Mediblogopathy - A Nurse Blog

I Can Post If I Wanna

2010-02-02T20:53:00.000-08:00

I can leave this world behind

Cuz your friends don't post and if they don't post...

Heh

Spent the day looking for some sort of work. This part-time-half-assed-per-diem junk is killing me. I've got nowhere near the amount of hours I need to pay the bills. School suffers less the more I work... the stress from working only part time interferes with my ability to concentrate.

BTW I'm going back to school to get my BSN right now. I'll graduate in July (yay!). Hopefully I'll get into the DNP program, we'll have to see what the Powers That Be have in store for me. Cross your fingers.

Working on homework right now, also playing a browser-based game called Evony. Pretty cool. I like it a lot better than TV and there are some nice people on there to chat up.

Gone Too Long

2010-01-31T05:49:00.000-08:00

OMG I KNOW! Please, before you light into me for not posting as often as I should.. or, well, ok... for like 3 years... understand that I actually started working in the real world of nursing. Things just started looking the same... day after day the scene didn't change much and although the stories of interesting first psychotic breaks, manic moods, and overindulgence in various mind-altering substances did begin to pile up, I got LAZY.

I do regret that now. Looking back I am taken right back to that time. "These stories are great!" I think to myself... "why isn't my practice like this?"

Well, it still is. I just got lazy and thought maybe the stories sounded too much alike. Too much pain and heartache with a generous bit of black humor thrown in. Who would want to hear another one? Today I finally got to publishing comments that have languished in my inbox for years. I remember the fun of posting, the self-discovery that went along with being a new nurse. I read the wonderful comments urging me to post more, making me feel like maybe it was worth it.

SO. Here we are again. PedsRN is gone, who knows when the last time I spoke to him was. Not sure what he's doing now, wish him the best of luck. I think I'll post some more. Maybe not a bunch, but enough to keep the ol' Mediblogopathy site up.

Nods and thanks to all the readers who might still have me on their feeds. Surprise! A post! So much has changed, I'll have to fill you in on where I've been and what I've been doing. Should be an interesting read for those of you who knew me back when.

ENA Responds to President's Comments

2007-07-18T22:38:00.000-07:00

The following is a statement from ENA President Donna Mason, RN, MS, CEN in response to comments made by President George W. Bush during a speech in Cleveland, Ohio, July 10, 2007.

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On July 10, a primary barrier to health care reform in the United States was illustrated perfectly by President George W. Bush during a speech in Cleveland, Ohio. Unfortunately, the President didn’t offer insight into a solution; instead he demonstrated a complete lack of understanding as to how health care is delivered today and how near the breaking point our health care system has become.

In talking about the challenges facing health care in the United States, the president said:

“The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”

The issues facing health care in America are complex, but it is clear by this statement that the President isn’t even aware nor understands the fundamentals of the crisis.

Emergency departments are required by law under the Emergency Medical Treatment and Active Labor Act to accept, examine and stabilize patients with emergent conditions. But with wait times growing, the severe shortage of nurses, violence in emergency departments rising, and the ranks of the un- and under-insured so high, treating the emergency room like a primary care clinic, mental health clinic and an emergency room all at the same time is a recipe for disaster.

While emergency departments are committed to providing quality care for all patients, they are intended to treat emergencies, not to provide primary care services. Patients with diabetes, heart conditions, high blood pressure, mental illness and other chronic conditions need the care of primary care doctors and specialists to manage their conditions. They need to be treated before their conditions become life threatening. By suggesting that patients in America have access to health care because they can always go to the emergency department, President Bush not only over simplifies the problem, he ignores the true nature of the problems facing patients and hospitals alike.

A Centers for Disease Control and Prevention report this year showed a 20 percent increase in emergency department patient visits while the total number of EDs in the United States declined by 9 percent. At the same time, the average emergency department wait times are as long as six hours in some states with some patients waiting as long as 24 hours to be seen. When you combine this with the growing number of elderly patients, the ever present shortage of nurses, the nearly 200,000 fewer hospital beds and the tens of billions of dollars of unrecovered treatment costs every year, it is clearly a false and dangerous assumption that all Americans have access to health care because there are emergency rooms.

As president of the Emergency Nurses Association, I know that a solution to the current health care crisis will not be easy. We must build an infrastructure capable of treating a growing and aging population. We have to find a way to train the individuals representing the more than 147,000 qualified nursing school applicants that were turned away during the 2004-2005 academic year primarily because of the lack of nurse faculty to teach them. But most of all, we must admit the failure of the current market-based health insurance system and find a way to truly provide patients with access to care, access that actually prevents illness and injury before they become emergencies.

Nursing Student Sues School for F

2007-06-24T21:15:00.000-07:00

June 24, 2007 -- Columbia University gave him an "F," but he deserves an "A" for audacity.

Nicholas Perrino was kicked out of the Ivy League institution's School of Nursing for missing an exam, and now he is suing to get back in.

"I should have went to Yale," moaned Perrino, who is representing himself in the case.

The 27-year-old Illinois native said he was working toward two master's degrees last summer, when his grandparents became gravely ill, forcing him to take a few days off.

He told his instructors he would be absent for a skills exam and tried to arrange a makeup, Perrino claims in documents filed June 15 in Manhattan Supreme Court.

Instead, he says, the school failed him in the course - part of a fast-track master's program.

Without the test, the school wouldn't let him continue his nursing coursework.

Filing academic grievances and appealing to the Columbia provost got him nowhere, he said, and he was withdrawn from the School of Nursing.

"It's insane," Perrino said. "It's not like I killed someone."

Perrino, who says he spent $65,000 on tuition, did complete a master's degree in public policy. He says he had a nearly spotless academic record at the School of Nursing.

A Columbia spokesman said he could only confirm Perrino had been a nursing student, and cited privacy rules preventing him from discussing the case.

Perrino is asking a judge to remove the "F" from his transcript, reinstate him at the school and reimburse tuition costs for classes he has already taken.

Found in the NY Post: http://www.nypost.com/seven/06242007/news/regionalnews/f_student_sues_columbia_nurse_school_regionalnews_kathianne_boniello.htm

Paging Doctor Borderline...

2007-06-19T17:22:00.000-07:00

Finally! A day off to catch up on things.

Work has been sort of stressful - the new charge nurse flits around the unit going 12 ways at once and pretty much accomplishing nothing. When I work with her I don't feel we're a team. Although I try to remind her of things she has to do it feels like there's no back-up for me (there are only two floor RNs, one med-nurse and about 6 mental health specialists for each floor).

To top that off, we've got several psychiatrists here and one of them is just losing it all the time. He's had to apologise to the whole day shift staff once, and to me personally about 3 times. It's like he gets a difficult patient and gets upset with them or doesn't pay as much attention to them as another doc might, and they don't get good care. He gets stressed out about anything and takes it out on nurses, saying rude things and raising his voice.

I came in the other morning and there was a new patient on this doc's team who was admitted at 7pm the evening prior. He was actually the doc on call for the whole hospital that evening anyway, so he made the initial orders over the phone. He knew he would be doing an admit in the morning. The patient was living in a group home and according to staff there had been med compliant. The doc didn't order any meds for her except PRN Ativan and Ambien. I called him on his cell phone at about 10:45 in the morning, asking if we could get this patient started on her normal meds because she had basically missed the noon (while she was being detained and medically cleared), pm, hs, and am doses and it was approaching noon again. He went off on me that he doesn't give phone orders, and I responded with "Well, its 10:45 now and the pt's been here since 7pm - when can we expect you in to assess her?" he went on to say that I didn't have the experience to know that in most facilities they never made phone orders and "when you've been doing this for longer" and other crap like that (all of our good docs get right on new admits first thing in the morning).

He did come in about 11am but wanted to play some sort of power struggle game and didn't assess her even though she was running down the hallway screaming and cussing out other patients and making a big scene (well, yeah, now she's off all her meds...). We could only give her Ativan, which sedates a person and does nothing for the psychosis. I don't know about anyone else, but in my opinion being unwilling to order her own meds for her was about the same as ordering "hold all meds" - and this counted for the psych AND medical meds. I don't mind that so much, sometimes they want the pt off meds for a bit, but this was without assessing her! It is so frustrating to work with someone who has to prove a point at the cost of care of the patient. I mean, if she got in a fight or had to be restrained for safety because she was out of control, this would have bearing on her court case and she might be there longer or worse yet, she could be injured. I spoke to my nurse manager, and she told me to inform the medical director, who was ALSO wondering about this patient who is so out of control. He speaks with Dr. Attitude and nothing happens. At 15:30 when our shift is leaving she still has no orders. I'm in the back office with the medical director (aka PsychDoc from my previous posts) and a discharge planner and Dr. Attitude comes in and says "I want to talk to you" and I say "I was supposed to be off at 15:30, I'm 15 minutes overtime" and he just starts talking anyway: "You don't want this to turn into one of those things where people talk shit about each other behind their back and try and hurt each other - you don't need to go over my head, you can call me if you need something!". OMG oh well whatever now I know you're messed up. I only asked when we could get some meds for this pt.

Anyway, after I leave I guess he has a chance to think about how it's not nice to threaten your nurse - and he tells PsychDoc he wants to call me at home to say he's sorry! I'm glad he didn't because I would have told him to .... well, I'm just glad he didn't. Maybe I should call him Dr. Borderline. The next day we worked together, he tried to say he was sorry and I told him I didn't need his "sorry" and that if he could control his own behavior he wouldn't have to keep apologising to me. At lunch he bought pizza for the staff.

Yeah, you're a swell guy.

Thank god the rest of the people I work with are so cool.

WAKE UP!

2007-05-31T18:45:00.000-07:00

Alright, that's it!

I'm going to start writing again.

I had a bit of a tough time finding time to blog as we bought the house, moved, tore out the kitchen, and remodeled, but now that's pretty much done (I say pretty much, because I still can't find my other black slingback mule... still some unpacked boxes in the basement!)

I'm still working at the Psych Hospital. I get along well with most of the people there, and have some good friends now. We have fun, and keep it interesting. We work well as a team, and you've got to have that when safety can be a concern. Work is always challenging and it's a new experience every day.

The full-time charge nurse position opened and I applied for it, but they hired someone from the outside. Up to this point I was only a fill-in charge nurse along with one other nurse and would rotate days. She has something like 25 years of nursing experience, but I'm not really seeing a difference from what was going on before. I made my own choice and decided that if I was going to wait around for a promotion I might be old and gray before it happened -SO- I started school again!!

I'm taking care of 15cr of prerequisites and hope to be able to start in the fall at The University. I say hope, because I'm applying pretty late. I expect to get in, but if that doesn't work I'll get in in Jan. I need 10cr of foreign language and I'm taking Spanish (yea!!) and I also needed Statistics, which I can take online (hmmm...). I'm super-duper-awesome-happy about going back to school even though the idea of now working full time and going to school in the evenings is a bit scary.

So what else is going on? My sister is coming from Florida to visit in September, and in August my family is going to Texas to meet my husband's family. I'll get to meet his mom and sisters finally after being with him for almost 7 years!

The house is improving a bit at a time, and we've made great strides in the yard, which was overgrown and hadn't been pruned back in at least 10 years. There are about 30 rhododendrons and tons of other trees, many I can't name. It was an amazing yard back in the day, but it sort of went wild and scrubby. Things look MUCH better - I'll probably post pics.

Anyway, I'm going to go barbecue some burgers now and take advantage of the beautiful weather. I'll write more soon about work and school and anything else I can think of that might be interesting.

Let me know if you're still reading....

-HK

Too much of a good thing

2007-03-05T04:37:00.000-08:00

Ok, here's the deal. I like having a child's parents at the bedside. It's fantastic. It's the way things should be, with the parents providing care, reassurance, and valuable "insider information" on my patient.

Sometimes, though, you just need the room to yourself. (The following is heavily paraphrased.)

"So, what's that you're giving her now?"

"Nothing new, the dopamine infusion is about to run out so I'm swapping in a new one. You'll see her blood pressure go up for a bit, but it'll soon settle."

"Oh, right. Has she had a suction at all?"

"Not on my shift."

"Did she hoik?"

"I'm sorry?"

"Hoik, you know, like cough? Or was it all in the tube?"

(Struggling to keep up) "Uh, her last suction was before my shift, so I really couldn't say."

"Ah, ok." Brief pause. "What's that she's getting now?"

"This is one of her antibiotics." I check the clock. 0120 hrs. Please, please, go to sleep. Your child is sedated. She won't wake up unless... you start... to rub her feet and talk to her in a loud voice...

"So that's one of the ones to put her to sleep?"

"Yes, we don't really want her to wake up just yet, she needs to be relaxed."

Parent gets out own thermometer to check temperature. "Do you use these? These are good."

"Uh, we have some other kind." I am willing you to go to sleep. You are getting sleeepy. Sleeeeeepy...

Pointing to the monitor, where the respiratory rate has fallen slightly. "Where do you want the respiratory, boss?"

Boss? "Don't worry too much about the numbers on the screen. It's normal to pause a bit when you breathe, especially when you're in a deep sleep. You and I probably do too. If she stops for too long, the ventilator will kick in."

"Right, right. So what's that she's getting now?"

Poison. I'm giving her poison, IV stat. "This is another antibiotic. I'm just adding it into the line in a different place."

"Why's that?"

And on, and on. Don't get me wrong, I'll answer questions with the best of 'em. However, some parents feel obliged to do the heroic guardian bit and stay up all night, completely exhausting themselves and adding to their family's already significant stress levels.

Plus, on night shift the bedside nurse's patience is less abundant.

Why Not?

2007-03-01T19:21:00.001-08:00

I guess I've got to do my part to spread this around :) I hope they got extra credit for it!

Mistakes

2007-02-09T08:54:00.000-08:00

Let's start here: I've never killed anybody. Yes! Score one for the big guy. To the best of my knowledge I've never caused serious harm either. Here are some of the mistakes I've managed to make in the course of my career so far:

Informed a patient's parents that we would call them when their child was off the heart bypass machine and back in the intensive care unit. That went down like a lead balloon as the child was in fact having spinal surgery. Oops.

Gave a medication IV when it had been switched to oral.

Gave a larger than usual initial dose of adenosine due to making an assumption about its concentration which turned out to be incorrect.

Gave a medication that recently passed its expiry date.

Missed giving a charted medication due to rushing and not checking the chart carefully enough.

The reason I know I made those mistakes is that, where I didn't discover the problem myself, I was notified by the constant checking and cross-checking and reviewing of my colleagues. It's a given that humans are fallible, and that in an increasingly complex hospital world, we will screw up from time to time. The trick is to minimise how often that happens, not to make the really big mistakes, and to put measures into place that reduce the risk of them happening again.

I've caught any number of mistakes from both nurses and doctors. Some examples follow. In each case I can see exactly how the mistake was made, and I can imagine doing that myself given similar circumstances.

A ventilator's pressure release valve screwed in all the way, which would not allow excessive pressure to be vented to atmosphere.

A bag of IV fluids made up correctly for the unit's standard orders, but incorrectly for the particular patient who had other requirements.

A 'ten times the dose' charting error made by a tired registrar.

A ventilator set up 'backwards', with the expiratory limb plugged into the inspiratory flow outlet. Patient was ventilating fine but it confused the hell out of the humidifier.

An unnecessary medication prescribed by a consultant who made an assumption about the patient that turned out to be incorrect, based on a mis-reading of a fluid balance chart.

A dopamine infusion advertised as 5 mcg/kg/min by an anaesthetist that was in fact 10 mcg/kg/min. Sort of explained the extremely 'healthy' blood pressure we were getting.

I mention these not to try to sound clever, but to illustrate that the process works both ways. You make some mistakes, you catch some mistakes. There's a peculiar kind of ego-supression that has to go on in order to survive in this environment, where you swallow your pride and realise that you're not super-nurse or super-doc but rather a mere fallible mortal who gets it wrong some of the time.

I know that people who come into hospital would much rather believe that mistakes don't happen, but the truth is that little mistakes happen all the time. Big mistakes, thank god, are much rarer and (if you're careful, and lucky) tend to be the sort of thing you hear about but don't see.

The same themes recur throughout incident reports submitted when a mistake is made: haste. Overwork. Overtiredness. Inexperience. The risks inherent in understaffing are well documented. A less popular admission among hospital staff is that, even under the best circumstances, errors will still occur.

More About Money

2007-01-25T19:15:00.000-08:00

I don't normally state plainly what country I'm blogging from following the closure of GeekNurse, although it's fairly easy to look up which is why I don't try too hard. Hence the ambiguity of my previous post on finances.

In that post I was out by quite a long way. Told you I was bad with money! I make $37 613 in US dollars before tax. I lose 25% in tax and a further 7% in student loan repayment, so by subtracting 32% we get the unhealthy net amount of $25 577 USD. This is after 8 years of clinical experience.

As you can see, it wouldn't be hard to do better on US RN wages, even taking cost of living into account. In fact, with rentals the way they are where I live, and with accommodation often provided for in travel nursing contracts, I'd probably be quite a bit better off. But I love my country, I love the way we practice intensive care here, and it's just not the right time. So I should stop complaining!

I can increase my earning slightly by 'upgrading' myself according to our hospital's mind-numbing grade system, which ranks how competent I am by asking me to produce a large body of 'evidence' and fill out a vast form. Sheer laziness on my part (and a certain amount of resentment at having to do it in the first place) has so far prevented me from complying.

If you don't mind disclosing, how about posting your own income from nursing (converted to USD) in the comments section? Here's a currency converter if you need one.

New Sink

2007-01-23T18:57:00.000-08:00

I've been working on the house, I guess I took on a lot because I'm still not finished - but then again I'm sort of slowing down after the holiday. The kitchen isn't quite finished yet, but it's completely operable and missing mostly (mostly....) cosmetic details. I'll post more pics when I've really got it done.

The story behind the sink is that I bought it off of Craigslist for $50. It was the original sink out of a torn-down 1910 farmhouse and the grandson of the owner kept it to resell. It was sitting in his field when I got there, but the rust spots weren't rotted and it was fixable. A few people laughed when I showed them my "new sink" for my new kitchen, but my husband has enough belief in my funny ideas to merely say "Wow, thats big!" and leave me to work some magic on it. After 2 weeks in the refinishing shop and $320 later here are the pics to prove it was well worth it. It is a full 4" long so I had to get two smaller 24" under-sink counters for it. The basin on the right is standard depth and the basin on the left is about 12" deep! Huge!! :)

Here are some before and after pics of the kitchen and sink (the album called "sink" is the public album). The new kitchen isn't really this orange - more like a spice color. Counters are black and the cabinets are pure white. That's a new window too. The old kitchen was even fuglier than the pictures show (and very used). I had to take it down to the studs to replace all of the plumbing, wiring, and insulation - the house is 80 years old, after all.

So whatcha you think - you like-a de sink?

-HK

Literature Review: Severe Sepsis in Children

2007-01-23T01:19:00.000-08:00

Watson, R.S., Carcillo, J.A. (2005). Scope and epidemiology of pediatric sepsis. Pediatric Critical Care Medicine, 6 (supplement) S3-S5.

WHO defines "severe" sepsis as that which causes acidosis and/or hypotension (low blood pressure). There are four major killers of children worldwide:

pneumonia

diarrhoea

malaria

measles

(in order of deaths per year, highest to lowest.) People in developed countries don't think of diarrhoea as a deadly condition, but it kills children like you wouldn't believe. Check out what WHO has to say about it:

Amongst the poor and especially in developing countries, diarrhoea is a major killer. In 1998, diarrhoea was estimated to have killed 2.2 million people, most of whom were under 5 years of age (WHO, 2000). Each year there are approximately 4 billion cases of diarrhoea worldwide.

4 billion. Crazy, huh? If it were spread evenly throughout the year (unlikely), that'd be almost eleven million a day. Anyhoo, moving right along...

Low & Very Low Birth Weight (VLBW) infants made up one quarter of all paediatric sepsis cases in the US in 1995.

Sepsis in children often occurs with an underlying condition. In babies, it's usually chronic lung disease or congenital heart disease. In the 1-9 years bracket, neuromuscular disease is more common. In adolescents, cancer.

Severe sepsis is associated with a 10.3% hospital mortality in children. 7.8% in those who were previously healthy, and 12.8% in kids with underlying disease. Overall 4 400 deaths associated with severe sepsis. Endocarditis and infections of the CNS had the highest mortality. (All US figures from 1995.)

Sepsis is expensive. 1.7 billion total hospital cost associated with severe sepsis nationally.

A preliminary look at 1999 data shows a pattern of increased incidence and decreased mortality. The authors postulate increase in VLBW babies and increased rate of sepsis among those babies.

One of the difficulties of getting better at treating children who are vulnerable to infection because of underlying diseases is that they survive longer, which increases the 'at risk' population. That probably sounds horribly callous, but it's a reality of healthcare today: we've gotten better at keeping people alive, so we need to deal with patients who are more vulnerable to infections--in every age group, not just paediatrics. Everybody's got their 'frequent flyer' stories... patients who present again and again with pneumonia, bronchiolitis, vomiting and diarrhoea, name your poison.

1.6 million neonates die worldwide every year from infection. That's not solely premature babies, folks... that's any baby under 28 days old. Newborns, in other words.

They point out that sepsis can usually be identified in developing countries without sophisticated laboratory facilities. Tachycardia (a faster than usual heart rate) and other physical signs can be predictive of sepsis, and the use of cheap antibiotics in patients identified in this way has significantly reduced mortality rate.

Shock is the most important risk factor for mortality in septic children.

The authors warn about the difficulty of generalising results in adult studies to paediatric populations. This is not a new problem. It's often difficult to justify doing trials on kids. Getting ethics approval is fraught, and parents are obviously worried about the safety of their children so obtaining consent is no picnic either.

Trouble is, adults and babies are different (duh). What works for severe sepsis in adults may not be as effective in children, or have unforseen consequences particularly when you take the differences in their underlying diseases into account.

ED med review by Pharmacy 1st?

2007-01-20T19:36:00.000-08:00

Dear Colleague:

Your response to the JCAHO survey dealing with pharmacist first-dose review of non-urgent medications administered in the ED is URGENTLY needed. Despite ENA's efforts along with colleague organizations AAEM and ACEP, we have been unable to convince JCAHO of the lack of necessity for its Proposed Revisions to the Medication Management Standards MM 4.10. ENA believes the JCAHO revisions are not evidence-based and that they will overburden the ED and compromise patient care.

For a link to the JCAHO survey, click here,

Background information on ENA's position can be accessed by clicking here.

The survey deadline is January 24, 2007. Please act today!

Donna Mason, RN, MS, CEN
President
Emergency Nurses Association

The Overdraft Blues

2007-01-20T14:25:00.000-08:00

I wanted to do a few papers towards my masters degree this semester. After Christmas it's become clear that not only do I not have the money, I barely have enough to pay the bills.

Let me be plain, this is not because I'm paid just on or above the poverty line. I earn something like $40 000 per year, gross. Not US dollars (if only!) It's enough to live, if not comfortably, then at least without worry over where the next meal is coming from. If I worked at a comparable job in a PICU in the US I would make between twice to three times what I make here, depending on location and bonuses. In the UAE, about the same once you discount the taxation differences. Still, I get a reasonable wage. I think it should be more, but I'm aware that there is not a whole lot of extra money flying around in our national health budget and I'm (somewhat) resigned to that.

The trouble is, I'm not terribly good at managing what I earn. Real estate is extremely expensive here, and at my current rate of saving I'll be fortunate to be able to afford to put a deposit on a house sometime in my fourties. Very fortunate, actually. I may need to become resigned to something else: renting for the rest of my life.

So, further education is on hold for at least the first half of the year. It's becoming more and more tempting to take a working holiday overseas to build up some reserves, although right now it's the last thing I want to do.

Home

2007-01-19T20:59:00.000-08:00

Well, I'm back again. A great rest.

I learned quite a bit about our country over the past month. Particularly, it's very beautiful, and has fickle weather!

Back to work soon, and about time too. I suspect I'll have to learn everything from scratch. I dimly recall the general principles... something about any patient you can walk away from is a good one?

Happy New Year!

2007-01-01T17:30:00.000-08:00

I'm nowhere near home right now, and Internet access is sporadic hence... oh, I could use it as an excuse but mainly I'm just skiving off and not doing useful things like blogging and, well, shaving. Touring some favourite areas of national park and spending time with extended family.

Here's hoping you and yours are enjoying a holiday too, if that's what you do at this time of year, and best wishes for 2007.

Merry Christmas 2006

2006-12-24T18:39:00.000-08:00

Merry Christmas to all! I hope you've all had a healthy and happy year and best wishes for a great 2007.

A big Thank You to all our families (mine included) who understand why we don't always get Christmas off, and deal with it in a gracious and understanding manner. Support at home makes it just that much easier to do what we need to do. Christmas is a state of mind, not a particular hour of a specific day.

Love to you all,
--HK

Turkey Cake and Whiskey Cranberries

2006-11-29T21:29:00.000-08:00

Ah - you've found my early post archive! I talked about making a cake in the shape of a turkey, decorated with piped-frosting feathers with large feathers for the tail created by pouring feather-shapes out of chocolate onto skewers and letting them harden then poking them ever-so-gently into the turkey bee-hind region! Sound like a chore? It is! Sound extra-yummy? Heck yeah... the kids especially love walking around nibbling on the tail feathers which can be carried around like lollipops once removed from aforementioned turkey butt. Big hit with my family.

In another post I wrote about brining a turkey - it makes the absolute juiciest turkey you've ever tasted for just a tad bit of forethought and an overnight soak. I didn't soak it in whiskey, although that does sound interesting, but I made a really awesome sauce out of whiskey and cranberries.

I never did get pics of the turkey cake posted. I couldn't make one this year because my kitchen still isn't finished. Some days I'll work hard on it and get a lot done, others I get home from the hospital totally worn out and have no energy left to do more than look at it and sigh. I guess that's also my excuse for not posting.

My sister is coming from Florida mid-December and she'll see the new house for the first time. I'm trying to get the kitchen done prior to that and also paint the livingroom/diningroom. I'm really not that far from finishing if I can just focus a few more days of solid work into it.

It's snowing at the house right now. My daughter had the last few days of school cancelled because of the icy roads and it's looking like tomorrow will be a snow-day too. I just bought a set of studded tires so I'll be sure to get to work - does that count as a tax deduction? :)

Hope tomorrow isn't too bad. When it's bad they don't open the espresso bar...

Nurses and Ventilators

2006-11-29T18:03:00.000-08:00

How much do nurses need to know about ventilators?

This is another of those questions found in the "search engine keywords" section of our counter software.

The answer is, it depends where you work.

In the US, for example, many (but not all) critical care units use Respiratory Therapists to do much of their ventilator management. The position of RT does not exist where I work, so nurses do all of the ventilation, guided by the senior medical staff.

In our PICU, I would hope that the new nurses would know at minimum:

Which type of ventilator we use for which patients

Which circuit size and type to choose when setting up

How to set up and check each ventilator correctly (this is quite a lot more complicated than it sounds)

How to strip and clean each ventilator without throwing anything important away!

Standard settings for inspiratory time, PEEP, assist sensitivity and so on.

How to set sensible alarm limits.

How to manually ventilate safely and effectively using an anaesthetic bag.

How to wean a patient from ventilation.

This is a fair bit of learning in itself, especially when you take into account all the different age groups and conditions that a nurse here might be expected to encounter. There's also all the attendant skills like being able to suction, change ETT taping, good positioning, preventing ETT-related pressure areas and the list goes on. Fortunately we never work in isolation, and there is always someone to ask in case of uncertainty.

More senior nurses would need to be able to:

Set up, test and use our various transport ventilators.

Set up, test and use a High Frequency Oscillator.

Troubleshoot all ventilator types on the unit.

Be able to distinguish between a machine problem and a patient problem (this can be a particularly hard skill to learn.)

Have a sense of what their patient will tolerate in terms of weaning, level of activity, procedures, how much sedation is required, and so on. You can't teach this, it's experiential.

Be able to spot deterioration early, and do something about it.

There will be a subset of the nurses, maybe four or five in the unit, for whom ventilation is a particular area of interest. They're good resources on ventilation and provide a sounding board for the team. Ditto some of the docs.

The junior medical staff are often unfamiliar with the ventilators depending on what their background has been. I say "junior", really they've been at this awhile because we don't have beginner docs rotating through PICU. Still, it's unrealistic to expect some of them to have anything more than the fundamentals of ventilator theory. They can tell me about Bernoulli's law but are not used to standing and watching the rise and fall of a chest, listening to the subtle changes in sound from the machine and the circuit, reading blood gases and the monitor with the patient and not just the textbook in mind.

They might, for example, understand in a basic sense what SIMV mode implies, but not know the details of how SIMV is delivered on one particular ventilator. Since all manufacturers have their own interpretation on SIMV, this can be distinctly different from machine to machine. Often senior nurses fill in the gaps in this understanding, which requires that you know the common modes on your ventilators inside and out. Not just the manual's description, but what you've learned about patient response to the mode during thousands of hours of observation.

Oh, and just in case you weren't feeling like you had enough responsibility yet:

You are your patient's last defence against hospital-acquired respiratory infection.
You are your patient's last defence against apnoea.
You are your patient's last defence against baro/volutrauma.
You are your patient's last defence against a bad ventilation order.
You are your patient's first and last defence against accidental extubation and airway occlusion.

We take it seriously because, well, it's breathing. Breathing is good. Not breathing is bad. In randomised controlled trials, 100% of patients who breathe do better than patients who do not. Scientific fact.

Your Questions Answered (Again)

2006-11-28T17:56:00.000-08:00

It's time for another round of search keywords from our Tracksy counter!

You asked: Decorated turkey cake?

Er... a cake made of turkey, or a cake in the shape of a turkey? I'm assuming you mean the latter. Well, let's see now. I don't recall ever posting about turkey, let alone a turkey cake. Maybe HK did?

A quick Google gobble later... yep! Actually in her second ever post to Mediblogopathy, HK posted about turkey cake. So there you are. No photos or recipes though.

You asked: What does ETOH mean?

Again with the ETOH? It's alcohol. Just plain common or garden alcohol. Sheesh.

You asked: What is the effect on patient care when nurses don't take their lunch breaks?

I'll tell you what the effect is. They get crabby. The nurses, that is. They get crabby and tired and frustrated and, well, hungry. Same with surgical residents. Actually that goes for anyone who doesn't get a few minutes to strap the feed bag on. I don't have references for you, but at the end of the day no matter how much you try not to let it affect your performance, it does. Not to be recommended.

You mentioned: I hate my job.

I'm terribly sorry to hear that. I love my job! I just am growing to dislike the little moonlighting position I'm in at the moment. 12 days to freedom!

You asked: Decorated turkey cake.

Cake made from decorated turkeys? Curiouser and curiouser.

You wondered: Grays Anatomy, If I Lay Here?

Yes. That post may come back to haunt me. It's Snow Patrol, ok? The song is called Chasing Cars.

You asked: Nursing sucks?

Sometimes. Sometimes it sucks. It sucks being awake at night when sane people are tucked up in bed. It sucks scraping vomit off your shoulder, vomit that doesn't belong to you and has no business being in contact with your person. It sucks watching people die. It sucks getting paid less than you'd get mowing lawns for a living (in this country, at least.)

But we do it anyway. Because it rocks. So there you have it: nursing sucks some of the time, but mostly it rocks. QED.

You asked: brining a turkey in whiskey?

Two thoughts occur. One is that I really shouldn't do this exercise so close to Thanksgiving. The other is that I'm coming to your place for dinner!

White Ribbon

2006-11-23T15:57:00.000-08:00

The White Ribbon Campaign is a statement by men against domestic violence. Conversely, it's also an opportunity for men to stop talking and listen to women about violence in the family.

It's happening all over the world.

Yay!

2006-11-05T17:12:00.000-08:00

The technician's position I'm relieving for has been filled!  I get my old job back.

It's such a relief to have this over with before I go away on annual leave at Christmas.  Man, I missed being a bedside nurse.  Plus I get my 12 hour shifts back.  And... night shifts.  Oh well, nothing's perfect.

Only a month to go!  Scuze me while I go celebrate.

Sun's Out

2006-11-01T19:05:00.000-08:00

It's been awhile.  I've been rather blue lately, unmotivated to blog.  A combination of life's woes and being stuck in a job I don't enjoy.  Hopefully the new year will bring me back to what I love, and in the meantime the sun is out and the sky is blue.

To the woman who drove me to work in her taxi this morning: yes, paediatric intensive care units are open 24 hours.  We don't pack up all the ventilators at 5 PM and go on home.  Sheesh.

I still struggle to explain to people what it is we do here, which I guess is why Nick once called many of my posts 'didactic'.  I feel the urge to lay it all out for people to read, but at the same time to circle the wagons and protect us from scrutiny.  I want to say, we have to make some horrible choices here, and yet you should know we exist.  And yet, you shouldn't worry about us until you need us.  And yet, and yet...

Sun's out today, and I don't have to teach anyone how to bleed the nitric two-stage regulator.  That's got to be enough to feel good about.

Pointing The Finger

2006-10-23T11:06:00.000-07:00

Happy, Yoda is not.

Usually, in blog-mode, I try to stay positive. I know rant blogs get more hits, but I don't really want to go there. Today I have to make an exception to that policy. This is not directed at any one person, but at the growing and annoying trend in medblogs to trash either nursing, doctoring, or [ insert profession here ].

It's happening on all sides, with lashings of hyperbole and shrill yearning for the mythical "Good Old Days". The bleating goes something like this:

Oh, but those people aren't very intelligent, and those ones over there make lots of mistakes and that other group is insulting and these people are arrogant and those don't know their place, and I've got a story about how bad they are...

Please.

Everyone has stories. I've got a million of 'em. Professionals of every ilk making woeful mistakes. That's because people do, on the whole. They screw up. Over and over again, myriad bone-headed errors. Telling anecdotes (some of which are first-hand experience, some the hospital equivalent of urban legend) is all very droll, and it will score you lots of hits and a healthy comment section, but it does little to reflect the reality of any professional body.

You want to do something that makes a difference? Right here and now? Clean up your own damn backyard. Fix what's wrong with your profession, before you come bleating to me about someone else's.

I am so off-the-scale tired of people in healthcare using other professions to score political points or make themselves look smart. There's been so much discussion of who's more intelligent lately that I'm forced to wonder if anybody has more than a couple of brain cells to rub together. Apparently bright minds suggesting that one professional group is ruining healthcare in their country. Aren't we past this yet?

We're supposed to make each other better. Professions are supposed to evolve. Along the way, guess what? We're going to make mistakes. We don't have all the answers yet, and anyone who purports to in their blog o' t' week is yanking your chain.

All Out of Sorts

2006-10-18T21:54:00.000-07:00

I couldn't seem to concentrate today. Slouched through the morning like a zombie... a listless, tired, bad-tempered zombie. Spent the afternoon trying to resurrect myself with caffeine and sugar, which is no doubt going to make me feel even worse.

So, let's go with a happy story. Didn't recognise the kid making all the noise today, but man did he have some lungs on him. Turns out he'd just been 'decannulated' (had his tracheostomy removed). Wasn't a fan of breathing the normal way, after a couple of years of having a plastic tube.

Then his parents were saying hi to me as I was wandering around the room doing equipment checks, and I realised I'd looked after him when he'd first had the trach put in, and for quite awhile if memory serves.

So we fixed one. Cool.