think I've blocked it because whenever I have to give some kid a tetanus or Bicillin shot, I have to ask someone else to help me pick out my needle.

Anyways, a new study is recommending choosing needles for deltoid injections based on weight rather than age:

A 1/2-inch needle for any girl who weighs 70 kg or less and any boy who weighs 75 kg or less.
A 5/8-inch needle for any girl who weighs between 70 and 115 kg and any boy who weighs between 75 and 140 kg.
A 7/8- to 1-inch needle for any girl who weighs 115 kg or more and any boy who weighs 140 kg or more.

Apparently there have been some issues of overpenetration (funny word):

"Potential dangers of needle overpenetration from the intramuscular level to the bone or periosteum may include pain and/or damage to the bone or periosteum and detachment of the needle from the syringe."

The study's authors concluded that the CDC recommendations for thigh injections are still appropriate.

Maybe I can remember this? More than likely I'll just forget and have to look it up again.

There will be no overpenetration when this nurse is giving shots!

Sheesh!

noreply@blogger.com (Jacob) — Wed, 13 Aug 2008 20:54:00 +0000

Can this guy eat, or what!?!?!?

Makes me feel a little bit better about eating a whole sub for lunch today...

Edit: Fixed the link - thanks GeekRN

Too funny

noreply@blogger.com (Jacob) — Tue, 12 Aug 2008 15:25:00 +0000

I just had to put this up:

In no way is this intended to be an endorsement or a put-down. It's just funny.

School and the NCLEX

noreply@blogger.com (Jacob) — Tue, 05 Aug 2008 21:12:00 +0000

This is something I've been meaning to post for awhile. One of my clinical instructors emailed and asked me how well prepared for the NCLEX I was after school. This is what I wrote:

Regarding the NCLEX and school...I don't know. I did learn a lot during school. The senior year is when everything really seemed to come together for me - before that, it was kind of hard to make sense of everything. I don't think I would have passed the NCLEX without any school whatsoever. I had the good fortune of lots of extracurricular experience (nursing home, externship, nurse's aide), all of which helped me think like a nurse. I am glad I was in nursing school before I started working as a nurse's aide - I was able to learn a lot in that position because I sort of knew what was coming. I think I've gotten off-topic.

Personally, I think teaching to pass the NCLEX is not right. Cedarville seemed to stress NCLEX a lot, when they should be stressing how to be a nurse. The NCLEX is not the point. Maybe if post-graduation internships become the norm, the NCLEX will be altered in someway. I sort of feel the same way about standardized testing, in general. I get standardized tests, so I do well on them. Other people may know just as much as me or even more but fail simply because of the tests. It seems very harsh to say to one person you can continue in life because you passed this and to another you can't continue because you didn't pass. But I can't think of another way to produce safe nurses, at the moment.

I wonder if standardized testing will ever become extinct. And I still haven't thought of a feasible way to produce safe nurses.

Link Love

noreply@blogger.com (Jacob) — Mon, 14 Jul 2008 20:32:00 +0000

I feel compelled to repost this post by Not Nurse Ratched.

Read it.

Sssssllloooowwww....

noreply@blogger.com (Jacob) — Thu, 03 Jul 2008 13:25:00 +0000

Well, there are only 2 patients in the entire ED. It's slow.

I've said it. Sloowwww...

According to legend, saying "slow" or "quiet" will immediately bring in a busload of patients.

Let's see what happens.

Today is the Day!

noreply@blogger.com (Jacob) — Tue, 17 Jun 2008 20:42:00 +0000

It's Firefox 3 Download Day, everyone!

Go download and help Firefox break a non-existent world record!

You can get a nifty certificate too!

Twitter Back Ya'll...

noreply@blogger.com (Jacob) — Mon, 02 Jun 2008 17:07:00 +0000

I missed Twitter too much...so now I'm back on. I restored my account, so everything should be the same as when I left.

Too bad real life isn't like that, huh?

Done

noreply@blogger.com (Jacob) — Mon, 02 Jun 2008 14:08:00 +0000

Well, the NCLEX is done.

It took me about 45 minutes. I only had 75 questions. I felt like I didn't know any of the answers (lots of medication questions...blech).

If you'd care to check up on me and see if I passed, click here. It'll take you the Ohio Board of Nursing licensure verification site, where you can see when I've passed or failed. Currently, my status is "PENDING".

Does anyone know of any better ways to find out if you've passed or failed?

NCLEX

noreply@blogger.com (Jacob) — Sun, 01 Jun 2008 22:05:00 +0000

I sit for the NCLEX tomorrow morning.

I know I should feel nervous.

But I'm not...yet.

I'm not even feeling excited to get it over with and start working as a nurse.

I know I should feel excited.

But I'm not.

Sniff....thanks.

noreply@blogger.com (Jacob) — Sat, 31 May 2008 02:29:00 +0000

It was nice to get a few comments from people on the previous post regarding minimizing my online time. I'll still be on Blogger (it'll be easier to neglect the blog than it was Twitter).

Thanks again.