March, 2006 Archive

March 31, 2006, 1:06 pm

The Key To A Smooth Running ER? Nurses!

There is a person in this photograph who suffers from a rare, dare I say extinct affliction.

Yes.

It’s an actual photo of “Flat Cap Syndrome”.

Flat Cap Syndrome developed when the brim of one’s nursing cap was larger than the fold behind it.

Some say that the victims were responsible for choosing to go to a School of Nursing identified by those caps.

Don’t blame the victim.

Maybe it was the only School that she was accepted to.

Maybe…..maybe she didn’t know….

By the time I graduated, designs in nursing caps had pretty much made Flat Cap Syndrome a thing of the past.

My cap was never flat, and to this day it stands proudly in its case in the den closet in pristine condition.

(Disclosure: it’s in pristine condition because I just bought it off of eBay.

I have to get the green and gold ribbons on it and then I have to get the courage to wear it to work because my co-workers will have a field day with me.

If all of a sudden there is no more Emergiblog, it’s because they killed me with ridicule.

Call the authorities.)

hhhhhhhhhhhhhhhhhh

Some of the advantages of working in different facilities are the exposure to different styles of nursing, different opportunities, different patient populations and differing protocols regarding what nurses are able to do on their own.

I’m not talking about using nurses instead of doctors, a la the problems that Dr. Crippen at NHS Blog Doctor describes, I’m talking about protocols that allow nurses, using certain criteria established by the ER physicians, to initiate care prior to the doctor seeing the patient.

Sounds like a great way to facilitate patient flow and satisfaction, right?

It is!

The best ERs that I have worked in are the ones that, per protocol, allow the RNs to do what they do best.

Conversely, the worst ERs I’ve worked in allowed the nurses to do nothing without an order.

  • When I worked at “World Renown Medical Center With Hard To Get Into Medical School”, this was the case. The nurses could not make a move without an order.
    • Why?
    • It was a teaching facility. How could the interns/residents learn to order appropriately if the nurse did it first? And forget verbal orders, if some resident gave an order you grabbed the nearest order sheet and made them write it. So often you’d have five or six different order sheets going.
    • Why?
    • Because if there was a descrepancy between what was said and what was done, guess whose derriere would be on the line? Right, the nurse’s. Remember the old saying about how excrement flows downhill? It’s true.
    • And the wait to get into a room? Hours. We’re talking 5-7 hours at times. You could be vomiting, have a 5-day migraine with photophobia, writhing on the floor with right flank pain secondary to a kidney stone and you would STILL be sitting in the ER with all the feverish, coughing bronchitis patients. And don’t think asthma would get you a front row seat, either. If your O2 sat was normal, have a seat like everyone else.
    • Why?
    • Because the beds never turned over. Because one nurse would be responsible for six monitored patients plus the psych isolation room across the hall. Because….
    • … first the “Pulmonary Team” had to see the patient, then they would decide this was a cardiac problem and you’d wait a few hours for the “Cardiac Team” who would discover that the patient wasn’t on that service after all and a different “Team” would come in an hour later, only to discover that said patient couldn’t be admitted there anyway, but then the patient would vomit blood which meant that they were too sick to transfer and you had to wait for the “GI Team” to come down and finally admit the patient.
    • Not to mention every single pediatric patient in the clinic area getting conscious sedation for their boo-boos.

Get the picture?

Then we have example number two.

  • Small community hospital, one that I will call “Mini County Hospital”. Sat right in the middle of a very ethnically diverse, lower-income area of a suburb that could be called the Meth Capital of the SF Bay Area. Many patients. Many clinical, non-emergent patients. Some very emergent patients.
    • The nurses were not allowed to do anything. Nada. Kaput.
    • Why?
    • Because the department had a wide mix of nursing experience, from new grads to newly designated dinosaurs like me, and there were no protocols because they could not depend on all the nurses to have the same level of competency.
    • So one day, Nurse Experience (me), brings in a patient with chest pain, starts a line while the tech does the EKG and within five minutes hands the doctor the EKG and the orders for CBC, Chemistry Panel, Cardiac Enzymes and portable chest to the unit clerk. No problem, right? Wrong.
      • I was curtly asked, “Who the hell told you to order those labs?”.
      • I looked at Dr. Who Was In Training Pants When I Graduated From Nursing School and said that they were the standard labs ordered for a chest pain patient suspected of having a cardiac problem.
      • “You are not covered to order these labs!
      • I said , “Are you telling me that after (then) 24 years experience in nursing, that I cannot at least get a cardiac workup started?
      • That was exactly what he was telling me. I had three times the experience and was old enough to be his…..older sister, but it didn’t matter. The nursing expectations went to the lowest common denominator, that of a new grad.
    • Which meant the patients in the waiting room waited, sometimes 8 hours for the same reasons stated above. The nurses could not facilitate patient movement. Because we worked with relatively new doctors, every child who vomited even once got an IV and a bolus. Most got septic workups.

Now let’s contrast this with an ER that runs quite smoothly, which happens to be where I am now and plan to retire from when I’m so old I can’t stand up straight.

  • This ER has nursing protocols. Detailed, well written protocols. Here’s what happens when you come into this ER:
    • For example, you come in and your chief complaint is nausea, vomiting, diarrhea for three days with fever and you are extremely dizzy when upright. I’m your nurse.
      • Before the doc shows up I will have orthostatic vital signs, an IV in, bloods drawn, a bolus of Normal Saline initiated (unless you are elderly or have heart trouble) ,at least a CBC and Chem 14 ordered (with additional blood in case more tests are added) and you can expect me to ask for and collect a UA and an stool specimen, which may or may not be needed, but they will be collected just in case.
    • Or you are an elderly male who looks 8 months pregnant and hasn’t urinated for 2 days except for a little bit here and there. You can barely walk, you are in so much pain. If I’m your nurse you will have a catheter in before you can say “ouch”, assuming your prostate co-operates.
    • Your wait on a bad day in our waiting room may be three hours max.
    • Why?

Because the Registered Nurses in my department are covered by extensive ER protocols and we work with doctors who respect our judgement and know we would not order outside of our protocols.

My attitude is that by the time that doctor walks in to see the patient, everything he/she needs has been at least considered. I am able to do much more than described above, but it often isn’t necessary because the doctors see the patients so quickly, they are usually right behind me.

(Yeah, I have a great job, which I appreciate all the more because I’ve had some bad ones.)

So the Emergency Departments that give nurses the most autonomy via protocols wind up being the ones that really need it the least. And they wind up being the ones with the highest patient satisfaction ratings.

A little ironic…

Doncha think?

ddd

Addendum: Dr. Who Was In Training Pants When I Graduated From Nursing School turned out to be one of the neatest persons I have ever met and he is a fantastic doctor. He was the one I missed most acutely when I left for my current job. Go figure.

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March 30, 2006, 8:21 pm

The Sign of the Four

Ummmmm……

Oooookaaaaay……

Midol made Betty gay?

They key to same-sex attraction has been in an over-the-counter pill all this time?

How does that explain the guys?

Did they get into their sister’s stash of Midol and there was no turning back?

Well, hey, at least Betty is happy. She probably called Steve, broke up and asked Shirley to the soda fountain hop.

Who knew?

hhhhhhhhhhhhhhhhhh

I have been “tagged”.

Normally I do not participate in “tagging” because this is a professional blog where only professional matters are discussed. It is not about me.

Like hell!

It’s TOTALLY about me!

So, thanks to Kimberly at R_N For Your Life, you shall now learn more than you ever wanted to know about….

Me.

  • 4 Jobs I Have Had In My Life:
    • Registered Nurse
    • Nurse’s Aide
    • Telephone Sales for Montgomery Wards, in their Appliance Extended Warranty Department. Freakin’ hell on earth.
    • Waitress at Bumbleberry’s Restaurant (now defunct – similar to Marie Calendar’s); spent all my tips on albums
  • 4 Movies I Could Watch Over and Over:
    • A.I. (Artificial Intelligence) – hands down, the best freakin’ movie ever made. So creepy, so sad, so totally futuristically cool! Such a beautiful mix of Speilberg AND Stanley Kubrick in one, beautiful homage to the eternal story of Pinochio and the moral question of our responsibility to artificially created intelligent beings. I own it, I watch it regularly. You HAD to see this on the big screen. I saw it four times in the theater. I was the only person bawling into my tissue! If you do watch it now, make sure it is on a large screen TV, preferably with all the lights out and when it is raining! DAMN good movie!
    • I, Robot – Will Smith in the shower, OK? I’m just sayin’. A great rendering of Isaac Asimov’s classic novel – his whole robot series is mesmerizing. SO sci-fi! When I came home (saw it twice in the theater), I looked into what it would cost to rent one of those robots that Mazda makes (“Asimo”)…..it was something like $300,000 per day. Guess I’ll have to get me a robot vacuum instead…..
    • Hitchhiker’s Guide To The Galaxy – Martin Freeman as a yarn man vomiting up yarn in a bin. I’m just sayin’! Actually, I was also partial to Zaphod Beeblebrox. Hilarious movie if you are hip to British humor and if you are just hip in general. I saw it late on opening night (three times total) and there were only six of us in the theater and we were ALL hip to the Douglas Adams vibe. I laughed so hard I cried. Who you calling a nerd?
    • Sgt. Pepper’s Lonely Hearts Club Band – Barry Gibb in Technicolor, OK? I’m just sayin’! I saw this four times in the theater in one day! Of course, this was prior to my becoming an RN and having responsibilities. I saw it alone, then took my little sister, then took my friend and then took my fiance! And he married me anyway! I love the Bee Gees and they do fantastic versions of the Beatles’ hits. Of course Peter Frampton looks like a powder puff but I saw him in concert a couple of years ago and he looks mighty fine with no hair!
  • 4 Websites I Visit Regularly:
    • James Lileks – at lileks.com , writer extrodinaire, hilarious blog called “The Bleat” – trust me, all he writes about is his day and you’ll be rolling in the aisles! And he is one of my “blog parents”! If you check him out, you have to read his archives – he’s been “blogging” since 1997!
    • Praying For Karis – at www.aup.org/Karis. She is a friend of my son’s at Notre Dame who has just gone through the second transplant of her entire digestive tract. This is a website the family put up a few years ago to keep friends and family in the loop.
    • Stuff On My Cat – at stuffonmycat.com. This site is exactly what it says. Pictures of cat whose owners have put stuff on them. You have to see it. It’s hard to describe.
    • Emergiblog – at, well, here! (1) because it’s my blog and (2) this is where I link to everybody else so I can read your blogs!
  • 4 of my Favorite Foods
    • Avocados
    • Guacamole
    • Diet Pepsi – fountain
    • Quarter Pounder With Cheese – I have no shame!
  • 4 Places I Would Rather Be Right Now
    • Mendocino, California – I was meant to live on an ocean bluff
    • Hollywood, California – as an American Idol finalist (or sitting on Simon’s lap, I’m not picky).
    • England and Scotland – because I definitely feel the roots of my ancestors calling to me from across the Atlantic, and because they have totally cool television and that is where Martin Freeman lives. And they have Judi Dench and Patricia Rutledge. Oh, I’m sorry, don’t know who they are? Well, I suggest you spend more time with the BBC, thank you.
    • Australia – I want to volunteer to work at Roo Gully, it is a sanctuary for kangaroos (and other animals) with the goal of getting them back into the wild. I am a foster mom to a ‘roo and this would definitely be a working vacation. For a few months. For some reason my hubby says no. Maybe because there are no ugly men in Australia.
  • 4 Most Wonderful Places I Have Been
    • Mendocino, California – stunning
    • St John’s – the one place in the Carribean I remember with fondness
    • Puerto Rico – shaking hands with Steve Perry
    • Mexico – at the market in Mazatlan feeling guilty that I was supposed to bargain with the already low prices for these totally cool things.
  • 4 Books I Could Read Over and Over
    • Shelby Foote’s 3000 page, 3 volume Civil War Trilogy. Truly amazing…
    • The Complete Hitchhiker’s Guide To The Galaxy (all the books)
    • The entire Mitford Series by Jan Karon
    • The entire Isaac Asimov catalouge
  • 4 Songs I Could Listen To Everyday
    • “My Immortal” – Evanescence
    • Anything by Journey
    • The entire “Mad Season” album by Matchbox 20
    • Anything by Robin Gibb (or the Bee Gees)
  • 4 Reasons I Blog
    • I enjoy writing (and being read)
    • I learn so much more – it’s like free CEUs
    • I love reading what everyone else writes and feeling like a part of the community
    • It has brought home how similar we all are, no matter where we are from, that never ceases to give me goosebumps!
  • 4 People To Tag
    • I am too embarrasssed/shy to tag someone
    • Any volunteers willing to take this on?

Now that you all have officially “Too Much Information” on me, I shall sink, red faced into the oblivion of the internet…..or more specifically a bubblebath!

UPDATE: DR. FLEA HAS VOLUNTEERED TO BE TAGGED!
UPDATE NUMBER TWO: BIG MAMA DOC IS UP FOR TAGGING!
UDATE NUMBER THREE: MARY AT “A MOTE IN THE LIGHT” HAS JUST BEEN TAGGED!

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March 28, 2006, 12:39 am

You Got To Know When To Hold ‘Em…..

Holy cow!

I never saw this in Microbiology!

Just a bunch of stressed out student nurses trying to cram in it into one summer session going five days a week for five hours a day.

Mr. Graham Positive here was nowhere in sight.

Then again, I took Micro so long ago that if he was in my class he’d be wearing Angel Flight pants, a silk shirt open to the lower sternum showing (hopefully) chest hair and gold chains, as he walked to his desk in platform shoes and feathered hair a la Barry Gibb.

I think I need a cold shower.

hhhhhhhhhhhhhhhhhh

Ah, it isn’t often that I feel a “rant” coming on but there is something that I feel very strongly about.

Maybe it makes me a heartless nurse.

Perhaps it makes me a bad mother.

The issue?

I cannot stand it when conscious sedation is ordered for children who have a laceration.

I am old-school. I believe in wrapping them like a mummy, placing them in a papoose and holding them during the suturing. It’s faster, the pain stops after the lidocaine injections and the child is then up and ready to go immediately.

For the uninitiated, “conscious sedation” is a term used when a patient needs an especially painful procedure done. An IV is placed and they are given medications that (1) reduce the pain (2) sedate the patient and (3) cause amnesia so the patient doesn’t remember what the procedure was like when they wake up.

During the procedure the patient is placed on a cardiac monitor, oxygen, a respiratory therapist is present in case there are airway problems, reversal agents are kept at the bedside in case of emergency, and the patient has the IV as previously mentioned.

It is a wonderful way to get patients of any age through procedures like reducing shoulder dislocations or fractures or hip prosthesis dislocations.

It also ties up one nurse with one patient for however long it takes that patient to recover. The patient is never left alone. The drugs are short acting, but recovery can take as long as one hour for some patients, depending on how much medication they were given and how fast they metabolize it. Vital signs are taken every five minutes during the procedure and then every 10-15 minutes after until the patient is awake, able to tolerate clear fluids, have vital signs near pre-procedure levels and can ambulate.

Is this really necessary for a child with a one-half inch laceration on his forehead?

Ah, I hear the chorus now….

From the parents: “But it is so traumatic on my poor child to hold them down!”

They’ll get over it. I not only remember getting stitched at the age of three I still have the scar!

It does not “scar”you psychologically for life. Getting stitches is a part of life. Are we raising a generation of wimps for whom a boo-boo is a life altering trauma?

From the ER docs: “It’s hard to hit a moving target!”

Then your nurse doesn’t know how to hold. I developed the (not-patented) chest hold many, many years ago where the child couldn’t move his head if he tried. Let’s just say that it involved removal of my scrub jacket and namebadge, leaning over the gurney, placing my chest on one side of the head and using my arm to surround the top of the child’s head and holding it against my chest.

Works every time.

ddd

Just a couple of my personal beliefs.

  • Every person getting conscious sedation, including kids, gets an IV whether or not the doc believes it is warranted. Emergency situations are rare, but that patient is my responsibility, too, and my derriere is on the line if we aren’t prepared for them.
  • If conscious sedation is ordered, I feel it is the doctor’s responsibility to explain to the parents exactly what that entails, including oxygen, monitoring, IV medications, etc. Just telling the parents that the patient will sleep through the procedure is not enough. They shouldn’t have to hear that from the nurse who is having them sign that they have received informed consent.

End of rant.

Now, to end on a positive note:

Emergency room physicians are second only to plastic surgeons when it comes to stitching lacerations on patients of any age. I’ve seen some beautiful repair work by ER doctors in my time.

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About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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