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.

Grand Rounds

2006-10-17T19:44:00.000-07:00

Speaking of caffeine, Kim delivers a Grand Rounds this week that's bound to get your dopamine levels up.

I Hate My Job

2006-10-17T19:41:00.000-07:00

No, not my real job. I had a clinical shift yesterday, and god it was good. Today, back in the office, it's been one long climb up Lack Of Motivation Hill.

I miss my colleagues. I had so much fun yesterday, and it was with the simplest of patients that really didn't need a PICU admission. It was just interacting, teasing, working together on all of our patients, figuring out problems. Healing the sick, y'know?

PaedsRN: My caffeine is wearing off.

RN1: (Concentrating on changing a feed line.) What?

PaedsRN: I said, my caffeine is wearing off.

RN1: (Thinking she's missed some important clinical statement, moving over to me.) Sorry, I didn't hear you?

PaedsRN: MY CAFFEINE IS WEARING OFF! NEED MORE CAFFEINE!

It was a fun day. I want my job back.

Mondays

2006-10-16T11:34:00.000-07:00

This relief job I'm doing at the moment has introduced me to a new concept in the wage-slave's life: Mondays.

I've been a shift worker ever since I left school. The days of the week have less meaning when your 'weekend' is on a Tuesday, and you start night shifts on a Thursday. You just don't notice what day it is, although you do remark that there's an awful lot of people out partying on Friday and Saturday when you're trying to sleep, and hanging around looking hung over on Sunday morning when you're on your way to work.

Nowadays, I get to work on Monday morning and the entire weekend's accumulated detritus is waiting for me in my office. Usually five or six ventilators have had some problem occur and need 'treatment'. Some were user error, ignorance, or just a nurse in a tearing hurry who didn't have time to sit and troubleshoot, so grabbed another one. There'll be cables that don't work, monitors that need rebooting, heat tables that don't heat, and all the other things that Murphy's Law dictates will go wrong on the weekend when there's fewer people to fix 'em.

And the notes. Oh god, the notes. Scribbled on scrap paper, paper towels, the back of opened sterile packs, clinical note paper. Ballpoint pen, fluorescent felt tips, highlighters. "This passed its checks but doesn't work." "This one has rust on the battery mount." "This keeps alarming and I don't know why!"

None of them signed. Why don't they want to leave their names? Are they afraid I'll punish them for breaking things?

Hrm. I could start a whole new line of staff education... don't break it, or You Will Be Punished.

Go ahead. Break it. Make my day.

Demystifying PICU, part 2: Chaos Theory

2006-10-14T16:45:00.000-07:00

So, you've had some very bad luck and your son or daughter has been admitted to PICU.

What you see when you get here will likely dismay you at first. After that has subsided, most people we talk to profess relief that they are in critical care. They figure, if they're going to have to go through this ordeal, they'd rather go through it with as many experienced people around as possible. All our resources and equipment concentrated in one spot.

The trouble with having all that cool stuff: lots of technology, and lots of people, is that the more interactions you concentrate into a small space, the more chaotic it seems. We're like ants, or bees: we swarm, and it can all happen very quickly indeed. I wish we were better at it. One PICU even worked with Ferrari's pit crew to improve their routine. Maybe they'll come up with something good, but in the meantime it's chaos.

In their own way, the child creates their own chaotic locus. Their anxiety, distress, difficult breathing, low blood pressure or whatever has caused this admission demands an answer, now, and the PICU ant swarm must assemble its response! We try to create order from their chaos, first of all.

Because of this, one of the first things you may see us do is sedate your child. People react in different ways to this. Some are glad to see their son or daughter finally get some rest, albeit enforced. Others are frightened when they see how still their child has become. Often you will notice our work seeming somewhat more organised at this time, because we no longer need to restrain or distract the patient.

Depending on how sick your child is, you may see a great deal more activity. It's not uncommon for us to have three nurses and two doctors working with the same patient, not to mention all the extra people like radiographers, consultant physicians, surgeons, anaesthetists, a transport team, maybe a social worker and a ward clerk thrown in there for good measure. During all of this we may occasionally lose sight of our need to keep you informed. For the most part we try not to, but sometimes we don't know ourselves what to say yet. Sometimes it really is better to step out into the hallway for a few minutes, grab some water and take a few deep breaths.

Usually there are people ducking and weaving around each other as they reach for a pump alarming, the ventilator, a peripheral line, a chest drain, or whatever else they need to work with. It's a clumsy kind of dance, people in pyjamas pirouette and bow as they negotiate the throng. Sometimes I wish I could watch it from above... one of these days I'll install a camera on the ceiling.

Thankfully, in PICU chaos is fleeting. Sooner or later the pyjama dance is over and the bodies at the bedspace drift away. There should be a plan for the next few hours in place. The bedside nurse will still be working through various jobs but she will have time to talk again while she's doing them. Hopefully the PICU consultant will also have extricated herself from the ten different conversations she's been having with various teams, trying to arrange the next steps in the process, and can sit down to chat with you about what's just happened.

Don't be surprised if you don't remember a thing about all this. Chaos does funny things to a person's memory.

I once talked to a dad several days after his son's admission to PICU. He said he couldn't remember the helicopter ride, couldn't remember arriving to the hospital or much of anything about the first hours of admission. The only thing he could recall with any clarity was the big ugly soft toy singing nursery rhymes a nurse was using to get another baby to sleep.

Next week: Access All Areas.
(Last week: Ventilator, Schmentilator.)

Nurse Blog of the Month

2006-10-12T11:46:00.001-07:00

R_n for Your Life wins October's NBOTM award! Congratulations! HK and I had a fun time figuring out why we were getting so many hits from bowling sites ;)

I'll cook up a decent sort of link button when I get a sec this weekend.

In other news, HK is engaged in renovating her new home, which involves a lot of hard work, a pressure washer, and something called 'sheet rock' which I don't really understand. I'm sure we all wish her sanity and a speedy recovery from 'renovatopathy'.

When You Least Expect It

2006-10-11T19:20:00.000-07:00

We were on opposite sides of her, me gently patting with one hand and very slowly syringing milk into her NG tube with the other. Her mother wrapping her tighter to stop busy limbs from flailing. Hoping for sleep.

It'd been a horrible day for them, a catastrophic diagnosis revealed, and little time to take it all in.

They always say it: "I don't know how you do your job."

I smiled gently. "There are good days and bad days. Mostly you just try to make things better, a little bit at a time. Even when I know I can't fix what's wrong, the main problem, I can usually help with the rest."

I paused, unsure whether to make the point or not. Patronising? Maybe, but it felt right. "Maybe that's something to think about, when you go home with her. Nobody knows how to make her better, but doing the little things will make a big difference to her, to the way she feels."

Next day I was astonished to discover the baby had died suddenly later that evening, only hours after I'd been with her. No-one had expected it.

Hindsight isn't always a wonderful thing. I wish I hadn't talked about the family going home.

Your Questions Answered

2006-10-10T19:05:00.000-07:00

Here we go with some questions from referring search engines, answered for your edification.

You asked: What does ETOH mean?

Ethanol. Y'know, alcohol. Booze. Grog. Plonk.

This one always comes up on the list. I guess a lot of people out there need a drink.

You asked: Funny nursing shirts?

Well, there's these ones.

You asked: "'if i just lay here' 'gray's anatomy'"?

Snow Patrol. See below.

You asked: 75 questions on the NC-LEX?

Yes, sometimes the test does shut off after 75 questions. I've never had to sit the NC-LEX, for which I am eternally grateful. However, I've been on the SNURSE-L student nurse mailing list for years now and in my experience the number of questions you get has very little predictive power as to whether you pass or fail.

So, don't panic! Wait for the results. Take a breath. Drink less caffiene. Go outside. Talk to your family. Do all the things you didn't do while studying for the damn test.

You asked: Nurses work Christmas?

Hell yes. And New Year's, often enough. Depending on where you work, you can usually arrange to get one or the other off. You may or may not be on night shifts. We've tried hard to convince all the sick people to look after themselves over the holidays, but they are by and large selfish creatures and insist on trivialities like breathing and having a heartbeat.

I'm taking Christmas off this year for the first time in ages. It will be quite strange to actually be with my relatives rather than listening to machines that go ping.

You asked: Who implemented mandatory immunization?

Massachusetts. If I may extrapolate from your question the following: "Which US state first passed a mandatory vaccination law?" It was MA, in 1809. If you want to take names and kick asses, you'll need to dig deeper than that.

In the US, although there are no federal requirements, a state can require immunisation against certain diseases prior to school entry. However, there's an awful lot of variation from state to state as to what exemptions exist, and how they are applied.

You can read about the concept here, here, and many, many, many other places.

Pride Cometh Before a Recalcitrant Ventilator

2006-10-09T16:14:00.000-07:00

I shouldn't have written about how good nurses are at working with ventilators, because the gods sent me a test soon afterward.

I was called to a bedside where the vent was reading high expiratory volumes and low inspiratory volumes. Usually it's the other way around... some of the gas escapes around the side of the ETT and isn't measured by the machine, or there's a leak somewhere else. However I'd just had a morning of recalibrating vents that weren't reading volumes correctly, so my index of suspicion was higher than usual for a machine fault.

It could be the patient, it could be (most likely) the small amounts of blood that had gotten into the flow sensor, could be any number of things. I wasn't happy to ventilate a patient with a machine whose problem I didn't immediately understand, so I decided to swap it out for another one.

Well. Then I thought I'd get clever. While a colleague 'bagged' the patient, I swapped the old circuit (plastic tubes and wires) over to the new ventilator so as not to waste it. I'm fast. I'm cool. I can do it, no problem.

Uh... checks failed. Hrm. No worries, probably just a loose exhalation valve. I pull out the valve, disassemble it, put it back together. Run the check. Fail.

I check the flow sensor, gas lines, look for leaks in the circuit. Run the check again. Fail. I run to the store room for another valve. Run the check again. Fail. Dammit!

By this time I am starting to sweat a little. My colleague is being extremely patient, but obviously didn't expect to be standing there hand-ventilating a baby for quite this long. I imagine the conversation in the tea-room... "Yeah, PaedsRN tried to be a smart-ass again. I was bagging until end of shift while he built a ventilator from scratch..."

I decide to switch vents again, and check the equipment room. Grab another one, put a new circuit on, run the checks. Fail. Oh god...

Meanwhile the patient is absolutely fine, but my colleage has that expression which says they wish they'd never walked into the room.

I rip the exhalation valve apart, check each seal, and fit it back into the vent. Please please please...

Pass! Whew. Persistence pays off. I reconnect the patient and spend quite a bit of the rest of the day stripping and testing those two ventilators.

Couldn't find a single thing wrong with 'em. Bastards.

Doc Links

2006-10-08T17:04:00.000-07:00

Way down on the left sidebar we have a couple of docblog links. I've added three more, to blogs I read on a regular basis which I highly recommend.

Neonatal Doc is always topical, a bright and compassionate neonatalogist with a knack for choosing touchstone subjects and an active cohort of commenters.

Barbados Butterfly is a talented surgical registrar who describes her training with remarkable insight and humour.

The Underwear Drawer is written by Michelle, a resident in anaesthesiology and mother of one. Consistently funny.

Demystifying PICU, part 1: Ventilator, Schmentilator

2006-10-05T17:00:00.000-07:00

I often hear with some frustration the press talk about patients being in such-and-such a hospital, "on life support".

It's a dramatic phrase, but what does it mean? Just about everything we do in critical care can be thought of as life support. Give an adrenaline infusion to keep the heart pumping and the blood pressure at acceptable levels. Insert a drain into the brain's ventricles to prevent pressure from building up and killing the patient. Use a baby warmer or incubator to prevent hypothermia. All of it is life support.

What the press really mean, at least most of the time, is that the patient is on a ventilator. The breathing machine. The bit with the accordion going up and down that you see in the movies (actually, most modern vents don't have those things in 'em but it looks cool, so movies are taking awhile to catch up.)

Normally when we breathe we suck air in. We create a slight negative pressure in our lungs which draws in air from the atmosphere. Positive pressure ventilators shove air in, sometimes using quite high pressures, and allow it to flow back out again. Usually the air is pushed in via an endotracheal tube, or ETT inserted through the nose or mouth and down the windpipe.

This is not a natural way for a person to breathe. There are long-term consequences of this kind of treatment on the lungs, which are worse depending on the pressure and volume of gas used. The lungs can become scarred and inflexible, occasionally even punctured. Infections can develop. The entire process is highly stressful for both patient and family.

It's a regular activity for me to have to stop a person from breathing. Sound crazy? Sometimes we have to take over altogether, so we give a drug which prevents a patient from using most of the muscles in their body, including the diaphragm. I can do this because I know that the settings I put on the ventilator will do the breathing for the patient.

When you think about it, it's a big responsibility. If I screw up, the patient will stop breathing. If I don't take immediate action, they die. I laugh when I hear people talk about nurses 'getting back to basics' which, if you inquire further, is usually thought to involve wiping bottoms and feeding patients. I find it funny because of course I do those things too, but I also perform the slightly more immediate function of preventing children and babies from dying. Not dying eventually, but dying right there and then, in front of me.

That might sound like a grab for attention, and perhaps in a way it is. We deserve it! However, I mention this because I read with depressing regularity articles which misrepresent what nurses actually do. They're often written by people who really should know better. They perpetrate a charming, wistful stereotype of the 'good old days' of nursing with little or no understanding of what the job involves today.

Let me say it plainly: if I am ever unfortunate enough to have a child of mine in hospital on a ventilator, although of course I want a good intensivist involved, my most immediate concern will be to get an experienced PICU nurse at the bedside. Someone who knows the ventilator back to front, all its weaknesses and idiosyncrasies. A nurse who knows exactly what the last blood gas results were, and whether or not her patient was agitated or breathing fast when the test was taken. A nurse who knows what little settings tweak to make when nothing else has worked. I want someone who knows when to leave well enough alone and not fuss over small variations in the blood gas.

Someone who makes me laugh when I think I've forgotten how.

There's a lot of inuendo flying around these days about nurses and what their job should be. Allow me to take this opportunity to remind my readers that most of us are skilled at doing two or more things at once. Yes, even the men! We do the basics, and we do the more advanced stuff too. I like to call it wiping bottoms and kicking ass. How's that for a mixed metaphor?

(Now, if only I can get HK to let me change Mediblogopathy's slogan to, "Wiping bottoms and kicking ass since 2003"...)

Next Friday: Chaos Theory.

And the nominees are...

2006-10-04T19:43:00.000-07:00

Nurse blogs up for a blog of the month award:

It's a Nursing Thing
KT Living
N... is for Nurse (someday)
Nurse Ratched's Place
oncRN
R_n For Your Life
The Nurse Practitioner's Place
Zanta HCL

Vote in the garishly-coloured box at the top of the sidebar. May the blog whose author most shamelessly bribed the judges win!

Little Green Doohickeys

2006-10-03T20:48:00.000-07:00

It's all very sexy, this business of connectors.

Every part has a male and female end, for example the 22m - 22f straight connector (yes, it really is called straight) which I had to order this afternoon. Only, it turns out I actually needed a 22m - 22m - 22m/15f three-way. Connector. Three-way connector.

That lasted about half an hour, until I realised what I really wanted was a 22f - 22m - 22m/15f three-way. Look, let's just call it a T-piece, ok?

I'm not sure if that's any better.

I also may have set a new personal best today for the fastest inhaled nitric oxide setup at the bedspace of a baby with SpO2 of 40%. Got to beat that time!

Bits and pieces

2006-10-02T17:34:00.000-07:00

Well, I suck.

I should never say, "I'm going to start posting daily," because that'll mean I don't post for a week!

It's been an interesting week. I got to ride an ambulance for the first time in my professional career. You'd think as an RN I'd have been in plenty by now, but in fact this one was a first for me. Not a terribly exciting transport, escorting a patient back to another hospital. Still, fun for a change. No lights and sirens though!

The rest of the week has been spent trialling a new monitor, keeping up with supplies on the unit and doing all the troubleshooting and education that this job entails. Today I'm writing a spreadsheet to handle the data from the monitor trial, and working on some written material for a ventilator training session I'm giving later in the week.

Doesn't sound terribly exciting, does it? Just goes to show, you never really know what you'll be asked to do after you graduate as a nurse.

Elopement and a Cuppa Joe

2006-09-29T19:51:00.000-07:00

Perry, a Mental Health Specialist (the folks who do a ton of the patient care work around the hospital) comes to me Monday morning as I'm finishing up a discharge and asks if I've seen Curt, one of our new patients. Perry was doing rounds and saw Curt on 15" checks at 10:45, but now it was about 11:05 and he couldn't find him anywhere.

I call "Staff!" to alert the other MHS's that I'd like to have some help, and I get a reasonably good response. "Perry can't find Curt - can we all look?". Sometimes staffers doing rounds can't find a person because they're in the shower or sleeping in another patient's bed by accident or maybe just hiding in a corner somewhere. We spread out and do a thorough sweep. No Curt.

Somehow Psych Doc ends up at the end of the hallway and pushes one of the fire exit doors and no alarm sounds - the door pushes open just like *that*. Staff can use the doors by keying them open, but we're not supposed to because sometimes patients can go out if you're not watching carefully. The doors work a certain way to remain safe yet patients can't escape through them easily unless someone leaves one open.

I jogged down the stairs wondering if I'd catch a glimpse of Curt but no luck. Outside there is a reasonably high fence in a courtyard that will not open without a key. I found a piece of wood leaned up against the fence where he must have climbed over.

I came back inside and called the police. They usually locate patients who get out in a matter of minutes - some more easily than others. Curt was wearing a hospital gown, a yellow wristband, and was sans pants.

He was down the street at a coffee stand having a "free" coffee as the owner of the stand called us. From what I understand, the espresso stand owner motioned him over (believing him to be one of ours) and said "Hey buddy, free coffee today - under new management!!", sat the patient down in a patio chair on the deck, gave him a cup of coffee, and called us.

We've got some great neighbors.

Oh, and we checked the video and one of the utility guys had gone out the door. Looks like Curt caught the door and kept it from closing all the way, and then snuck out after the utility guy had gone around the corner.

(All names in this completely fictional story have been changed. In fact, it never happened. That's the ticket.) :)

Songs

2006-09-24T19:09:00.000-07:00

Well, this weekend was a washout for blogging! Good job, as Kim has frequently pointed out, not too many people read blogs on the weekend.

In the meantime, Neonatal Doc has tagged me with the "Songs of the Moment" meme. Some of these aren't terribly current:

1. Snow Patrol, Chasing Cars.

If I lay here
If I just lay here
Would you lie with me and just forget the world?

Apparently this one was on Gray's Anatomy. They've been playing it here a bit, coinciding with a difficult week it seemed to speak volumes.

2. The Martinis, Free.

Omniprescent phrase in my mind
Spoken word I've heard one million times
Who are you to tell me that I'll always be this way
I close my eyes and I turn around
Leave it all behind

Sometimes simple is best.

3. Red Hot Chili Peppers, Soul to Squeeze.

I got a bad disease
Up from my brain is where I bleed
Insanity it seems
It's got me by my soul to squeeze

4. Goldenhorse, Dark Forest.

Underground the roots are your hair
And the leaves, leaves are your hair
Behind your changing face

Many times we try
Caught there by the tide
We walked into the light
But we couldn't find her
We didn't find her

Fantastic New Zealand band, do yourself a favour and check these guys out. Off-beat melodic pop.

5. The Muttonbirds, Anchor Me

Another classic from the land of the long white cloud. This is a Don McGlashan song that was covered by a group of artists recently for the anniversary of the sinking of the Rainbow Warrior.

How many was I supposed to do? Bugger it, I'll finish this later. The last of the sun is shining outside!

Change of Shift 7

2006-09-21T14:24:00.000-07:00

KT Living hosts this edition.

Belated Grand Rounds pointer: at Tundra Medicine Dreams.

Today's lesson in medical equipment management: if an oxygen bottle is on your desk with a note taped to it saying "Can't turn on!", try turning the valve in the other direction. Nine times out of ten, it was already on...

Call for Nominations: October NBOTM

2006-09-20T15:02:00.000-07:00

Now, with HypnoKitten in the throes of buying and moving into her new home (everybody know what that's like? You do? Any questions? Didn't think so!) the Nurse Blog of the Month award has been on hiatus. This will not do! Therefore I'm taking the liberty of stepping in and calling for nominations for October.

In fact, it's the award for March, April, May, June, July, August, and September combined; a very prestigious honour!

Although we love Third Degree Nurse, we probably won't be putting a big permalink to her blog at the top of our site forever. It's somebody else's turn... feel free to nominate the blogger that inspires you, educates you, makes you laugh... it's also absolutely fine to self-nominate. The only restriction: their site must carry the NurseBlogs logo, and must contain recent posts.

Nominations in the comments section of this post please.

(Attempting to maintain a daily posting schedule, figured this was a good way to start ;)

Called

2006-09-18T18:15:00.001-07:00

Lately I've been reticent.

I think about what I want to say, and then about what my colleagues would think of it. What the wry and acidic anaesthetic consultant would say if he knew I thought this way. How nurses on the floor, many of whom are already a bit sceptical about me, would react. I pause, and don't write anything at all. We're such good censors of ourselves, aren't we? It's insidious.

Then last night I--well, to do this right I have to go back a few days.

It has been, folks, a rough fortnight. Rough month, really. Our unit got worked. Everybody's tired. Things are just now starting to slow down this week, and I hesitate even to say that because they might speed up again!

Towards the end of the week I received an admission who coded on the ward. A few months old, disasterous medical history. As we worked to stabilise him, it became clear to us that this was not a child who would grow "to make old bones", as the saying goes.

It was one of the longest, hardest days I've had in recent times. One of those shifts where you're still catching up on documentation long after you should've been home. A fast, sad, taxing shift. I went home without much expectation that the infant would survive.

The next morning it was all absolutely clear: with a lactate above 30, terribly coagulopathic and on high ventilatory pressures, in fulminant liver failure, there was no going on. We withdrew care and he died.

I will leave the details out of this account. Suffice it to say I regard this as the hardest 'withdrawl' I've ever had to perform. Alone, in a single room, pulling out tubes and coping with the inevitable bleeding, managing analgesia and monitoring the patient, all amidst the loudest and most visceral outpouring of grief I have ever seen or heard.

I was beyond exhausted at the end of the day, and the weekend was rough. You do start to question whether or not you're in a sensible profession after all, that has these experiences in it. I don't know anybody in this city outside of work, so stewing in my apartment alone for two days didn't exactly help my frame of mind.

At the start of this week I met with our very smart psych who helps with debriefing after traumatic events on the unit, and talked it through. At the end of the day I went out of the hospital, down to the harbour and hopped a ferry across to one of our local beaches.

It was getting dark as I walked along the foreshore, and not the warmest of winter days. I was having trouble with the images: black deoxygenated blood oozing from central line sites and between my gloved fingers; the shock on the face of a young cousin, maybe three years old, eyes wide as he stared around the room at his crying relatives. Sometimes these images are addictive. It can be very hard to stop playing over them in your mind, once they get burned in there.

By the time I got to the end of the esplanade it was completely dark, and the wind was getting up. Lights flared on the ferries as they passed, making black waves. I said my goodbyes there, looking out over the water, told him I was sorry. A cold gust blew in across the sand, hit me in the face and I realised: this is what I was going to do for the rest of my life.

Suddenly I understood why people talk about their calling; why, in the face of difficulties that seem intolerable, with token pay and anti-social hours, they keep coming in to work. It's no longer cool to say it, but it has become inescapable for me... I feel the call. It is not just an occupation. It is a life's work.

I am where I am supposed to be.

The clarity of purpose I felt was astonishing. I can feel it now, surrounded by the distractions of the day. Perhaps my colleagues here would chuckle if they read this, but I reckon more than a few of them feel the same way, even the ones who would never admit it.

Is thirty-four years of age late to find your true calling?

9/11/06

2006-09-11T18:03:00.000-07:00

They that love beyond the world cannot be separated by it.

Death cannot kill what never dies.

Nor can spirits ever be divided, that love and live in the same divine principle, the root and record of their friendship.

If absence be not death, neither is theirs.

Death is but crossing the world, as friends do the seas; they live in one another still.

For they must needs be present, that love and live in that whch is omnipresent.

In this divine glass they see face to face; and their converse is free, as well as pure.

This is the comfort of friends, that though they may be said to die, yet their friendship and society are, in the best sense, ever present, because immortal.

William Penn, from More Fruits of Solitude

Decommissioned

2006-09-09T13:10:00.000-07:00

As I mentioned previously, I'm on a little 'sabbatical' from the PICU this month, filling in for the technician's position which involves looking after all our electronic and mechanical bits and pieces. The first week has gone well. I had to put quite a few hours in, but it was an enjoyable change of pace.

I actually fixed things! Me, who is not in the slightest bit 'handy'. A bed side was broken, I found a part for it, took it to pieces, figured out how it worked and put it back together again. Ok so it's not laparoscopic surgery but I felt an inordinate sense of pride at having contributed to the unit on such a basic level.

Then on Wednesday one of our baby warmers, an ancient and reliable frontline soldier in the PICU trenches, started alarming. "E0 13", it said. "E0 13". Nothing we did could convince it to stop shrieking, so we disconnected it and swapped it out for another warmer. I went to look up the manual. "E0 13," said the manual, "heater not turning off."

When things like this happen, we turn to our biomedical engineers. "Fix it," I said, "if you can do it quickly. Otherwise it was probably going to be the first one taken off the unit anyway." We have brand new warmers coming, so there isn't much point spending money on the old ones.

A few days later biomedical get back to me with the report that the warmer needs to go. "The wiring is all corroded inside," they say. "Too expensive to repair. You'll need to decommission it."

It turns out there are forms involved. Forms to be filled out and signed, in duplicate, and barcodes to be recorded, and approval to be sought. Has the equipment depreciated in value? Is it to be scrapped, salvaged, sold? Has it, in fact, been stolen? (If so, please attach copy of police report.)

For awhile I was amused by the image of a burglar trying to sneak out through the security doors and across the helipad pushing our baby warmer, hopefully sans baby. "Honest, officer, I was only road-testing it!"

After I'd negotiated the paper war, I cannibalised several attachments for spare parts. And then it was done; bereft of all trappings, it squatted in the middle of my office, waiting to be discarded. Although I tried to dismiss it, I couldn't help feeling unsettled as I stood there, thinking of all the infants who'd died in its perspex arms. The same mattress, used and cleaned over and over, exposed to blood and shit and Betadine and snot and tears, the same mattress for all of them. So many nurses hands on the cotsides, so many tired registrars trying to duck under the heater to intubate at 1 AM. Radiographers folding back the overhead to take xray after xray, irradiated over and over. Parents leaning on the edges, struggling to fit between the ventilator and the haemofilter.

History, on wheels.

It somehow seems wrong that it'll end up in a dump somewhere, a scrap yard, left to rust. But the newest Plastic Fantastic is on the way, and everything is disposable. On Monday I'll wheel it out of the unit and not give it another thought. Except to say to the designers, the engineers who gave it birth, the guys who tend not to get a whole lot of credit in medicine: you done good. It stood the test of time.

Zipredol

2006-09-08T19:45:00.000-07:00

One of our nicer patients (who's still not quite oriented) visited me while I was passing out meds. With a shy smile he asked me if I could get the doc to prescribe "ZIP-red-ol" for him. "You know, that medicine that makes you not hostile".

"You don't seem hostile to me. In fact, you're quite nice."

"Oh, I know, but I've hear it's very good and I don't want to ever get hostile"

I've never heard of Zipredol - I imagine he was combining the names Zyprexa and Risperdal. I wish the patients that needed it the most would want it so badly...

:) Turn up your volume - this clip is a little old and you may have seen it before, but this scene reminded me of it.

Rounds

2006-09-07T21:36:00.000-07:00

Grand Rounds 2:50.
Change of Shift 1:6.

Yes, I'm sorry he's gone

2006-09-04T02:06:00.000-07:00

I wasn't a huge fan, but there's something about Steve Irwin that just made you want to watch. He seemed like someone with a good and true purpose, even if one didn't always agree with his methods, even if he became a caricature of himself at times. I'll miss him.

(I know I'm horrible, but when I first heard, I immediately thought -- wow, sting ray barb to the mediastinum. That'd make an interesting CT scan. Yes, I am an unfeeling monster. You may commence with the scathing comments.)

House

2006-09-03T22:51:00.000-07:00

No, not the tv show :)

PaedsRN is right, I have been pretty busy lately - I just bought my first house!

Now I'm working on finding enough boxes. We've got a lot of stuff to move and we're not going to take any days off to do it. Closing date is October 2nd so we've got time to pack neatly and maybe have a garage sale before we go. I'm so excited! Finally I'll get to decorate and paint the way _I_ want to, and plant things and make a garden however I like rather than worry about what a landlord has to say.

It's a really cool house, too. I'll probably post pictures of it while I'm cleaning and painting.

Anyway, in case you missed me that's what I'm doing. ;)

-HK

GeekNurse Link Repair

2006-09-02T23:07:00.000-07:00

I now realise when I shut down GN I also broke one of the links in the Grand Rounds archive. I've just rectified that by re-publishing GR 2 No 25.

That got me to reading through old posts again, which are no longer available for public browsing on the blog. There's some good stuff in there... some silly, but some worthwhile. I wish I knew which ones were found to be most offensive, and who felt threatened by them. Wish that people had come to me and discussed it openly, instead of hiding behind a manager. But turns out wishing ain't good for much except throwing money down wells.

Pitstop PICU

2006-09-02T16:09:00.000-07:00

Great Ormond St have been in the news lately with their improvements to post-op logistics, which they credit to a collaboration with Ferrari pit crews. The parallel never even occurred to me, but it's an interesting one and something which I'm going to be thinking about over the next month or so.

The major restructuring of the patient handover procedure, resulting directly from the input of the F1 pit technicians, will soon be described in two scientific publications.

"It is not too early to say that, when we look at the number of critical instances we encounter, they have reduced markedly since we introduced the modified training protocol developed from what we have learned from Formula 1," said Prof Elliott.

The single A4 sheet of paper, which contained the flow diagram of Ferrari's pit procedure, became several pages of twice that size when Mr Stepney and his colleagues at Ferrari were confronted with the critical transfer from operating theatre to recovery room at Great Ormond Street.

"They were quite shocked at the complexity of what we did and the kind of kit we had at our disposal," said Prof Elliott. "They saw us operating on a solid table with the child under a heating or cooling blanket and all the vital connections to the various bits of equipment and then having to unplug everything and use a hand-operated ventilator as we took the patient out of the theatre, into the lift and along the corridor to intensive care."

I have a new job, at least for awhile--I'm filling in for the departing PICU technician until they find a replacement for him. It's an interesting line of work, though not something I'd consider doing full-time since there is little patient contact. Basically I get to look after all the machinery around the place, troubleshoot ventilators, pumps, monitors, make sure there's plenty of all the major stock items we use (ever run out of ventilator circuits at 9 PM on a Friday night? It's not pretty) and in general find solutions for many of the odd problems we encounter in the course of our work.

It will mean no night shifts for a month or so, and a chance to try something different. Plus I figure more familiarity with the 'gotchas' of the technology we use every shift couldn't hurt.

I believe HK is in the throes of buying a house at present, so she is probably undergoing considerable stress!

Rounds

2006-08-30T02:52:00.000-07:00

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

Long Haul

2006-08-30T02:44:00.000-07:00

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

2006-08-26T01:21:00.000-07:00

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

2006-08-23T18:56:00.000-07:00

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

Guilt Trips

2006-08-22T13:20:00.000-07:00

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

2006-08-13T17:17:00.000-07:00

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

2006-08-10T17:38:00.000-07:00

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

2006-08-09T06:20:00.000-07:00

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

2006-08-07T18:10:00.000-07:00

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

-----------------------------------
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

2006-08-06T23:32:00.000-07:00

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

2006-08-01T11:24:00.000-07:00

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

Medblog Grand Rounds, this week at Inside Surgery.

Read. Enjoy.

Compromise

2006-08-01T10:52:00.000-07:00

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.

New and Improved!

2006-07-30T17:08:00.000-07:00

I am pleased to announce that I've taken on a partner (read:convinced him to join me...).

As a talented writer and pediatric nurse he will make a fantastic addition to Mediblogopathy! Now there will be more posts, with different aspects of nursing represented.

Please join me in welcoming PaedsRN!!

The New Pup

2006-07-24T22:57:00.000-07:00

But he is SO out of control.

We got him from a shelter - he's a 2 year old Australian Shepherd who had been kept tied out on a very short rope by his previous owners (completely untrained, never housebroken...) The Humane Society evidently asked the owners to give him up because of the mistreatment.

We've trained him to sit and lie down so far, and he loves to catch a frisbee - but only rarely brings it back. He's got a LONG way to go and right now he's such a handful, but he's so smart it's amazing. And what a total cutie!!

I Gotta Blog This

2006-07-18T19:41:00.000-07:00

Summertime fun and a new dog have taken me away from the computer for the past few days, but I've got one of those special stories to tell so I'll let you all in on the Good Times while the BBQ is heating up.

I've been oriented to do charge when the regular charge nurse is off. I had two days of shadowing the charge, and then there would be two days of her shadowing me. No problem, right?

I'm plugging along on my first day of doing the job myself with the regular charge shadowing me, and anyone who asks her a question is told "HK is charge today". I'm feeling like I got this handled. At least until noon rolls around.

Carlos (not his real name) was a big guy. Upon admit he had given us some trouble by becoming extremely threatening/violent/agitated and ended up in seclusion a few times in as many days. I think I've mentioned that we're a facility that only uses seclusion or restraint as a last resort, so you can believe he was really out of control. I was aware that he might act out again and was keeping an eye on him. He was really focused on getting out to get a smoke break, but you've got to maintain a certain level of behavior to go out. I told him at the start of shift that I hoped he would try his best to maintain control, take PRNs if they were offered, and if he did well we would try to get the lunchtime smoke break. At that time it would be more than 24 hours since his trouble. Rules, you know.

He couldn't do it. I was hoping not to have any trouble, but he got angry with staff and started yelling. I tried to redirect and gave PRNs, but then he yelled at Psych Doc shortly afterward. There's no way I can let him go out and smoke when he's screaming and cussing.

When I told him (as diplomatically as possible, trying to avoid a fight) that he wasn't going to get to smoke, he slammed his fist against the window of the nurse's station then ran full speed and planted his shoulder into the elevator door. As he ran down the hallway, we called for staff. He knocked over the linen cart when we followed him. At the end of the hall he slammed his elbow into the plexiglass cover of the fire extinguisher and removed it. Now he had a weapon which he brandished as if he'd like to crack someone's head open. Probably mine.

There were only four of us, and I knew well enough that even without a weapon we would have to wait for the staff who were still running toward us to catch up. We couldn't do anything but wait for them with him at the end of the hall. The he pulled the pin and sprayed clouds of nasty yellow fire extinguisher powder at us. But wait - there's more.

The billowing extinguisher powder did something to the fire alarms, which went off. The patient room doors around us which were magnetized open slammed shut. Screeching alarm sirens blasted. Patients came out of their rooms and we directed them into the other hallway where staff lined them up in a fire drill line. Carlos sat on the floor in the corner with the empty extinguisher while we emptied patients from the hallway full of the awful powder-fog. By then staff from the other floor arrived. When they restrained him and took the extinguisher, he didn't fight. I heard the sirens of the fire trucks arriving. I exhausted my supply of bad words and began inventing new ones.

Carlos went into seclusion in 4-points (I wanted to give him some extra-credit points, but didn't know how) as firefighters poured into the hallway from the stairwells. I noted the nurse managers were there also. The 30 or so other patients were taken down on an impromptu smoke break because the fumes were spreading down both halls.

Once the firefighters got the alarms off and gave us an all clear, doors were opened and a large fan brought in. Housekeeping was called. We aired out the unit, said goodbye to the fireguys, mopped up the floor, and brought the patients back up.

I sat down to fill out the paperwork, my shirt and hair still full of nasty powder.

So much for day one. :P

A Simple Blood Draw

2006-06-17T21:53:00.000-07:00

It sounds like a joke: "How many people does it take to draw one tube of blood?" Answer: "Depends on where you work, I suppose."
___________________________________

I drew her blood a few days ago. She told me I wouldn't be able to, that no one ever did a good job, and that I was going to hurt her. She had tiny veins that were deep and the other nurses decided I should do this. I did get both tubes, and it did hurt she told me. I haven't any cure for that - I've got to use a little needle to get in through the skin to where the blood hangs out. I told her I was sorry it hurt.

Today she refused the draw. Told me it "wasn't neccessary" and that she would not be participating in anything with me involving needles. I had hurt her, and now we'd never get blood again.

I asked her a few times throughout the day. I tried to reason with her, bargain with her, and then let her know that I'd have to get the team together to hold her down and get the draw done. She continued to refuse.

I had no choice - I got the team together. Everyone put on gloves and walked down the hall to her room. I was hoping the sheer intimidation of all of those people in her room would change her mind. I really had no choice in the matter of doing the draw, but I didn't want to make it any worse for her than it already was.

She agreed. Faced with the idea of being forcibly held down or doing it on her own terms, she did what many people would do and relented. She asked if there was anyone else who could do it, because it was me that hurt her. No, no one else. She asked if we could do it another time when she was feeling better. No, no other time. "Ok, fine" she said, "but you're going to mess it up and you're not going to get any blood anyway and you're going to hurt me because you've got no skill and you're probably the worst blood-drawer I've ever seen."

Well, you know my day isn't all peaches and cream (aside from the glamorous stories I tell here). No pressure... just 5 staff and a patient watching me try to find a teeny-tiny vein to get a teeny-tiny amount of blood from. I have to say it was almost as bad as having a room full of family members looking on. I could feel the eyes on me.

I say a quick prayer to the gods of bloodletting and do my best, getting that wonderful flash of red into the butterfly and then popping the vacutainer on.

"Hmmph" she grunts. I imagine the translation was that she hardly felt it.

But there I am, hunched over, watching the blood flow so s.l.o.w.l.y into the tube. Damn. The team's still standing there, of course. Watching. It's like slow motion. I angle the tip down slightly hoping to get a better flow. It drips slightly faster.

She lets out a huge bored sigh. No translation needed.

Finally, I've got enough. After what seems like hours (but was probably more like seconds) I have completed the Miracle Draw and I'm taping a 2x2 on her.

I say "You did a good job of holding still, and I appreciate that you let me do it that way rather than having to use help. I hope it didn't hurt too much."

She gives me a deadpan look and says "You're getting better."

Lordy.

Virtual Hallucinations

2006-06-11T21:56:00.000-07:00

One of the Pharm companies brought breakfast pastry and coffee along with a fancy little techno-device they called the "virtual hallucination machine". You hold it on your head sort of like a virtual reality mask. I chose the bus ride scenario - there was another where you try to fill a prescription at the pharmacy. Voices come in your head and tell you you're basically a worthless piece of crap and shadow people wait for you at the bus stop. Miserable.

Interestingly, if you paid close attention there were some wild details like names of streets and freeway signs putting you down too.

Here's a news article showing a police officer using one if you'd like to see what it looks like.

Make your own street signs at the street sign generator.

Breakfast Anyone?

2006-06-02T12:11:00.000-07:00

I found this wooden box from "Colace Cantaloupes" in a used record store. MMmmmmm... Great for dieters! ;)
____________

Check out the links - I've just added about 8 more blogs.

Inappropriate!

2006-06-01T22:05:00.000-07:00

Working in a psychiatric hospital is funny.

No, I mean it.

Patients will say the strangest things, and sometimes it feels like I'm walking a tightrope between laughing and running away at top speed. Sometimes when the thing is originally said to you it's not very funny, but when you tell the story in the chart room it becomes one of those "one day we'll laugh about this" things. Except the "one day" is often only a few minutes later.
__________________

An elderly lady who had just been admitted (and who I have never spoken to before) walked up to me yesterday morning and said, very seriously, "You shouldn't work upstairs - because if there is a fire, the firemen won't be able to carry you because you're so big and you'll roast in your own juices."

Uh huh.

Well, I put on my biggest "thank you" smile and kindly said in my very best customer service voice "Yes, I am quite aware of that, but thank you so much for your concern." She walked away. Of course after the initial shock wore off (and I've been picked up by enough firemen in my time, in case you care....) I figured it was a funny story and told it back in the chart room.
__________________

Today a man known for sexually inappropriate behavior (SIB) walked up to a one of my female co-workers and showed her a picture of a heart. "Look at this" he said:

He proceeded to draw two dots on the heart and turned it upside down.

"Look! TITS!" He laughed.

She sternly reminded him "That is very inappropriate."

He stopped for a second and said "Sorry, I mean BREASTS."

Happy Nurse's Week

2006-05-10T19:21:00.000-07:00

The SEIU folks have some e-cards you can send to your favorite nurse or yourself at their Value Care, Value Nurses website. It's an interesting site even if you don't use the cards.

Med Doc brought in Krispy Kremes for us, and I can honestly say I've never in my life had a FRESH Krispy Kreme before today. OMG. I always thought they tasted a bit like wonder bread with sugar water poured on them, but a FERSH one, now that's a whole 'nuther story!. I was good - I only had one. Psych Doc brought out a box of mint chocolate wafer cookies. I guess they like us fat-n-happy. :)

Speaking of fat-n-happy, I went to my first pharm dinner last night. It was at a very nice restaurant downtown, and I got to dress up for a change. They had great food, a real round-table sort of presentation, group discussion about issues within continuity of care in newly stabilized patients, and an impressive guest list from all over our not-so-small town. I was impressed. Everyone kept saying how this was so different from other pharm dinners (meaning interesting) and I think it was very important for so many parts of the whole patient care picture to come together to find ways of making it easier to help patients stay on track. Being new to the whole thing myself I thought I would keep quiet - but I couldn't help but join in on the brainstorming! We broke down into our individual tables (about 8-10 people each) and got out boards and worked on coming up with reasons why it's difficult for patients to follow up after hospitalization with outpatient medications(with some emphasis on Risperdal Consta). We then worked on ways to correct these problems (where possible) and then shared our findings with the group as a whole and discussed it further. Because guests came from inpt, outpt, private, and even correctional backgrounds, there was a lot of information exchanged. Anyway, I'm sure I'm going on too much about this, but I thought it was great and not at all what I'd heard about stuffy, boring, blah-blah-blah drug dinners. Nods to Janssen and Risperdal Consta for facilitating it.

Note to nursing students: Here's some info on Prolixin Decoanate, Haldol decoanate and Risperdal Consta. They're interesting IM injections you might not ever have to give unless you work in psych, but it's nice to know they exist. They serve a real purpose in a sometimes difficult patient population.

News Flash!

2006-05-01T22:20:00.000-07:00

Battery Girl was discharged today.

I know, I'm horrible... :P

No Flu Shot = Mask Yourself?

2006-05-01T20:32:00.000-07:00

Nurses Prevail - Virginia Mason Hospital Charged With Unfair Labor Practice by the National Labor Relations Board
Monday May 1, 6:37 pm ET

SEATTLE, May 1 /PRNewswire/ -- The National Labor Relations Board (NLRB) agreed with the Washington State Nurses Association and issued a complaint and notice of hearing to the Virginia Mason Medical Center (VMMC) for engaging in unfair labor practices against the registered nurses. WSNA, representing more than 600 registered nurses at VMMC, filed a complaint in January 2006 against the hospital on behalf of the RNs who were forced to wear face masks.

The complaint issued today by the NLRB charged that VMMC:

-- failed and refused to disclose critical information that the WSNA is
legally entitled to and requested in order to represent the nurses.
-- provided "false and misleading information about its intention to
implement such policy" to the WSNA in the Union's request to bargain
over an influenza immunization policy.
-- refused to bargain with the WSNA before unilaterally implementing the
policy forcing nurses to wear face masks.

"It is shocking and outrageous that Virginia Mason Hospital not only refused to provide information as required by law and refused to bargain over this policy as required by law, but also lied to the nurses and misled the nurse about their policy. We applaud the NLRB's decision to charge Virginia Mason Hospital with the outlined unfair labor practices. Employers should be held accountable when they blatantly violate the law," said Barbara E. Frye, RN, Director of Labor Relations at WSNA.

In early January, the United States District Court ruled in favor of the WSNA in upholding the arbitrator's decision against VMMC and stopped the hospital from forcing RNs to receive flu shots. The decision by the United States District Court denied VMMC's motion challenging the arbitrator's decision, which would have allowed the hospital to make flu shots a condition of employment and fire RNs who did not comply. VMMC responded by unilaterally implementing a policy to require nurses who refused flu shots to wear face masks during their shift.

According to the Center for Disease Control and Prevention (CDC), "no studies have definitively shown that mask use by either infectious patients or health-care personnel prevents influenza transmission." The Institute of Medicine on April 27, 2006 agreed that "There's little evidence masks truly block the influenza virus, and if they can, how much protection they offer."

WSNA absolutely supports the flu vaccination and in fact strongly encourages nurses to get them. But, it does oppose any health care facility threatening to fire or retaliate against nurses if they do not submit to the mandatory vaccination, especially in the absence of a declared public health emergency and a recommendation for mandatory vaccination by the CDC.

Founded in 1908, WSNA is the professional organization representing more than 13,000 registered nurses in Washington State. WSNA effectively advocates for the improvement of health standards and availability of quality health care for all people; promotes high standards for the nursing profession; and advances the professional and economic development of nurses.

Source: Washington State Nurses Association

--------------------------------------------------------------------------------

Jeremy, RN, shows off his special issue Virginia Mason influenza-proof mask and additional combination needlestick/xray-protective vest and bloodborne-pathogen-resistant cape.

Uganda Begins Testing Nurses

2006-05-01T19:46:00.000-07:00

Nurses do National Exam
New Vision Online
Publication date: Monday, 1st May, 2006

By Ronald Kalyango

The first ever national examinations for Nurses and Midwives begin today, the chairperson of the Uganda Midwives Examination Board, Margaret Nyakuni, announced yesterday.

Speaking at her office in Kampala, she cautioned students to avoid malpractices, saying culprits would be stopped from doing the exams.

Nyakuni said the new examination board was established by the Ministry of Education and Sports and they are to conduct the exams twice a year, in May and November.

â€œThis monthâ€™s exams are to be done in 24 nursing training institutions but more will come on board as time goes by,â€� she said.
â€œI have dispatched a strong team of examiners and coordinators who have been allocated different centres all over the country to ensure that the exercise is successful,â€� Nyakuni said.

Patrick Byakatonda, the senior education officer in charge of nursing education, said the beginning of the examinations is a milestone in the improvement of nursing and midwifery in Uganda.

The Ministry of Education and Sports supervises nurses? Ack! -HK

UK Nurses Now Prescribe More

2006-05-01T19:40:00.000-07:00

New rules allow nurses to prescribe
Press Association
Monday May 1, 2006 7:03 AM

Nurses and pharmacists will be able to prescribe a wide range of drugs as part of a Government bid to speed up patient treatment.

Under the plan, which caused controversy when it was announced last year, nurses and pharmacists will be able to undertake extra training to prescribe medicines for common illnesses ranging from acne to tonsillitis.

Nurses, some of whom run their own specialist clinics, will also be able to prescribe for long-term conditions such as asthma and diabetes.

Nurses can already prescribe more than 180 prescription only medicines while pharmacists have been able to prescribe in partnership with doctors since 2003.

But now those powers have been widened with the aim of giving patients more choice about where and from whom they get their prescriptions.

Last year, the British Medical Association (BMA) branded the move "irresponsible and dangerous" saying it put patients at risk.

Chairman James Johnson said at the time that it was difficult to see how health workers who were not trained to diagnose disease could safely prescribe appropriate treatment.

But the Department of Health has said the move will take pressure off GPs, allowing them to focus on more complex cases.

Health Secretary Patricia Hewitt said the the move was a "major advance" in improving accessibility.

Nurses and pharmacists will be able to take on the new role after successfully finishing a post-graduate prescribing training course. Once trained, they will be required to keep their skills up to date.

Â© Copyright Press Association Ltd 2006, All Rights Reserved.

+[Bipolar]--

2006-04-25T21:45:00.000-07:00

Our patient swallowed a AA battery from her toothbrush in some sort of suicide attempt and was taken to the ER. Because of a negative reaction to anesthesia, doctors decided to let it pass naturally.

Back on the unit again, she appeared more relaxed than when she had left. She laughed about the incident, stating it wasn't a very good idea. She had a bright affect and could converse easily with staff and peers.

-----

Back in the charting room, Psych Doc jokingly asked me if it was a lithium battery...

I said I didn't know, but would continue to check vital signs and voltage throughout the shift....

Patient Goals for Today

2006-04-23T22:17:00.000-07:00

I went through some paperwork that patients hand in when they request a "level" to be allowed to go out and smoke. This is a direct quote and not something I've edited in any way.
Daily Goals:
make up bed
clean face
read bible
sing praises to the Lord
praise the Lord
go out and smoke
take meds
shower
cast out the devil
eat food
go to classes

Another patient wrote something I thought was surprisingly clever in it's sarcasm (considering the patient). Now, I don't know if I remember it word for word, but it was really close to:
I shower I still stink
I brush my teeth they still hurt
I take my meds nothing changes
I love this place I want to stay forever
It's Paradise
I think by "nothing changes" he was referring to the fact that even after a few requests he still wasn't getting a level to go out and smoke. This was written on a level request form. Getting a level is also dependent on cooperation and going a little while without a behavioral problem such as arguing with other patients or being sexually inappropriate.

It's great to read what patients write because it shows a different side of them. Many of them are quite guarded and paranoid when you speak to them directly.

The Psych Hospital

2006-04-20T21:35:00.000-07:00

Sorry I haven't posted in a while. It seems the more days go by without a post, the harder it is to actually come in here and write one. I guess I get embarased that I don't have anything to say..

Work is going well. Psych is a whole diferent world, and there are sometimes not enough words in the dictionary to describe the feelings I have for some of my patients. Some just come in for 72hours of emergency crisis management (all involuntary) and some end up there for months because of placement problems. Lots of things happen during the day, but it seems to me the stories are sad rather than anything people would want to read about.

Somehow in the med/surg world (at least at the busy hospital I was at), interaction with patients gets pared down. I know I could rarely find time to spend a few extra minutes consoling someone or listening to problems or even serious medication or health education. People pull you in all directions. Stays in a medical hospital are on average - what? - three days? I don't know. You have so little time to really get to know your patients. In the psych hospital in many cases this IS the patient's home. You go to work day after day and see the same people, and even when they discharge, many come back. I've been there a bit over two months and I can already name a handful of people that have been in and stabilized, then out for a few weeks and decompensated, and were picked up in some manner and brought back.

The stories are just plain sad in many cases. There was one young woman who had a long history of psychiatric problems and her father is a scientologist - he told her she should go off her meds, and that she could cure herself (I'm not sure quite how). The woman goes off meds and decompensates and becomes psychotic and does who knows what and gets herself another stay! He still calls her and tells her she shouldn't be taking the medications. She is so messed up by this - I mean, it's bad enough to have a mental illness thats debilitating in its intensity, but then to have your own parent tell you you're supposed to somehow fix yourself. She's simply not functioning well enough to deal with this sort of stress in addition to the delusions and voices.

So thats a horrible story. How about this - A woman was brought in unable to care for herself and homeless. She had such a bad case of lice and constant scratching had scabbed up her scalp to the point that her matted hair was in some places tangled under the scabs. I practically had to get into the shower with her and try to shampoo and then comb the lice out. It was a lost cause because of the matting and scabs, and I got scizzors and cut every hair on her head (after some diplomatic patient education). I felt so sad for her because she had no idea how bad the problem was. She also had scabies. I went out and bought her a wig to cover up her bald head, and went to value village to buy a shirt and pants for her. Some staff wondered why I did that, but I said basically that she came in with nothing, we took her clothes and disposed of them (scabies) and then we took her hair. We took everything this woman had, her clothes and her hair. She looked like a little old man - she'd already lost her teeth long before she met us.

Anyway, thats how things are going. The stories are miserable.

My life is going well. I truly enjoy many parts of my work. We're starting to look for a house to buy. I'm traveling to NYC in May for a class and an extra day of sights. I bought a (used) Escalade.... I guess renting that DTS spoiled me!! :D heheheh

Nursing School Uniforms

2006-03-26T17:41:00.000-08:00

I know it's been about a year since I graduated, but I've always wanted to do an informal poll on this. Collect a little database of ideas and opinions. :)

I think I came out pretty lucky as far as uniforms go. Prior to our class, all students wore white scrubs and a white jacket. We got a white polo shirt and navy blue scrub pants and jacket. Of course we had to wear white shoes. I think we looked pretty good, but as we neared graduation they started to look a bit 'used'.

I think nursing students look good when they match as a group, but since we had to buy them ourselves we should have been able to buy whatever brand we liked so that they at least fit properly. When I was working in med-surg there were some CNA students who had maroon-colored scrub tops with the school logo on them and white scrub pants. I thought they looked pretty good.

What constitutes a good nursing school uniform? What did you (or do you) wear and what's your opinion on it?

You May Be A Winner!

2006-03-26T17:20:00.000-08:00

Ok, so it's not the publisher's sweepstakes, but you really COULD win Nurseblog of the Month for March.

Or maybe you've got a favorite blog you've been reading and would like to nominate.

Do you? Who's caught your eye this month?

I'm going to bring forward all of the past nominees (who link back to me either through regular links or a NurseBlogs logo badge) so if you've been nominated in the past, you're up again this month.

Yeah, That Was ME!

2006-03-12T21:49:00.000-08:00

New fuel pump for broken Suburban: $140
Rental car from Avis for 3 days: $153

Picking up my daughter from a weekend at my ex's house in a spankin' new midnight blue 2006 Cadillac DTS: Priceless

The Voting Booth

2006-03-12T20:58:00.000-08:00

Here's a wagonload of nominees for Nurseblog of the Month for Feb!

The Nurse Practitioner's Place

Third Degree Nurse

Nursing Student Hell

I am a Nursing Student

Geek Nurse

Death Maiden

I Wanna Be a Male Nurse!

Livin' Large

Head Nurse

Pinoy RN

Haiku of the Id

NP Open House

THIRD DEGREE NURSE wins for Feb followed closely by Nurse Practitioners Save lives and Geek Nurse!

yaaaaaay! :) Good showing folks! Thanks to all of you who voted.

(Think about nominations for March as you're reading your favorite blogs!)

Nurse's Stress Prevention Diet

2006-03-05T20:34:00.000-08:00

This diet is designed to help you cope with the stress that builds during the course of the day.

BREAKFAST
1/2 grapefruit
1 slice of whole wheat toast
8 oz. skim milk

LUNCH
4 oz lean broiled chicken breast
1 cup steamed spinach
1 cup herbal tea
1 Oreo cookie

AFTER LUNCH PICK-ME-UP
1 Venti quad-shot lowfat white chocolate mocha from the stand in the lobby.

MID-AFTERNOON SNACK
Rest of Oreos in pack
2 pints Haagen Daz ice cream
1 jar hot fudge sauce
nuts, cherries, whipped cream

DINNER
2 loaves garlic bread with cheese
large sausage & cheese pizza
1 large pitcher beer
3 Milky Way candy bars

LATE EVENING NEWS
Entire frozen Sara Lee cheesecake eaten directly from the freezer.

A Second Helping of Nurse Blogs

2006-03-04T19:05:00.000-08:00

Here are some more for you!

Dust in the Wind (Peds ER RN)

Nursing Student Hell (student nurse in GA)

From A to Zimbabwe (An American RN travels to Zimbabwe for a year!)

Pinoy RN (NCLEX info for Fillipino nurses and nursing students)

I Am A Nursing Student (Heather, BSN student in Louisiana)

CASF in the Sand Pit (RN in the Guard over in Iraq)

I Wanna Be A Male Nurse! (need I say more?)

Nurse Wannabe (student in a BSN program, Indiana)

Student Nurse Jack (from Austin, TX)

You Know You Wanna (pre-reqs with Jaxia in the Southwest)

NP Open House (discussion on the future of advanced practice nursing)

What School Doesn't Teach You about Being a Nurse Practitioner (I'm not sure how to shorten this so it fits - I think "Being an NP" will probably work...)

Misadventurous Melissa (a nurse/attorney in CA)

Picklecakes (an ER RN)

Jan's Video Blog (why did I never notice this before? I didn't know he was a nurse, but I saw the link for the longest time over at Becoming A Nurse. Welcome, Jan - a new-grad RN!)

Nursing Stress (SN in Georgia)

Nurse Diva Extrordinaire (student)

Join the Community!

2006-03-04T17:51:00.000-08:00

The NurseBlogs community is growing so fast I can hardly keep up with it! I remember when I started there seemed to be about 8 blogs written by nurses with reciprocal links. Now, that's not to say that many of you haven't been blogging for longer, but the group seemed much smaller then.

I used to check to see who was linking to me by googling Mediblogopathy, but at this point there are so many it's a bit hard to sort through. This should make it really simple! Just post a comment with a link to the blog you'd like me to blogroll - I'll check it out and decide which category it should go into, and it's done! Comments go directly to my email address.

Also, if there is an awesome link out there that tells a great story, or is something that you think nurses or student nurses would really get a kick out of, by all means let me know. I'd like to continue building my "links for students" which is basically a list of great places to go to get clinical-type educational information and online quizzes.

If you are a business and would like to do a "link exchange" post it here also, but keep in mind I don't really like the idea much. I will review those particular comments and delete them if I don't feel they are what I'm looking for.

Please put the full address of the blog even if you don't know how to make a link. Thanks for helping build our NurseBlogs community! :)

New Additions to the 'Roll

2006-03-03T20:42:00.000-08:00

I know, I know: "HK, you never post new blogs anymore... what are you doing - sleeping?"

Well, some of the time, yes. I do sleep.

Of course, that's no excuse not to continue to bring you the best nursing blogs in the world all condensed right here on one page!

So my guilt is getting to me. So many blogs, so little time! If you thought the blogroll was long before, wait until after today. BUT I've just got to include some of these folks - they're just THAT GOOD. Oh YEAH. I know you want it... so without further delay may I present:

The Miscellaneous Mischievious Misadventures of Missbhavens (L&D RN in NY - r/t limited space this will be referred to as "Missbhavens")

Zanta (student: Pacific Northwest)

Jourdan's Nursing Blog (student)

Writings of a Caoimhin (student:Malta!)

Who Moved my Cheese? (student: Cape Cod, MA)

Random RN Ramblings (Catepillar RN: California)

ISED8U: Adventures in Anesthesia (("I sedate you" for our ESL readers) A busy CRNA!)

The Student Nurse, NY (student: NY)

Julie Anna Infantry Wife (student: Pacific Northwest)

Dog Food Sugar (student)

Highway Hypodermics (RN who writes books about travel nursing)

The Journal of Genki (pre-reqs in the Big Woods)

The RN's have been added to the blogroll, and the students will be manually added to the sidebar next chance I get - maybe tomorrow.

Call for Nominations - NBOTM for Feb

2006-02-27T16:03:00.000-08:00

I'm looking for nominations for NurseBlogger of the Month for Feb!

Please nominate your favorite blogger (or yourself!) by posting the blog name in the comments and we'll vote in a few days.

Let your blogger of choice know you nominated them. If you have a favorite post, put up a link to it so we can all read it.

That's Just Crazytalk

2006-02-22T10:56:00.000-08:00

Oh wow.

What a weird career I'm having so far! I never planned to jump from specialty to specialty, but the experiences I'm having are amazing.

I started at the psych hospital last Thursday and I thought I'd put off posting until I had a good feel for how things worked. My very first day was like "awwHELLno!" and I thought I'd gotten in over my head, but the second day (Friday) was pretty cool, and Monday and Tuesday went well also. Today I think I can give a good overview of what it's like.

The first day I followed the LPN (a current RN student and very nice young woman) as she did med pass. She set up a mobile med cart sort of backed up into the seclusion hallway so that no one can get behind her. Patients lined up to get their meds, and it went smoothly until a female patient (who had to sit in a chair next to the med cart for 20 minutes for cheeking precautions after taking her meds) went off on her verbally. I mean, this patient was spouting insults, hostility, swearing and calling the LPN every name in the book and insulting her in any way possible - some very personal. It was not only bad, but it went on for 20 minutes! I could tell the LPN was just barely controlling herself, and practically shaking with anger, but she was professional. In retrospect, although that exchange really made me mad and frustrated that nothing could be done about it, it was a great learning experience and a very good example of what I may have to go through myself. There were also 2 shows of force that first day, and maybe the attitude of the whole unit was thrown off by that early-shift hostility-fest. A lot of patients seemed to be screaming about one thing or the other for the rest of the shift.

The second day I was put on an hour's duty of line-of-sight for a female who was on self-harm precautions. We got a chance to talk, and I enjoyed that. Later I did another hour on an underage female who basically had to have a chaperone wherever she went because the rest of the patients are adults. We had a nice conversation also. I'm quite aware that not all of my exchanges are going to be cooperative, many patients are hostile and delusional. I honestly felt much safer at the jail, because there was always an officer right there. That day was much nicer, patients were a lot calmer, and as I walked around on the unit, I was able to meet several of them and introduce myself.

A major difference in psych nursing for me is that sometimes there is just nothing to do but go out into the unit and talk to patients. The charge nurse is very nice, and she's making sure I get a good orientation and learn what I need to know. She said "I know it's weird, and I had a little trouble with it myself at first, but sometimes the job is just going out and interacting with patients. You feel like you should be doing something more to earn your wage, but being out there and connecting is really important also." It makes perfect sense, it's just that I guess I expect to have to chart everything, and I don't. I redirect patients, make sure they're using their coping skills, try to get them involved in groups, reorient them if they're delusional, and sometimes just listen.

One of the nurses precepting me told me to make sure I don't stay in psych nursing too long or I'll lose my other skills, and I believe that. I'm going to work on getting my BSN in the evenings. I'm not anywhere near as exhausted after work as I was at the hospital, and this will be a great time to do it. The program that I'm looking into requires 10 credits of a foreign language as a pre-req and I'll see if I can get that this summer. I've always wanted to learn spanish! :) I've got to do statistics also, but they say that can be done concurrently with the BSN program.

That's all for now. I think I'm going to put up a bunch of new blogs tonight, so stay tuned. I'm sorry I didn't get to NurseBlog of The Month last month, but think about some nominations, because NBOTM is happenin' this month!

Where's the Beef?

2006-02-14T23:52:00.000-08:00

For Valentine's dinner hubby took me to an Indian restaurant we haven't been to before. I love anything named "chana" with the chickpeas (garbanzos) in it, and had a wonderful spicy masala dish with puffy poori (or puri) bread to scoop it up. We didn't know it was all vegetarian before we went and hubby had to 'suffer' through cauliflower curry and rice. After we got in the truck to go home he told me "We're never going there again! No meat!!" . LoL! Poor man... ;)

I suppose I could be telling you all sorts of other mundane bits about my life. I mean, I'm just bumming around the house until Thursday, why not? Ok so here are some things you may not have known about me but didn't care to ask:

We have a fish tank with a bunch of cute little fish in it. Sometimes it's more interesting to watch them than TV. I have had cats and dogs in my life and I guess I'm a little bit more of a cat person, but once we get a larger house I'd also like a German Shepard. My last kitty left home about a year and a half ago and we searched and never found her. She was fixed and tagged, and I guess part of me is ready to admit she's probably not coming home. I'll get a kitty again after we move.

If I do watch TV I like House, Medium, and King of the Hill. Hank and the hubby are similar enough it's uncanny (except hubby doesn't watch sports or have a narrow urethra). It's so funny! We have My DVR from Comcast (like Tivo) and I use it so I can watch the shows I like when I want minus the commercials. Highly reccommended.

I still have my old truck (well, sort of like that...) and haven't traded it in for a newer model now that I'm actually an RN. Hubby's being sweet and saying I can get a Jeep Commander (He's got a Wrangler) and I would go for that except I'm too much of a chicken to take on a huge car payment! What I've decided to do is find a local 1991 Jeep Grand Wagoneer with low miles and drive that for a few years until the commanders are a few years old. If you follow the last link to the Grand Wagoneer you'll see the most beautiful one that just sold on Ebay. Pristine! Way cool - I didn't know they made those things all the way up to 1991. So now I'm an FSJ fan!

I love games - video games, board games you name it. Scattergories, Win Lose or Draw, Taboo and Cranium are some of my favorite board games. For the PC I like things like Warcraft, Diablo, Morrowind, and my new diversion Sacred. If I ever get a chance to play the PS2 I like Call of Duty, Ratchet and Clank, and the LOTR series. I jut bought Dance Dance Revolution and it's hilarious because hubby and I have been playing it as much as my daughter!

I'm a thrift store/garage sale fan and I've probably bought more stuff used in my life than new. I used to sell on Ebay and did it up until nursing school started. I still have boxes of things in the basement specifically for sale on Ebay. I believe I've got a good eye for what's going to sell and manage to do pretty well when I devote the time and energy to it. Strangely, I hate clutter and knick-nacks myself. The only things I can say I collect are books on spirituality and hypnotherapy and two "caboodles" worth of fine vintage costume jewelry (all of it sparkly and stunning) that I do wear when the occasion presents itself. Note: these are not actually pictures of pieces I have, but sort of represent what I like. I have never paid full price and only add to my collection from garage sales and the occasional foolish thrift store.

Alrighty - time for bed. Thats probably as much trivia about me as anyone can handle in one sitting!! :)

LA Weight Loss Stories

2006-02-14T23:03:00.000-08:00

Does anyone have any experience with LA Weight Loss? Have you heard a story or know someone who went on it? I'm spring cleaning right now and besides cleaning out the basement, the extra pounds should go too!! :)

I've heard it is sort of expensive and you've got to pay up front, but that doesn't bother me as long as it works. I think I'd like the fact that I was sort of accountable because they say you've got to weigh in three times a week. It's so close to my house it would be easy to stop in after work.

What's Going On Here?

2006-02-13T11:21:00.000-08:00

I've been "gone" for a little bit because of some changes in my life. Well, actually just one big change. I'm no longer working at the jail and have started a position in psych. Why I'm no longer working at the jail took me about two weeks to get over and I guess I'm just not going to get into that here, which is why I haven't been posting. (I will let you know that although it wasn't something I did, that doesn't help me feel any less like I could have done something differently or that I'm any less of a failure. I'm really hard on myself. Really.)

I feel like I'm in a whirlwind. What happened to my ideas of working in the ED or CCU? I do really enjoy those units, but when I had to look for something new, I called a psych position I interviewed at before I was hired at the jail. It had looked like they were going to offer me a job at the interview, but I ended up taking the jail position first. When I called her up, she remembered me well and asked me to come down to discuss terms (less than the county, but more then the hospital!). I needed the transition to be easy / pain free / worry free and this was it. So now I'm in psych.

For about a year now I've been studying and taking courses in EFT. I know it's still a new therapy/modality/treatment/whatever you like to call it, but go take a look at it. Out of the 20 or so people I've used it on, all of them have been "one minute wonders" - It's amazing! I'm finishing up my level 2 training now and am planning on going to the NY area in May to take a level 3 course. I haven't mentioned it before because I wanted to continue studying, using, and getting a feel for it. You can download information from the website (free!) on how to do it yourself. Please contact me and let me know if you're interested in this. My email is in my profile.

I think I'll enjoy psych. I know I won't be able to use EFT at work without discussing it in depth with the providers and my manager and getting their OK - that's much further down the road. Right now I just want to go to work and get used to it and try to reach that point where I feel confident and comfortable with what I am doing, and I know that may take a while.

PS: click on the picture if you like it.

Manic Often?

2006-01-23T21:22:00.000-08:00

I got a chance to deal with my first "real" psych inmate today. Sure, lots (maybe most) of the folks in jail have psych issues - diagnosed or not - but this was my first opportunity to do intake on a person who was completely in the grip of an unmedicated manic episode.

**I have to thank Crazy Tracy for writing such moving stories of her life and often manic times. Her thoughts and feelings led me to a deeper understanding of mania than any textbook ever could, and added texture to my own experience and attitude when I interacted with this inmate. I admire Tracy and thank her for her ability to share such a personal part of her with the rest of us.**

It really isn't much of a story. I took him back to the exam space and asked him about some of the things he had mentioned to the officers. You have to understand this is the EXTREMELY ABBREVIATED version. I just don't have enough time in the day to type as fast as he was talking. BTW, we chart in SOAP (different than hospital charting!) and this was the S part.

He said he never did drugs - his booking sheet said he told them he did "ALL" drugs.

He told me he had no history of SI/SA - he told them he had.

He told me he didn't have ADHD - he told them he did.

"Alright! So tell me is there anything I need to know about while you're here? Anything medical?"
"I got shot in the leg while these gangsters were invading my house and looking..."
"Do you have a scar you can show me?"
"Oh, yeah!" (rolling up pants leg)"The gangsters broke in and stole all of my stuff..."
[Hx GSW to RLL...]
"Yes, I see the scars. So how does this affect you?"
"It doesn't - I'm fine"
"No problems moving or anything?"
"Nope. It's perfect"
[Hx GSW to RLL "but fine now"] (sigh)

He told me he DID have a closed head injury (noted + on the booking questions)- flying 36 feet through the air during an MVA and hitting his head on a rock. I'm scribbling furiously: [Hx closed head injury r/t MVA ejection...]
"But that's all better now"
"What did the doctors at the hospital tell you about the injury?"
"No, I never went to the hospital. Just a concussion, but I'm fine"
[I/M Hx closed head injury r/t MVA ejection "but fine now"]
(ok, good save)

"I'm really looking for anything medical that's affecting you right now. I need to know so we can help you. So basically, you sound like besides the psych issues we've discussed you're medically ok?"

"I have a weak heart"
"A heart problem - that's important. What sort of weak heart do you have?"
"I don't know. I just have a weak heart."
"Are you taking any medication for it?
"My mother did."
"Your mother had a weak heart also?"
"My mother has the weak heart."
"Do you have a weak heart also, or is it just your mother?"
"It's just my mother."
"So you think you might have a weak heart because your mother had one - but has anyone ever told you that you have a weak heart also?
"No."

I sort of decided shortly after that that any further questioning would be useless unless we could get him back on his meds. Some of what he said was delusional and other parts were what I think is referred to as "flight of ideas", although I could follow and re-direct if need be. His vital signs were stable and he was in no apparent distress, so he had to go to psych eval. Luckily, I verified the meds easily and he's going to get his first dose tonight.

Like I said, that really is a lot less than what actually went on, but I had to stop and interrupt him so many times. The stories he was telling just went on and on. It was scary and fascinating at the same time, because I kept thinking about Tracy. I thought "So this is what it really looks like".

I have to thank God I don't know what it feels like.

Click the image to go to the wonderful Brain Atlas!

What's Your Issue?

2006-01-17T17:42:00.000-08:00

The topic of knowing what a prisoner is in for was brought up in comments, and I thought I'd make a post on that.

In some ways I'm concerned that knowing what a person is in for might cloud my judgement when interviewing them about health concerns. Would you believe someone in on drug charges is drug seeking? Would you treat a rapist differently? I think it's better that I don't know, so I have an opportunity to treat everyone equally.

There are opportunities to find out anyway - when you're in booking, the charges against them are usually discussed at the desk right outside the exam room so you can't help but hear. You also might find out that someone is a "commercial sex worker" (don't ya love that - PC at it's finest!) when they're discussing what STDs they've been treated for in the past and which ones they think they have now. We can offer free STD testing and HIV/AIDS testing.

I want to do my best in giving care. I would like to think that some of these people can be helped, and can come out of jail in better condition than when they came in (yes, maybe I'm idealistic and living in a fantasy world...). This might give them an opportunity to change their life. True, some of them should be locked up and never let out, but that decision isn't mine to make at work - only at the polls.

On one of my first days shadowing another nurse we interviewed a young woman who was very pretty, polite, and well-spoken. She didn't fit in with the other inmates and we did end up looking her up to find she was in for burglary with a weapon. There's just nothing we can do with the information. We're not there to counsel or preach - there are plenty of people for that. I hope she straightens out before she becomes one of the repeat customers.

The title of this post is from a page of prison slang terms I was reading: What's your issue = What are you charged with. I never hear it, but I don't know if they talk amongst themselves like that. It may happen more often in prison than in jail.

More Triage

2006-01-13T17:40:00.000-08:00

I walk over to the place where incoming prisoners are held before they're sent to whatever unit they're placed in. They wait there after giving up their outside clothes, being searched, and putting on jail scrubs and sandals. They can get called up by a social worker, fingerprinting and photos, the booking officers, or nurses.

I call the guy's name. We've got to see everyone who comes in who says they have a medical or psych issue, just to do a quick assessment and make sure they let us know if there are any meds they have to get while in jail. Sometimes it's really easy and they say they've had a BTK amputation or something and we'll just make sure they get a bottom bunk. Other times it's not so easy and we've got to make sure they can continue with whatever treatments they got on the outside i.e. dialysis, breathing treatments, wound care. Sometimes they've never had any medical help for something (like an abscess or wound) and this will be the first time someone has looked at it.

This guy starts following me back to my little exam room. It's pretty well stocked, and has quite a bit of equipment in it. Crash cart and everything. (is this story getting long??)

Anyway, he walks soooooo slowwwwwly and he's sort of hunched over and he's using a cane to help him walk.

Step.
Step.
Step.
Step.

He's not even that old, but he's certainly looking like a train wreck. All the slip said was "back pain" so I'm not really sure what I'm getting into - and how much of it is an act (you have NO IDEA unless you actually work in there what sort of things inmates will do for NO APPARENT REASON OR BENEFIT TO THEMSELVES). I think anyone who has worked in a jail or prison system can back me up on that. I'm still in shell-shock at how often I get straight-up LIED to! It's like a hobby to them or something. There's no reason I can think of for some of the crap they pull. I'm still learning.

He comes into the exam room. I'm already seated at the desk. He slowly lowers himself down into the chair I've motioned for him to sit in.

Once he's settled he just looks at me in a goofy way and sort of shrugs his shoulders.

Me: "Didn't take much to capture you, did it?"

He and I both bust out laughing.

My charge nurse says I'll do fine.

Winner for December!

2006-01-10T17:37:00.000-08:00

Becoming a Nurse wins NurseBlog of the Month for December. She gets a fancy graphic trophy, top mention on the NurseBlog links, some good-smellin' Bath and Body Works antibacterial gel, and of course, the love and admiration of her peers!

Go check out her ultra-cool video posts, listen to stories of nursing school, and (as always) comment bunches.

Triage Exchange

2006-01-07T11:31:00.000-08:00

"What are you taking Celexa for?"

"uh. I dunno."

"So how's it working for ya?"

Nursing Duties

2006-01-06T20:45:00.000-08:00

I'm getting more comfortable at the LCJ and things are starting to come together. There are many differences between hospital nursing and correctional nursing, but one thing that really stands out is that we rotate (daily, not hourly!) through four different types of jobs.

The RNs in the booking help triage or flag patients who are coming in with problems. This is a full-time job and can get quite busy. Because we're a large jail "chains" of inmates often stop over while being transported between facilities, most forming new chains going in new directions - always splitting and reforming. It's like a freeway interchange, and the nurse up there needs to make sure that anyone who might be spending the night with us has their health needs addressed. It gets really busy sometimes, and I know today they sent two more RNs up there to help the one that was there already.

Another place you'll find RNs is in the infirmary. LPNs help with drawing blood, administering meds, taking vitals, and a lot of other stuff. I have only spent one shift in there, but it can get really busy too. There are no CNAs, but there is a medical records person. The RNs and LPNs work very well together, and it seems to run smoothly as busy as it is. Besides the inmates who are sick and need to see a provider (usually an NP, sometimes an MD, Dentist, or Mental Health provider), there are basic health assesments that must be done on every inmate after they've been there 2 weeks. That's a lot of people to see!

RN's go on rounds to each unit and triage the inmates there. Inmates can see a nurse by putting in a request. Obviously, if someone is very sick or injured they can get immediate attention any time of the day. Triage rounds take up the whole shift for the nurses who are assigned to them. If you see someone who needs to go into the clinic, you refer them and they'll go according to a priority. A dislocated shoulder would get higher priority than bacterial vaginosis - pretty basic stuff.

The fourth job is med pass. Most of the time this is done by an LPN, but RNs can do it if there aren't enough LPNs. This is pretty much an all-day gig too.

OK! Well, that's enough of a post for now. I don't want to bore you to death, just give you a basic idea of what I'll be doing. I had fun today - the RN I shadowed was great to work with.

More Voting For You

2006-01-06T15:33:00.000-08:00

I just found out that I am in the running for Best Medical Weblog over at MedGadget! Although I SERIOUSLY DOUBT that I am anywhere near the best medical weblog... it would be nice to at least make a showing. I see that 3 people voted for me already - Woo Hoo! Thanks people! That makes me feel good. :)

If you'd like to give me a vote, click here. There are a few other nursing blogs nominated in best new blog including The Nurse Practitioner's Place, and Emergiblog. Vote for them, too, and show those med folks that nurses can blog with the best of them! I'm going to go back and see if I find any more NurseBlogs in the mix.

I looked for a picture that said "Vote", but I found this. It is slightly dated but (no offense, Floridians) it IS pretty funny:

December Vote

2006-01-04T21:33:00.000-08:00

Sorry, I'm running a bit behind here. I've been getting up somewhat earlier than I did when I worked at the hospital, and MUCH earlier than I did for the month and a half that I just lounged around the house unemployed!!! :P

That said, I'm proud to present to you the nominations for December's NurseBlog of the Month:

Becoming a Nurse, who has some really cool video posts on her blog that I have yet to be able to figure out how to accomplish. Geek Nurse, who gives us pictures of the inside of a NZ PICU. The Nurse Practitioner's Place, who stirred up quite a hornet's nest regarding the qualifications and ability of NPs when she commented on a stuffed animal (I'll leave you in some suspense there, because the whole thing was so wild you've got to see it to believe it....). Head Nurse, who took an in-depth look at sexual harrassment and nursing. Haiku of the Id posted this picture I thought was really funny of some very un-politically-correct Christmas decorations - look at your own risk unless you don't mind blood (Wait a sec.. who am I kidding? Go ahead and look!). Third Degree Nurse's husband wrote a super guest-post on her blog about what it's like to be the SONS (Significant Other of a Nursing Student) - well worth a read. Death Maiden wrote a poem and said "I don't want to go to the morgue today". Livin' Large finally met her Dutch Boy!

Now, of course, these aren't the only posts they've made. I just picked ones that I particularly liked. So read up on what they have to say then come back here and vote. You can vote only once, but at that time you can vote for more than one blog - it will even itself out. Since I'm posting this sort of late on the 4th, lets close voting sometime in the evening of the 9th.

Big Dog Nurse

2006-01-01T15:21:00.000-08:00

I found this t-shirt at the mall yesterday!

Click on the picture and select 'graphic tees' if you'd like one for yourself. They're cheaper at the Big Dogs retail store than they are online. I like the idea of "Get 'er Done!" better than all the dorky angel stuff they make for nurses.

Who is December's NurseBlogger of the Month?
	Becoming a Nurse
	Geek Nurse
	Nurse Practitioners Save Lives
	Livin' Large
	Head Nurse
	Haiku of the Id
	Third Degree Nurse
	Death Maiden

Free polls from Pollhost.com