May, 2006 Archive

May 31, 2006, 9:29 pm

Because the Night Belongs to Us


Whoa! Check this out!

“The Mark of the Beast” Cold Medication!

For when you have a “devil” of a cold!

For when you would sell your soul just to breathe normally!

For those days when you think hell will freeze over before you get well again.

Guaranteed to take care of all your cold symptoms for as long as you live!

All you need to do is pay with your soul!

Instead of an antihistamine you get an antichrist-amine!

I wonder if you drink it if you will be “Left Behind”?

Sorry, I couldn’t resist.

(I actually love that series, Jerry Jenkins is, ahem, one hell of a writer!)


It’s no secret that I’m a night person.

I’ve said before it is easier to stay up until 0700 than to get up at 0700!

And I prefer the night shift for many reasons, not the least of which is that there are less people around and you can spend more time with your patients.

And….I have no young children and can sleep when and how long I want. Usually.

The males of the household have learned, sometimes painfully, that to wake me up results in a voice that makes Luciano Pavarotti sound like Barry White.

But if I had to give advice to someone who was just starting the night shift (and that may be a few new grads out there), I can only tell you what works for me and I’ve learned this over the years through trial and error.

  • Put All Your Piggies In A Row
    • Try to get your shifts scheduled sequentially.
    • Under no circumstances allow yourself to be scheduled “one-on-and-one-off”. Unless you live the hours of a night nurse whether you are working or not, this will do you in!. It’s easier for me because I tend to be a human “Bat” (except I don’t hang upside down in a closet.)
    • Always have at least two days off in a row before returning to the night shift. This is not easy if you are working full time, eight-hour shifts. So….
      • I suggest that if you are given the opportunity, work only 4 days a week or less.
      • The differential of the night shift should make up for the missing day.
      • It is possible to work one-week-on/one-week off and I have done that before. I remember liking it. I don’t think I had gray hair then. Not that I have it now mind you.
    • If you have the chance to work three 12-hour night shifts per week, try to avoid working them all in a row.
      • It will take you two days to recover, at least.
      • You will feel (and look) like death warmed over by the end of the third shift.
  • Don’t Give Your Piggies Roast Beef
    • I’m not sure what it is about nocturnal consumption, but I found that eating during the night caused bloating and discomfort.
      • A snack is okay, a few crackers with some milk or half a sandwhich.
      • Also, eating at night is a sure way to gain weight, especially if it is not a busy unit/night and you’re eating to stay awake or out of boredom.
    • Watch the coffee intake
      • If you’re like me, you’ll pour five cups and actually have time to drink about half a cup.
      • If you are sleeping in the morning, watch the caffeine after about 0400.
      • If you are an afternoon sleeper, it shouldn’t affect you.
      • And remember, coffee is acidic so can contribute if you have that bloating/discomfort discussed above.
  • Back at the Ranch
    • Make your environment sleep friendly
      • Get your room as dark as possible or sleep in the darkest possible area
      • Consider using a fan or another type of machine as “white noise”. This will drown out neighborhood noise, barking dogs, cars,etc.
    • If you can’t sleep
      • Get up. Laying there trying to sleep is only going to make it worse.
      • Take a hot bath, read.
      • Be careful about using antihistamines to sleep, they can cause a “hangover” type feeling and you will be groggy while awake. I, personally use melatonin but please do not constitute that as advice.
      • If you sleep for a few hours only and then are wide awake, try to take a nap before going to work.
    • Stay hydrated
      • Dehydration can cause headaches. I left the night shift once after suffering from prolonged low-grade headaches that would last 5-6 days. It was because I drank nothing but coffee and Diet Pepsi. It had nothing to do with the shift.
  • So why put yourself through working the night shift?
    • Minimal management presence – not that management is bad, it just means less distractions from taking care of patients.
    • Group cohesiveness – night shift workers tend to take care of each other and there is much less back-biting.
    • Usually a less number of patients, giving you more of a chance to do more for them and get to know them better, at least in the ER.
    • A shift differential – where I work, it is rather substantial, thanks to the work of the California Nurses Association over the years.
    • You can be home for your family when they are awake.

So night shift is a doable, often desirable shift to work. It’s the best shift for me.

But that old saying that a nurse needs to take care of herself first is truer in this situation than any other.

If you are meant to be a night nurse, you will know it!

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12:24 am

Walk on Over to Grand Rounds!


Since when do patients leave the hospital looking like they are on a business trip?

This guy even has had his shoes shined!

The sentiment at the top of the photo is quite nice and very true.

However, on the new nursing cap rating scale instigated by KACNAC (Kim’s Accreditation Commission on Nursing and Caps), this nursing cap is a 6.75 on the 0-10 scale.

However, since very few nurses wear their cap, except me, I don’t believe this will put a cramp in anyone’s work habits.

And besides, I don’t think I have the authority to impose it.

But one can dream.


It it’s Tuesday if must be Grand Rounds! Today our host is our favorite New York nephrologoist at Kidney Notes.

I was surprised and honored to find that an Emergiblog post was selected as an “Editor’s Pick”.

Again, an amazing selection of stories, education and information. “Walk” your keyboard on over and check it out (with or without your suitcase!).


I was happily blogging via WiFi at a local Seattle’s Best this afternoon (see above) and it totally rocked! I’m going to do it on a daily basis. Being there during the day is wonderful because

  • Everyone who is studying is in school.
  • Everyone who works 9-5 is working 9-5.
  • Seattle’s Best, although owned by Starbucks, has better coffee and cleaner shops.
  • The coffee shop is attached to Borders bookstore so I am 20 feet away from a vast expanse of written literature and fun stuff like totally cool pens and stationery.
  • I’m easy to please.

During this idyll time I received an IM from my son who informed me of the results of my husband’s visit with his surgeon today.

His gallbladder was gangrenous.

I’ll save the full story for Scared to Health.

My reaction was one of total, retroactive shock. My legs went numb.

It’s a good thing I was sitting because blogging face down in a coffee shop would have attracted attention, I’m sure.

I then did the most stupid thing I could have done. I googled “gangrenous gallbladder mortality”.Wrong.

It’s between 25-50% if surgery is not done in time. The mortality rate was zero in one study of over 200 patients with a 21.5% incidence of gangrene when the surgery was performed on a timely basis.

The problem is that a gangrenous gallbladder presents no differently than a regular gallbladder in terms of symptoms – the type of symptoms that bring people to an ER.

How many times have we taken care of people with gallbladders that are, unknown to us, gangrenous, taken care of their pain, given them an ultrasound and sent them home to follow up with a surgeon in 1-2 days?

The surgeon said she was surprised hubby was not sicker than he was given the state of the gallbladder upon removal. It only had two tiny stones in it.

I took the last sip of my latte, closed down my computer and on legs that weren’t exactly steady, met the kids after their movie and drove them to cross-country practice.

Life goes on now, pretty much as it did two weeks before.

I said a prayer of thanks as I walked to my car, shedding a few tears in the process.

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May 28, 2006, 9:49 pm

Triage: How Much Is Too Much?


This ad is for fire sprinklers.

Notice the quick and efficient nurses executing the hospital fire evacuation plan.

I guess they are waiting for the patients to become victims so they can then put their “quick plans” into good use.

The one on the far left looks like she has comes from a “dreaded harsh toilet tissue” ad.

The next one looks like she is eating an ice cream cone.

Hard to do in a fire, don’t you think?

I mean, it melts and all.

Then we have two with so much air in their heads they have risen spontaneously like human helium balloons.

The enthusiastic professional on the right is just counting the minutes until her shift is over.

I thought automatic sprinkler systems were a more recent invention.

Sure would wreck havoc on a nurse’s cap.


In my department, the designated Charge Nurse is the triage nurse.

This can be tough on hellacious shifts because one cannot be in triage 100% of the time and really know what is going on in the department itself.

This is not as big a problem in my ED because, well, basically everyone is so experienced and self-sufficient there is no need of any major interventions. The Charge Nurse gets involved if there is a patient complaint, a problem with getting a patient upstairs or re-arranging patients if a specific ED room is needed.

I love triage, but don’t like being in charge.

In the huge tribe of health care I am an excellent Indian with no aspirations to the position of Chief.


There are three theories to how triage should be handled.

  • The Down and Dirty Doorway Destination Decision
    • Pass the triage room and go directly to Park Place, meaning you park your derriere immediately in a place on a gurney.
    • Chest pain, severe dyspnea, CVA symptoms or hemmoraging at the secretary’s desk gets you this designation. Throwing up on the secretary’s desk can, on some occasions, also facilitate your entry into a room.
    • You usually meet 90% of the ED staff within one minute of arrival as they all converge to get you “settled” (an IV, blood draw, EKG, portable chest and monitors all over your body, foley or CPR if you’re unlucky). Then they all disappear.
  • Surf ’em and Turf ’em
    • A one sentence chief complaint, multiple hash marks in a few boxes, allergies and half a set of vitals as you visually surf the patient.
    • Then you turf ’em to the waiting room to wait for registration.
    • NEXT!
  • The Triage Trifecta
    • A complete history of the present illness with focused assessment.
    • Past medical history including surgeries, last period, pregnancy status (yes/no), Gravida/Parida, and immunization status including last DT when appropriate.
    • A full set of vital signs including pain scale, weights on pedi patients and head circumference on infants (don’t get me started on that one)

There is no problem with the first system – emergent patients are emergently treated and that is universal.

So how far should you go when triaging a patient? How much information is too much information? Can you ever have too much information about a patient?

For the record, I’m a “Teresa Trifecta”. Every inch of that triage sheet is filled, checked, slashed, listed and signed. I ask about previous surgeries. I send families home for the medications or the list they forgot if the chief complaint warrants it.

But….I’m confused.

I’ve been told by a colleague that, in her opinion, I’m too thorough. Spit ’em out faster is her philosophy (a full triage with a patient that speaks English takes me 5 minutes, a child slightly longer).

I’ve had physicians tell me they love my triage notes, that they know what to expect when they go to see the patient.

How can you just “spit ’em out faster” when some EDs require that tetanus boosters and fever control medications be given at triage? Along with the usual ice, elevation and the occasional pressure dressing or splint? Or the extra time it takes to get rectal temps on small children? Or the writing of 15-20 medications for the elderly?

It’s a catch-22. You are supposed to move faster because there are more people to see, but every year more information is required from each patient at the point of intake.

I say that the more information you collect up front the better. Some will say otherwise and as long as we do the mandated check marking, it gets by quality control.

But 5 years from now, I don’t want to be sitting in a courtroom with a practically blank triage note blown up for a jury with my name on it.

So “Teresa Trifecta” I shall remain.

When you’re dealing with someone’s health, there is no such thing as too much information.

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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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