You might be an ICU nurse if:
Your measurement of time is "minutes until it's time to write vitals."
Friday, July 29, 2011
Tuesday, July 26, 2011
I Just Don't Know
Lately I've been contemplating the direction I'd like to take this blog.
The longer this space exists, the chances of my true identity being unmasked grows, possibly exponentially. When I started this iteration of my blog, I had no idea that it would grow to be even as mildly popular as it has. I wasn't clear sighted enough to plan for that from the start. As a result this "anonymous" blog is hopelessly entangled with my "real" life.
For instance, the master email Blogger associates with this account happens to be my gmail account that I use for *everything*. Not a big deal because that email address isn't used anywhere except for me to sign in. Nicely compartmentalized I thought. Only when somebody sends me a Google+ invite, suddenly my Picasa account (with all my blog pictures) will be linked to my uber-Facebook experience. And suddenly my real name will be substituted where my nicely anonymous username had reigned. Blast it.
I can't say that it isn't tempting to exit the proverbial blogging closet, and just become a real person in both senses. But that would pretty much preclude any patient stories no matter how fabricated. And frankly, do I have enough important things to say regarding nursing that people will continue to visit without the sensationalism of my patient encounters?
Am I ready to give up the sanctity of my virtual repository to unload and get things off my chest?
I just don't know.
At some point I'd like to transition my writing to more mainstream outlets. Does an anonymous body of work allow for that?
"I'd send you examples of my writing...except I can't...you know patient privacy and all. I write real good though. I swear."
I just don't know.
The longer this space exists, the chances of my true identity being unmasked grows, possibly exponentially. When I started this iteration of my blog, I had no idea that it would grow to be even as mildly popular as it has. I wasn't clear sighted enough to plan for that from the start. As a result this "anonymous" blog is hopelessly entangled with my "real" life.
For instance, the master email Blogger associates with this account happens to be my gmail account that I use for *everything*. Not a big deal because that email address isn't used anywhere except for me to sign in. Nicely compartmentalized I thought. Only when somebody sends me a Google+ invite, suddenly my Picasa account (with all my blog pictures) will be linked to my uber-Facebook experience. And suddenly my real name will be substituted where my nicely anonymous username had reigned. Blast it.
I can't say that it isn't tempting to exit the proverbial blogging closet, and just become a real person in both senses. But that would pretty much preclude any patient stories no matter how fabricated. And frankly, do I have enough important things to say regarding nursing that people will continue to visit without the sensationalism of my patient encounters?
Am I ready to give up the sanctity of my virtual repository to unload and get things off my chest?
I just don't know.
At some point I'd like to transition my writing to more mainstream outlets. Does an anonymous body of work allow for that?
"I'd send you examples of my writing...except I can't...you know patient privacy and all. I write real good though. I swear."
I just don't know.
Sunday, July 24, 2011
A Different Kind Of Crazy
Amongst my least favorite patients to care for are those that have lost their noodle. Be it dementia, ICU psychosis, mental illness, it just wears me out having to deal with them.
I like logic. I like things to be orderly. I like it when people have been educated, and the information leads them to draw the conclusions I intend.
Crazy people don't do that. And that cuts across the grain of everything that makes my purplish haze of a world tolerable.
But I ran across a new kind of crazy this week at work.
This lady, (let's call her Eleanor), was 100% with it. She was completely lucid, she truly was that ever elusive A&Ox4. This is quite an achievement considering she'd come in for a valve replacement over a month ago and ended up with a CABGx5 and a balloon pump. Following her surgery, she rode our carepath upstairs only to come crashing back down as an RRT in respiratory stress.
It seems that the yahoo techs on our stepdown floor *still* cannot get it through their thick skulls that if a patient drinks too much water, with all the fluid shifts from being on pump, the patients drink themselves straight into pulmonary edema. Not to mention the atropine given pre-anesthesia makes *everyone* wickedly thirsty, for *days*. So when the techs get tired of answering call bells about drinks of water, they sure as heck will bring the patient a big huge pitcher of water and let them drink themselves into a gurglely, pink frothy mess.
So it was with Eleanor.
And she ended up re-intubated. Then extubated. Then re-intubated, and extubated yet again. If you've played this game before, you know that each subsequent re-intubation significantly reduces the chances of a favorable outcome. Counting her surgery, Eleanor is working on post-extubation #3. Even now after spending 8 hours each night on BiPAP, her PCO2 is routinely greater than 65 each morning.
She's also failed her swallow study 3 times now.
All this to say that Eleanor is *strictly* NPO.
She knows this.
And she knows why.
And she knows the consequences of noncompliance.
But this does not stop her from asking, begging, pleading, groveling for a drink of water as many times an hour as you are willing to entertain. She actively tries to deceive anyone who comes near her bed and trick them into giving her water. She tries to split staff and family members and play them off one another to manipulate them into giving her water.
Honestly I've been around better behaved toddlers. (Two of which happen to live with me.)
Really I'm at a loss to adequately convey the sheer, colossal, unbelievable stupidity of it all.
I performed impeccable oral care hourly to maintain her oral mucosa. But my reward for this above and beyond (unit policy and procedure is Q4)? Each swab is met with a greedy demand, "MORE!!" Upon refusal, she throws anything within reach on the floor in protest. Pillows. Blankets. Her Bairhugger nozzle. You wouldn't believe how low my bullshit tolerance for this kind of shenanigans is.
Maybe a better, more saintly nurse would have had the patience to deal with these outbursts. Me, with my curmudgeonly tendencies, simply didn't give the items back to her the second time they ended up on the floor. When she started immediately sucking the water out of each swab (nearly aspirating on that small amount of water each time) rather than letting me wet her mucosa, I promptly switched to using chlorhexidine gluconate instead. Funny, she was much less enthusiastic about her oral care after that.
On my second night taking care of her my frustration came to a head. My other patient, a fresh pericardial window was starting to act pretty sick. He was bradying down into the low 40s, and I had no pacing access other than transcutaneous pads on the crash cart. His pressure was dropping from 160's systolic on 5 mcg/kg/min of nipride, to a systolic of 90-100 with the nipride on standby.
In the middle of this, Eleanor started demanding water. Yelling, cussing, cajoling. Saying idiotic things like, "Just pour it on top of me, I don't even have to drink it. Just pour it all over me." When nobody was paying attention to her, and there were several of us in the room because of my other patient, she ripped her BiPAP mask off and threw it across the room.
I'd had enough, and as I was putting her mask back on, I kind of lost it on her.
"You need to *stop* this. You are a *grown woman*, you need to start acting like it. You are embarrassing yourself and your family by the way you are acting. My other patient is extremely sick right now, and instead of being able to help him like I should, I'm here, dealing with this foolishness."
In a poetic cinematic world, she would have realized how silly she was being, become remarkably compliant, if not apologetic. Then she would have written letter to the administration about the incredible life-saving care she received, highlighting each of the nurses she had.
In the real world, she pulled off the biggest 2-year-old pouty-lip I've ever seen.
But at least she was quiet.
I like logic. I like things to be orderly. I like it when people have been educated, and the information leads them to draw the conclusions I intend.
Crazy people don't do that. And that cuts across the grain of everything that makes my purplish haze of a world tolerable.
But I ran across a new kind of crazy this week at work.
This lady, (let's call her Eleanor), was 100% with it. She was completely lucid, she truly was that ever elusive A&Ox4. This is quite an achievement considering she'd come in for a valve replacement over a month ago and ended up with a CABGx5 and a balloon pump. Following her surgery, she rode our carepath upstairs only to come crashing back down as an RRT in respiratory stress.
It seems that the yahoo techs on our stepdown floor *still* cannot get it through their thick skulls that if a patient drinks too much water, with all the fluid shifts from being on pump, the patients drink themselves straight into pulmonary edema. Not to mention the atropine given pre-anesthesia makes *everyone* wickedly thirsty, for *days*. So when the techs get tired of answering call bells about drinks of water, they sure as heck will bring the patient a big huge pitcher of water and let them drink themselves into a gurglely, pink frothy mess.
So it was with Eleanor.
And she ended up re-intubated. Then extubated. Then re-intubated, and extubated yet again. If you've played this game before, you know that each subsequent re-intubation significantly reduces the chances of a favorable outcome. Counting her surgery, Eleanor is working on post-extubation #3. Even now after spending 8 hours each night on BiPAP, her PCO2 is routinely greater than 65 each morning.
She's also failed her swallow study 3 times now.
All this to say that Eleanor is *strictly* NPO.
She knows this.
And she knows why.
And she knows the consequences of noncompliance.
But this does not stop her from asking, begging, pleading, groveling for a drink of water as many times an hour as you are willing to entertain. She actively tries to deceive anyone who comes near her bed and trick them into giving her water. She tries to split staff and family members and play them off one another to manipulate them into giving her water.
Honestly I've been around better behaved toddlers. (Two of which happen to live with me.)
Really I'm at a loss to adequately convey the sheer, colossal, unbelievable stupidity of it all.
I performed impeccable oral care hourly to maintain her oral mucosa. But my reward for this above and beyond (unit policy and procedure is Q4)? Each swab is met with a greedy demand, "MORE!!" Upon refusal, she throws anything within reach on the floor in protest. Pillows. Blankets. Her Bairhugger nozzle. You wouldn't believe how low my bullshit tolerance for this kind of shenanigans is.
Maybe a better, more saintly nurse would have had the patience to deal with these outbursts. Me, with my curmudgeonly tendencies, simply didn't give the items back to her the second time they ended up on the floor. When she started immediately sucking the water out of each swab (nearly aspirating on that small amount of water each time) rather than letting me wet her mucosa, I promptly switched to using chlorhexidine gluconate instead. Funny, she was much less enthusiastic about her oral care after that.
On my second night taking care of her my frustration came to a head. My other patient, a fresh pericardial window was starting to act pretty sick. He was bradying down into the low 40s, and I had no pacing access other than transcutaneous pads on the crash cart. His pressure was dropping from 160's systolic on 5 mcg/kg/min of nipride, to a systolic of 90-100 with the nipride on standby.
In the middle of this, Eleanor started demanding water. Yelling, cussing, cajoling. Saying idiotic things like, "Just pour it on top of me, I don't even have to drink it. Just pour it all over me." When nobody was paying attention to her, and there were several of us in the room because of my other patient, she ripped her BiPAP mask off and threw it across the room.
I'd had enough, and as I was putting her mask back on, I kind of lost it on her.
"You need to *stop* this. You are a *grown woman*, you need to start acting like it. You are embarrassing yourself and your family by the way you are acting. My other patient is extremely sick right now, and instead of being able to help him like I should, I'm here, dealing with this foolishness."
In a poetic cinematic world, she would have realized how silly she was being, become remarkably compliant, if not apologetic. Then she would have written letter to the administration about the incredible life-saving care she received, highlighting each of the nurses she had.
In the real world, she pulled off the biggest 2-year-old pouty-lip I've ever seen.
But at least she was quiet.
Friday, July 22, 2011
You Might Be...
You might be a nurse if:
Before taking ibuprofen for body aches or headache, you automatically try to code the barcode for documentation...
Before taking ibuprofen for body aches or headache, you automatically try to code the barcode for documentation...
Thursday, July 21, 2011
25 Best
It seems nurseXY has been selected as among the 25 best nursing blogs by David Gurevich over at QI Exam Prep.
Pretty heady company he's put me in with, I'm not sure I quite belong. However, I appreciate the recognition.
Thanks David!
Wednesday, July 20, 2011
P. R. N-competence.
So I started working PRN at the ICU where I did my externship. I'll be working 4 shifts a month, which works out to one a week, but it's nice in that I don't have to work them that way, I can clump them if I like.
It works well since the hospital is about 10 minutes from my house, as opposed to 45 minutes minimum to my other job. It also works well considering I have only 6 months experience, 3 1/2 months really if you look at my experience since coming off orientation. Most hospitals around here won't even glance at you until you have one year plus at least. My manager had to go to the CNO to get me approved. It's nice to have people willing to go to bat for you though.
One thing I've learned quickly though in my short career thus far is that experience doesn't necessarily equal competence. This has been vividly illustrated to me a couple of times recently.
This past week I sat through hospital and nursing orientation, (again) at my new job. Part of that orientation process involved a pair of EKG exams. The first of these exams was 15 questions long, but only the 4 lethal rhythms held any point value--25 points each. The other 11 questions weren't worth any points--information not announced to us, but readily available because the computer displayed point values for each question during the exam. The lethals were not difficult. Predictably there were strips showing asystole, v-fib, and a couple v-tach (one even a torsades, but that wasn't even an option to be picked.) Not rocket science, not tricky.
The nurse next to me there in orientation had been quite vocal about her 1 1/2 years of big-time experience at an ED in a medium-size town about an hour away from our metro area. She unfortunately failed the lethal EKG exam. Studied for 30 minutes, and promptly failed it again. Now she has to complete an EKG/Dysrhythmia course, just to keep her job.
Secondly, my wife is currently precepting at work. Her intern is a nurse with 18 months experience up on the floor and transferred into the PICU. But this nurse lacks basic skills like passing meds on time. She's been sent to a couple codes, only to stand around and watch. Even tasks such as recording vitals appears to be beyond her skill-set. In fact, it seems what she's demonstrated she's best at is letting the PICU nurses know, "That's not how we do it on the floor..." The scariest part of this situation is that she's already started her acute-care nurse practitioner program--online of course.
So on behalf of all us with less than that magic bullet of one year's experience... I rattle convention's cage!
It works well since the hospital is about 10 minutes from my house, as opposed to 45 minutes minimum to my other job. It also works well considering I have only 6 months experience, 3 1/2 months really if you look at my experience since coming off orientation. Most hospitals around here won't even glance at you until you have one year plus at least. My manager had to go to the CNO to get me approved. It's nice to have people willing to go to bat for you though.
One thing I've learned quickly though in my short career thus far is that experience doesn't necessarily equal competence. This has been vividly illustrated to me a couple of times recently.
This past week I sat through hospital and nursing orientation, (again) at my new job. Part of that orientation process involved a pair of EKG exams. The first of these exams was 15 questions long, but only the 4 lethal rhythms held any point value--25 points each. The other 11 questions weren't worth any points--information not announced to us, but readily available because the computer displayed point values for each question during the exam. The lethals were not difficult. Predictably there were strips showing asystole, v-fib, and a couple v-tach (one even a torsades, but that wasn't even an option to be picked.) Not rocket science, not tricky.
The nurse next to me there in orientation had been quite vocal about her 1 1/2 years of big-time experience at an ED in a medium-size town about an hour away from our metro area. She unfortunately failed the lethal EKG exam. Studied for 30 minutes, and promptly failed it again. Now she has to complete an EKG/Dysrhythmia course, just to keep her job.
Secondly, my wife is currently precepting at work. Her intern is a nurse with 18 months experience up on the floor and transferred into the PICU. But this nurse lacks basic skills like passing meds on time. She's been sent to a couple codes, only to stand around and watch. Even tasks such as recording vitals appears to be beyond her skill-set. In fact, it seems what she's demonstrated she's best at is letting the PICU nurses know, "That's not how we do it on the floor..." The scariest part of this situation is that she's already started her acute-care nurse practitioner program--online of course.
So on behalf of all us with less than that magic bullet of one year's experience... I rattle convention's cage!
Monday, July 18, 2011
You Might Be...
You might be a nurse if:
When using the restroom you automatically reach for gloves before wiping...
When using the restroom you automatically reach for gloves before wiping...
Thursday, July 7, 2011
Up In The Air
Life is up in the air right now.
I have no real focus, and I'm really unsure what direction to proceed.
My original plan was painfully simple. Go to nursing school. (Check.) Graduate and get a job on the biggest, baddest ICU around. (Check.) In two or three years apply for CRNA school and get on with life. (.....)
Muddying circumstance #1:
This lovely president of ours, Obama, enacted legislation that dictates those that make 10 years of payments on their federal student loans while working in a public service capacity, will have the remaining balance of their federal student loans forgiven. RN's definitely qualify as long as they work for a not-for-profit organization, which I currently do. Interesting tidbit: Nurse Practitioner's qualify, CRNA's do not. After doing the math, this loan forgiveness could total as much as $200,000 in my case... Market analysis of compensation for NPs shows that the gap between CRNAs and NPs is starting to narrow. In short NPs may soon be making the kind of salary reserved previously for CRNAs.
Now consider that the cost of the CRNA schools in my metro area both top $75,000, while NP school falls under the category of regular graduate school. CRNA students are prohibited from working during school (in fact both schools here will kick you out of the program, no questions asked, if they catch you working.) NP students at local schools do not have any such restrictions. And here's the kicker--the tuition reimbursement program at my current hospital *almost* covers the tuition for graduate school. They also have a TDA (Two Day Alternative) program where employees work Saturday-Sunday every week--two shifts, but keep full time status and benefits, and earn an extra differential that approximates working three shifts instead of two--that would allow me to go to school full time during the week.
The nursing school I graduated from has an Acute Care Nurse Practitioner program...
Thinks that make you go hmmm.
Muddying circumstance #2:
My wife and I have been fortunate enough to have her younger sister living with us to watch our kids while both of us work night shift. This allows us to work as many shifts together as possible, allowing us to have days off together. However, that situation will be changing. I'll spare you all the drama and gnashing of teeth, but rest assured it hasn't been a pleasant situation with frustrations ranging from not being available when we were counting on her, to wondering about our kids safety while in her care.
The nice thing about working as nurses is that we only work 3 days a week, so it *can* be done not needing childcare at all. But that means that we will only have one day a week off together, and really because of the logistics of night shift, it means that we'll have two half days off rather than a full day.
We are exploring options that include me moving to day shift to cut down on the daycare needs, but that also requires me transferring to another hospital within the system since my wife and I work on opposite ends of the city currently. And that means leaving my beloved CVICU...
Muddying circumstance #3:
I have been dying to get out of this town since I got here (state, really). The summer heat/humidity kills me. I crave seasons. I crave snow. I crave being able to spend time outdoors without melting into a puddle on the blistering concrete or triple digit asphalt.
I began researching grad schools in other parts of the country, and have been very, very attracted to Duke. I love the idea of a big name school. I love that the hospital is next door to the school. I love that the hospital has a program for employees that pays up to 90% of your schooling in exchange for contract on graduation... I love the idea of North Carolina, where the average high temperature in the summer tops out in the low 90s... I love that North Carolina is a Nurse Licensure Compact state... I love that Duke has one of the few Pediatric Acute Care Nurse Practitioner programs in the country...
Aauugggh! My brain hurts!
I have no real focus, and I'm really unsure what direction to proceed.
My original plan was painfully simple. Go to nursing school. (Check.) Graduate and get a job on the biggest, baddest ICU around. (Check.) In two or three years apply for CRNA school and get on with life. (.....)
Muddying circumstance #1:
This lovely president of ours, Obama, enacted legislation that dictates those that make 10 years of payments on their federal student loans while working in a public service capacity, will have the remaining balance of their federal student loans forgiven. RN's definitely qualify as long as they work for a not-for-profit organization, which I currently do. Interesting tidbit: Nurse Practitioner's qualify, CRNA's do not. After doing the math, this loan forgiveness could total as much as $200,000 in my case... Market analysis of compensation for NPs shows that the gap between CRNAs and NPs is starting to narrow. In short NPs may soon be making the kind of salary reserved previously for CRNAs.
Now consider that the cost of the CRNA schools in my metro area both top $75,000, while NP school falls under the category of regular graduate school. CRNA students are prohibited from working during school (in fact both schools here will kick you out of the program, no questions asked, if they catch you working.) NP students at local schools do not have any such restrictions. And here's the kicker--the tuition reimbursement program at my current hospital *almost* covers the tuition for graduate school. They also have a TDA (Two Day Alternative) program where employees work Saturday-Sunday every week--two shifts, but keep full time status and benefits, and earn an extra differential that approximates working three shifts instead of two--that would allow me to go to school full time during the week.
The nursing school I graduated from has an Acute Care Nurse Practitioner program...
Thinks that make you go hmmm.
Muddying circumstance #2:
My wife and I have been fortunate enough to have her younger sister living with us to watch our kids while both of us work night shift. This allows us to work as many shifts together as possible, allowing us to have days off together. However, that situation will be changing. I'll spare you all the drama and gnashing of teeth, but rest assured it hasn't been a pleasant situation with frustrations ranging from not being available when we were counting on her, to wondering about our kids safety while in her care.
The nice thing about working as nurses is that we only work 3 days a week, so it *can* be done not needing childcare at all. But that means that we will only have one day a week off together, and really because of the logistics of night shift, it means that we'll have two half days off rather than a full day.
We are exploring options that include me moving to day shift to cut down on the daycare needs, but that also requires me transferring to another hospital within the system since my wife and I work on opposite ends of the city currently. And that means leaving my beloved CVICU...
Muddying circumstance #3:
I have been dying to get out of this town since I got here (state, really). The summer heat/humidity kills me. I crave seasons. I crave snow. I crave being able to spend time outdoors without melting into a puddle on the blistering concrete or triple digit asphalt.
I began researching grad schools in other parts of the country, and have been very, very attracted to Duke. I love the idea of a big name school. I love that the hospital is next door to the school. I love that the hospital has a program for employees that pays up to 90% of your schooling in exchange for contract on graduation... I love the idea of North Carolina, where the average high temperature in the summer tops out in the low 90s... I love that North Carolina is a Nurse Licensure Compact state... I love that Duke has one of the few Pediatric Acute Care Nurse Practitioner programs in the country...
Aauugggh! My brain hurts!
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