Rounds

This week it's Protect the Airway's turn to host Grand Rounds.

Long Haul

I had the great pleasure of a long-awaited cuddle with one of my primary patients today.

I know, not traditionally a nursing outcome, certainly nothing mentioned about it in the NANDA diagnoses, but after an extended PICU admission, with other patients not so lucky along the way, you love to see that one make it to the ward. The reassurance of an angry, coughing, hungry, tired baby wriggling in your arms for a few seconds is a reward born of many hours of worry and concentration.

Maybe I over-dramatise, I don't know. I do know I didn't want to put her down. Good way to end the day.

Rounds

Around and around and around till it don't stop...

Grand Rounds turns 100 this week, party's at Dr Charles' (no RSVP required.)
Change of Shift, at Kim's.
Paediatric Grand Rounds, at Millner's Dream (it's not up yet, but due in around 24 hrs. I'll direct-link it later.)

13 Weeks

You can watch snippets of these guys here. Some work stuff, some not-so-work stuff.

Guilt Trips

I think that's enough messing around with the template for one day! Still lots to do, but we're getting there.

I had one of those shifts yesterday which involved lots of TASKS. Gotta love those nursing tasks. Let's see if I can remember them all:

• 12 sets of hourly vitals, including complicated fluid balance.


• Primary assessment (A,B,C,D,E)


• Secondary assessment (body systems)


• Four antibiotic doses


• Six sedation/analgesia boluses, and one muscle relaxant


• Eight or nine doses of various oral medications


• Three blood gases, gentamicin level, thyroid function and cortisol levels


• Four ETT suctions


• One sponge bath and linen change


• Concentrate frusemide and milrinone infusions to reduce volume


• Switch three other infusions to 10% dextrose to offset lack of nutrition somewhat


• Switch feeds to more concentrated formula for same reason


• Re-tape ETT (tapes get a bit wet with secretions and loose, which is a safety issue)


• Position for mobile chest xray


• Change arterial line transducer set and infusion.


• Cardiac rounds


• Unit rounds


• Multidisciplinary rounds


• Assist colleague to complete checks on a ventilator she was unfamiliar with


• Assist colleague with extubating her patient


• Assist various colleagues with various drug checks


• Troubleshoot, then remove a peripheral cannula that was leaking


• Wean ventilation ever so slowly, due to patient's overall fragility and history of not tolerating sudden changes in treatment


• Handover, one at each end of shift.

When I write it down, it seems like a lot which makes me feel better because in actual fact I didn't finish everything I wanted to, and was rushed at shift change. At the end of the day I hadn't finished vitals for the previous two hours, and this was with several nurses pitching in to help. It always makes me feel deflated because if I'd only crammed more into the day, organised differently, etc.

If only.

The above list doesn't even begin to cover it, because it's TASKS. This is something healthcare management often does not comprehend when considering nursing staff ratios, although I will say for the record that I am extremely fortunate to work in a facility that very sensibly staffs ICU patients at one to one, or at most one to two.

What is the list missing? Constant assessment and monitoring. Do I do an assessment at the start of the day, then stop? Of course not. Critical care nursing is about watching for change, watching for trouble, looking for the previously-unnoticed problem. Planning (I almost want to say, scheming.) Talking with the family, since you're sharing space with them for 12 hours. Speaking with the team behind you. In yesterday's case, negotiating between them since everybody seemed to have a different idea of The Right Thing To Do. Supporting. Seeking confirmation. Seeking reassurance. Answering question after question after...

These things are difficult to quantify, and difficult to time. Often impossible to plan for. I know I have time management issues, always have done, even after seven years as an RN and five in intensive care. Can't do much more than try to improve, every day.

Nurses guilt trip themselves a great deal, it seems to me. The good ones get over it. I felt bad about the way the shift ended yesterday, but it's breakfast time now and I'm over it.

Mmmmmmm. Bagels.

A New Look for Mediblogopathy

No, you didn't visit the wrong blog by mistake. We've moved some of the furniture around, but it's still the same place!

This is a slightly unfinished version of our new look, so we hope you'll be patient with us while we iron out the little problems and transfer everything over from the old site. We decided to plug in the new template early to fix browsing problems for Firefox users, and a few other glitches.

Enjoy!

Mistakes

More on students... this is one page of advice I give my pre-registration 'preceptees' (hate that word!)


Shit Happens

One of the things you're going to discover as you begin your career is that nursing and medicine are imperfect. Some days I wonder that anyone leaves the hospital at all! Human error is part and parcel of what we do, which is why we have so many checks and balances in place.

Mistakes have a role to play, believe it or not. Making little mistakes occasionally can teach you to avoid making the big, life-threatening, catastrophic mistakes. That sick feeling you get when you realise what's happened; you do remember that, and it teaches you caution.

No-one expects a new graduate nurse, certainly not a pre-reg nurse, to be perfect. Or rather, those that do are kidding themselves. What they do have a right to expect is that you adjust your behaviour so that you don't make the same mistake twice, because this is the difference between a smart nurse improving their practice, and a negligent nurse who will eventually become a liability.

So in other words, learn from your mistakes but don't dwell on them.

There are things you can do to limit the possibility of making one in the first place. One in particular is a thing called 'mindfulness'. It's about being aware of exactly what you're doing and why you're doing it. Watching, listening to and making contact with your patient. Being more than usually alert to changes and details.

Staying in this state all day might be a bit exhausting! However, if you can teach yourself to assume this attitude before giving drugs, before doing procedures, and when you first receive a patient on admission, you will go a long way towards reducing the number of errors you make. (You will never entirely eliminate errors.)

Finally, stop and think. Take a breath. Ask, "What am I missing here?" Then act.

Oh, and have some fun with it. People who enjoy themselves make fewer errors. Scientific fact!

Medical Clearance

The CDMHPs (basically like mental health cops for the county) call us and screen patients in before they send them over. We have to make sure we can handle the patients needs - there are certain things we don't do being a psych hospital (dialysis for example). If someone hasn't been in very recently we ask the CDMHP to send them for medical clearance, which means they get sent over to the local hospital to make sure they haven't got a serious medical problem causing their mental status to change.

me: we're going to need medical clearance on her before she comes here

MHP: no need for that, she's fine

me: she hasn't been in the hospital in months and you're saying she's off all her meds

MHP: but she's ok, she looks fine.

me: whats her blood pressure - you say she's got HTN (among other things)

MHP: I'll have to check around the home and see if anyone's taken her blood pressure lately (shuffling noises.. muffled words...) They say she's taking her thyroid pill but she doesn't have anything for HTN, so she is fine. Even if you send her into the hospital she's not going to let them do any tests or draw blood or anything. She's only going to cause problems there. She's in a very bad mood. She's going to be extremely difficult.

me: (speechless)

me: would you like me to call my nurse manager and verify that I am following the corect guidelines in this case?

MHP: no, no... we'll send her.... it's just going to be a bother for her.

Fiji Nurses Battle Stupidity

Sorry to be so negative but this article deserves a note. Had to add in my own comments too. It's not that nurses shouldn't smile or shouldn't care, but if this guy thinks that's going to solve all of his problems he's in for a rude awakening.

I can imagine him telling his constituents that he's Doing Something about the "problem with healthcare". -HK

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FIJI: Health CEO Challenges Nurses
Tuesday: August 8, 2006

(Fiji Govt PR) - Health Chief Executive Officer Dr Lepani Waqatakirewa yesterday (07/08) challenged nurses to emulate the 'smiling service' of policeman Kolinio Baivou.

Mr Baivou, who can be seen every morning controlling traffic at the Ratu Mara Road and Mead Road junction in Nabua, was featured in the Fiji Times issue of Saturday, August 5. (ed: so nursing is about as easy as controlling traffic?)

With a photocopy of the smiling Mr Baivou in hand, Dr Waqatakirewa said that nurses should take up the challenge and learn to be more friendly while they serve people.

"You have to smile, even though you might not have a syringe to use. You can go out and greet those waiting to be served and talk to them," Dr Waqatakirewa said. (ed: obviously, you've got nothing better to do than entertain people who are waiting to see the doctor...)

Dr Waqatakirewa told the nurses that if they practiced smiling and friendly service then they would be able to win the confidence of the public. (ed: I bet with better hours, better pay, and a teeny bit of respect they wouldn't have to "practice smiling")

Senior nurses from the country's 19 sub-divisions are attending a Capacity Building and Supervision Strengthening Workshop at the Southern Cross Hotel in Suva.

Facilitated by the Public Health Division of the Ministry of Health, the workshop is aimed at helping nurses understand the importance of their daily work better in relation to the achievement of the Ministry's Strategic Plan and the international Millennium Development Goals.

Dr Waqatakirewa said lately nurses have been in the media because of poor attitude shown while serving patients.

He said this negative portrayal of nurses could be changed if the nurses themselves decide to show more positive attitude while working. (ed: did I mention better hours and better pay?)

Director Nursing and Health System Standards, Senior Sister Rigieta Nadakuitavuki also challenged senior nurses to review their supervision abilities and see if they have been effective.

"œThe next two days will present you with a lot of resources that you can use to help you better your supervision skills. This will give you the time to see for yourself whether you have been able to stay to the course or if you have not achieved your plans then that tells you that something is wrong," Mrs Nadakuitavuki said.

She also told nurses that human skills are very important in their field of work.

"We have to be able to show our human skills. The smiles, the caring. We have to do this in our field of work so that our patients feel good to be served by us," she said.

Director Public Health Dr Timaima Tuiketei said that the workshop would help the selected nurses become better nurses with the knowledge they would take back with them.

She said that the workshop was set-up so that nurses can be briefed on the new Ministry of Health plans in line with the new Development Plan that the multi-party cabinet is working on for 2007-2011. (ed: by god, get on board with the development plan - nevermind patient care, we're talking Big Picture here.)

"And more importantly we are trying to help nurses understand the linkage between their daily work, the ministry's strategic plan and the Millennium Development Goals, as we are signatories to a number of international conventions on health," Dr Tuiketei said.(ed: jeez, I thought daily work was all about helping the patient, not the Ministry...I guess I need more help to understand just how important that is!)

Book Meme

Well, I'm back from my weekend away up north, where it rained and rained and rained and rained and RAINED! We're talking flooding here, folks. But at least no city, no traffic noise, no sirens, no noisy neighbours. Gotta love it.

On my return, I find I've been tagged by Neonatal Doc. Please do yourself a favour and read his blog, updated regularly with thoughtful musings on life in the NICU.

One book that changed my life: The Dispossessed, Ursula Le Guin. When Brian Aldiss called it "a high water mark of modern science fiction, illuminating its medium" he wasn't kidding. It not only illuminates the SF medium but transcends it. The kind of book I find necessary to have in the house, just to know it's there to be read if I want.

"There wasn't a doctor. You couldn't do anything for him, except just stay there, be with him. He was in shock but mostly conscious. He was in terrible pain, mostly from his hands--I don't think he knew the rest of his body was all charred, he felt it mostly in his hands. You couldn't touch him to comfort him, the skin and flesh would come away at your touch, and he'd scream. You couldn't do anything for him. There was no aid to give. Maybe he knew we were there, I don't know. It didn't do him any good. You couldn't do anything for him. Then I saw...you see...I saw that you can't do anything for anybody. We can't save each other. Or ourselves."

"What have you left, then? Isolation and despair! You're denying brotherhood, Shevek!" the tall girl cried.

"No--no, I'm not. I'm trying to say what I think brotherhood really is. It begins--it begins in shared pain."

"Then where does it end?"

"I don't know. I don't know yet."

One book I've read more than once: The Bone People, Keri Hulme. This won the Booker Prize in 1985 and is a wonderful introduction to New Zealand fiction (if you've never read any.)

The sound of the sea.

A gull keening.

When the smoke is finished, she unscrews the top of the stick and draws out seven inches of barbed steel. It fits neatly into slots in the stick top.

"Now, flounders are easy to spear, providing one minds the toes."

Whose, hers or the fishes', she has never bothered finding out. She rolls her jeans legs up as far as they'll go, then slips down into the cold water. She steps ankle deep, then knee deep, and stands, feeling for the moving of the tide. Then slowly, keeping the early morning sun in front of her, she begins to stalk, mind in her hands and eyes looking only for the puff of mud and swift silted skid of a disturbed flounder.

All this attention for sneaking up on a fish? And they say we humans are intelligent. Sheeit...

One book I would want on a desert island: The Chicago Manual of Style, University of Chicago Press. My goal would be to get to the end before being rescued or gutting myself with a fish knife, whichever came first.

Among the factors governing the choice between spelling out numbers and using numerals are whether the number is large or small, whether it is an approximation or an exact quantity, what kind of entity it stands for, and what context it appears in.

One book that made me laugh: Good Omens: The Nice and Accurate Prophecies of Agnes Nutter, Witch, Neil Gaiman and Terry Pratchett.

Archbishop James Usher (1580-1656) published Annales Ve et Novi Testamenti in 1654, which suggested that Heaven and the Earth were created in 4004 B.C. One of his aides took the calculation further, and was able to announce triumphantly that the Earth was created on Sunday the 21st October, 4004 B.C., at exactly 9:00 A.M., because God liked to get work done early in the morning while he was feeling fresh.

This too was incorrect. By almost a quarter of an hour.

The whole business with the fossilized dinosaur skeletons was a joke the paleontologists haven't seen yet.

One book that made me cry: Towing Jehovah, James Morrow. Mainly because I was laughing so hard. Best satirist of his generation.

One book I wish had been written: Acquire an Encyclopaedic Understanding of Human Endocrine Disorders in 10 Easy Lessons. Endocrine stuff just confuses the crap out of me. I admit it.

One book I wish had never been written: Harry Potter and the Philosopher's Stone, JK Rowling. Sorry all you die-hard Potterites, but I am not a fan. Why is it the really good novels for children don't sell as well as this stuff?

Then again, I'm sure Rowling really doesn't give a crap about my opinion, or if she does her gazillions of dollars will be a comfort to her in her distress.

One book I am currently reading: K Road, Ted Dawe. Just finished it in fact. Novel for young adults about drug culture in New Zealand. Good narrative but left me feeling a bit, "Ok, so now what?" at the end.

One book I am meaning to read: A Farewell to Arms, Ernest Hemingway. Because I never have.

Five victims for further literary punishment: The Miscellaneous Mischevious Misadventures of MissBHavens, March of the Platypi, NeoNurseChic, The Ramblings of a Nurse Anesthetist, KT Living. Because they were the last five recently-updated bloggers that I read tonight on the Mediblogopathy nurse blogs list. Consider yourselves tagged.

Rounds and Rounds

Change of Shift, a collection of the best of nurse bloggers.

Medblog Grand Rounds, this week at Inside Surgery.

Read. Enjoy.

Compromise

So I'm sitting here on this rainy day, looking at the Mediblogopathy template (which HK, in a fit of what can only be described as insanity, has let me loose on) and thinking about compromise.

I could design something that would suit me perfectly. It would likely be minimalist, a kanji sort of blog...


My colleague's ideal blog could be more colourful, vibrant, in your face...


It's a very personal thing, to open up your writing space to some stranger on the other side of the world. Never mind that Mediblogopathy is a bit overdue for a tidy-up, and we were working on just that a few months back, but it's still an invasion of sorts to have someone come in and suggest changes, or even pass comment on what had gone before.

Having a nursing student is a bit like that. An interloper, come to scrutinise your territory and make observations about whether your clinical practice is in keeping with the standards of the day. There's nothing quite like some young thing comparing you to a textbook definition to make you take a second look at your work.

It's not possible to assign students their own patients on our unit, due to the unstable and challenging nature of the patient population. Instead, they're assigned to an RN who works with them for 12 hours at a stretch. That's 12 hours of one-on-one instruction. Even school teachers get to go home after 8 hours.

The energy required is not to be underestimated. I sometimes wonder if some people at my work think I'm lazy, having the student do everything for me and just sitting on my hands. The truth is, I go home exhausted at the end of those days when I'm assigned a student or new grad. Completely drained. It's hard. The easy route is to do everything yourself.

There is compromise, or a balance to be found, in having students in critical care at all. Allowing them to do more than just sit, staring at the monitor, but keeping them and the patient safe. There are certainly those in the profession who would like nothing better than to have students sit in the corner and never go near the patient, or better still not be on the unit in the first place! These nurses have perhaps never admitted to themselves this fundamental truth of paediatric intensive care:

Killing a patient is difficult.

Don't believe me? It's true, I swear! These kids are actually fairly hard to kill. We're so careful, but in fact much of what we do is of necessity over-cautious. Students, by and large, don't kill patients nearly so often as graduate registered nurses. It's not the students we have to be worried about.

I had a student once who, while I had a few days off, was assigned to another nurse and left a bedside down while she went to get something from out of the room. You simply would not believe the wailing and gnashing of teeth that arose from this simple incident. Never mind that doctors reviewing a patient do it all the time, or that the patient in the bed was no more capable of rolling out of it than of conquering Everest; safety had been compromised. Shock. Horror.

That's not to say I wouldn't have kicked her ass if I'd been there. Soundly and swiftly would that ass have been kicked. Tell you what wouldn't have happened though... she wouldn't have been left to feel as if she'd failed her training because of one ridiculous little incident. It's about finding a balance.

Maybe preceptors do assume a little more risk on behalf of their charges. I know this same student had other difficulties, where she was felt by those working with her to be overconfident, unsafe, even to the point that her clinical lecturer asked me whether or not she should pass or fail the placement, and what grade should be assigned. I told her I thought the mistakes stemmed from a tendency toward over-enthusiasm for her work, and that I felt sure she would settle down within her first few months of new graduate practice. I could have said, "No, kick her out for screwing up a few times," but then I would be compelled to recommend the expulsion of 95% of working RNs for the same offence.

Compromise. I will accept your questions, and sometimes your implicit criticism, because I know that you have yet to find your understanding of your intended profession, and I will keep you safe while you search for it. I will not expect perfection, and you will learn not to; we'll find the middle ground in our own time.