Turkey Cake and Whiskey Cranberries

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

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)

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

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!

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

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.