Self-Scheduling

One indication of how far nursing has come is the idea of self-scheduling.  Not long ago, nurses had their whole lives on hold, waiting for the next schedule to be posted.  They weren't sure month to month if they would be able to host a birthday party for their child on a certain day.  

Self-scheduling has its problems.  Like concerns that the skill mix will not be adequate or that the weekends will be skeleton crews. 

But somehow, the empire has staggered on.

Statistics

Statistics help us get a grip on our fear and uncertainty.  Consider these true but unpopular facts: 

Peanut butter kills more people every year than terrorists.

You are more likely to be shot by your dog than to use your gun legally on an intruder.

  

Statistics are easily manipulated.  They can "prove" that something causes something NOT to happen.  Like elephant repellent:

Here's another questionable correlation/causation case:  statistics clearly show that when ice cream sales start to rise, drowning deaths also rise.  Does ice cream cause drowning?

There are things we SHOULD fear:

And things we should not:

 

Compassion Fatigue

Nurses are vulnerable to compassion fatigue.  Our capacity to care can be severely challenged by patient's behavior. 

For example:

Patients who unplug their IV's and sneak outside to smoke

Obese patients on insulin drips who call patient relations because their nurse won't get them another bag of candy

Patients who leave AMA, go to the bar across the street, stagger back and pass out drunk in front of the hospital

And patients who smoke meth in their hospital bathroom, causing their monitored heart rate to double  

Nurse's break rooms should have a special vending machine for compassion rejuvenation!

Swan Dive

Doctors are as vulnerable to fashion trends as any other herd of people. The Swan-Ganz catheter is an excellent example.

When I first became an ICU nurse, swans were wildly popular.  Most ICU patients--regardless of their diagnosis--were swanned.  Swans generate a flood of esoteric numbers, so they MUST be beneficial, right?  ICU's had so many swans back then, they resembled aviaries!

The nurses spent a lot of time leveling, wedging and bolusing.  And charting all those numbers.  It was all paper charting back then--there was no such thing as downloading values from monitor to chart with a simple keystroke.  We faithfully charted EDVI, SVI, SV, CO, CI, PAS, PAD, PAM, PAWP, PVR, SVR, SVRI, MAP, RAP and CVP into tiny cramped flowsheet boxes while call lights went off and patients called out for help.  But, since this was IMPORTANT, we prioritized and charted on!

The result?  Did the attending physician call at two in the morning to check on the pulmonary artery diastolic and add dobutamine?  Did the cardiologist stop by, see the cardiac output and tweak the fluids?  What was the impact of all this writing, flushing, leveling and wedging? 

Not much.

I felt like someone who makes seven course dinner for guests who never show up.  Why were we doing this?  Is anybody there?  Does anybody care?

Then studies started coming out demonstrating clearly that swans do not improve patient outcomes.  In fact, with the combined risks of infection, overwedging, valvular damage, thrombus and pulmonary artery rupture, swans actually result in worse patient outcomes.

Younger physicians, current on the data, left the swans to fly in the wild (the cath lab and operating room).  To evaluate sepsis and cardiogenic shock, they used less intrusive means. 

When a swan is sighted now, it's almost always partnered with an old doctor too deaf to recognize the swan song.



Team ICU

ICU nursing is a team sport.  Some nurses don't get that.  They are too insecure to admit they need help, so they try to do everything themselves to prove their competence.  Offers of aid or advice can cause them to boil over with intense anger.  

Would you go into a basketball game and yell, "I got this!  Stay out!  I can do it myself!"

Your co-worker's eyes and ears and experience are like silver in a mine.  Use them.  A group is always stronger than an individual.  We are all learning and growing.  Policies, protocols and equipment change constantly.  Don't be afraid to say, "Will you take a look at this Arctic Sun and see if I've got it set up right?"  or, "I can't figure out why this balloon pump keeps alarming," or, "I'm concerned that I'm missing something here--got any ideas?"

And if a co-workers says, "Hey, that's not how this Swan is supposed to be hooked up," or, "Do you want your dopamine  running at this rate?" or "The heating coil should be on this return line," be strong and secure enough not to take it as a personal affront.  People who reach out with constructive criticism are trying to HELP YOU.  Getting angry and defensive and making stupid excuses will make you co-workers go silent, step back and let you fall. 

Take a deep breath and say, "Thanks for catching that!"

Together, we make a great team. 

Mos Def, be Les Dum

There's an online video showing the rapper Mos Def attempting to tolerate having a small-bore feeding tube placed.  I have to say this to his outraged audience:  you don't need to go all the way to Guantanamo Bay to see this.  Poke your head out your door and peer down the street at the nearest hospital.  There are dozens of patients right there with feeding tubes.  

Besides that, brides pay big bucks to have feeding tubes so they can lose weight before their horrific weddings and exercise fanatics proudly wear them to control every calorie.   

I have placed plenty of feeding tubes, mostly in frail, elderly people.  But I've NEVER seen a wild, sobbing breakdown like Mos Def's.  Only about 10 cm of his tube went down--but I guess that's more than this delicate flower can handle.  Where's his murderous public persona when it counts?  Man up, Mos Def!  Be Les Dum!   

I've also never seen handcuffs disappear like they do in this video, (although it allowed his hands to flail around desperately and then cover his eyes while he cried piteously).  And how did his head strap come loose from the chair where it was clearly shown in the first take?

Mos Def--you're a bad actor and you have a very bad film editor. 
.
About Mos Def's statement that this was the worst pain he's ever experienced--what a sheltered, petted life he must have!  What if he had to give birth or something that is actually uncomfortable?


Nurse's Note:  To the upset people posting comments about how "the doctors" were trying to get the feeding tube down:  doctors don't place small bore feeding tubes.  Nurses do.

Costume Faux Pas

What people wear makes a statement.  Our costume choices reveal a great deal about us.  We expect something different from a man in a tuxedo than from a guy with a Confederate flag wrapped around his head.

Here are some of my favorite--REAL LIFE--bad costuming choices:


The Cool Doctor with the black Vampira nails and trendy tattoos

The even Cooler Doctor with the greying ponytail

 

The exposed thong

Nurse's Note:  To save laundry costs, people should  just have their thongs tattooed on. 

What has the government done for me lately?

One afternoon as my daughter and I were trailering to a nearby park, and I heard a radio commentator criticizing the government.  I joined right in, complaining bitterly.   

My daughter protested mildly.

But, I retorted, "Really--what has the government done for me?"

She stared at me, shocked and appalled that I could be so ignorant  Then she said,  "How about:  the condition of this road,"

"The safety specs on this truck,"

 

"The ingredients in your can of soda,"

 

"the education in your head,"

 

"And the immunizations in your body."

"That's just a start."

Embarrassed, I shut up.




Nurse's Note:  When our youngest daughter was in third grade, she learned this poem in school:

"Services!  Services!  Our taxes pay for services!
Schools and pools, parks and roads.
Services are good as gold."

I try to keep that in mind when tempted to complain about the government.

The Attenders!

Nurses have superheroes just like Batman and Spiderman.  Here are some of them:



Nazalyzer has a supersensitve nose that can make many diagnoses.  She doesn't need lab tests, xrays or CT scans.  She can SMELL what is wrong with the patient!

Nasalyzer is famous for her superstrength!

Ultima  has been a nurse for many, many years.  She remembers when trepanning was done at the boulderside!  Ultima brings with her long and wide experience.  Her most famous line was to a physician who was arguing with her:  "Perhaps I am not being clear..."

When a patient is found pale and semi-conscious, with a rapid pulse and profuse perspiration, many experts are called in...

They offer different opinions...

Ultima sweeps in to save the day!!

Ultima devises an amazing, high-tech solution...

All ends well!!

Rez-Q-erz  can quickly assess any emergent situation and immediately predict what should be done and what the doctor will need.  By the time the doctor arrives, Rez-Q-erz  has all the supplies and equipment at the bedside, the labs drawn and the tests ordered.

Res-Q-erz is not afraid to take on drug reps in the parking lot!

Later, when this story is told to other staff members, some questions arise...
 

Solaci is a nurse with a magical soothing voice.  When patients are confused and climbing out of bed, when family members are argumentative or sarcastic, Solaci can walk into the room and de-escalate any stressful situation with his voice.  It works better than a warm blanket!

When a nurse yells for the code cart, if the wheels are locked, that doesn't stop Solaci!!

Solaci  doesn't know his own strength when it comes to the door latches...

But that doesn't prevent him from getting the code cart into the room!!

Solaci can leap large sewage floods with a single bound.

He can be turned into a toad by his nemesis, Dr. Duh Nyle.

EmpaSee has the unique ability to always see the world through other people's perspectives.  He wears Ryaban© eyeglasses, which can be adjusted to allow him to understand anyone's point of view.  

Empasee has the ability to contort his body into ANY SHAPE!!

Together they make up, THE ATTENDERS!

Nurse's Note:  Their shirts spell, "NURSE".  No one's seems to be getting that...I guess no genius is understood in their own time...*sniff*

In that sleep of death what dreams may come

Propofol is a milky-white drug that sedates patients beautifully.  I like propofol!  Its short half-life makes neuro assessments easy;  it controls hypertension and its soy base even provides some nutrition. 

But since Michael Jackson's death, I just gotta add this:

1.  Propofol is used ONLY IN A HOSPITAL'S ICU
2.  Propofol is used ONLY ON VENTILATED PATIENTS
3.  The only other exception is when it is used during conscious sedation BY A PHYSICIAN WITH DEEP SEDATION PRIVILEGES

Trust me--I'm right about this.

The Dating Game

There's a question that reveals immediately if a person will be a good partner.  I discovered this question quite by accident one night on a date with a surgeon.  I said, "Tell me about your ex-wife."

He rolled his eyes, took a deep breath and said: "God!  Those were the longest three months of my life!  I couldn't wait to get rid of that crazy bitch!  She was a huge bipolar disaster!"

Our appetizers had just arrived and they looked really good.  I wondered if it would be okay if I ate some before I suddenly remembered that I needed to take my hamster to the hairstylist.

When I met my present husband, I reached into my old bag of tricks and asked him about his first wife. 

He said, "Cindy and I were married for fourteen years.  We had a lot of good times together.  It didn't work out, but I have many great memories.  We both made mistakes and we recognize that we're better off apart now.  But we share two wonderful daughters and I wish her all the best."

I was so impressed, I married him.

Nurse's Note:  The question reveals nothing about your ex.  It reveals how you view your past and how you take responsibility for it.

The Name Game

The nurses in Labor and Delivery should be paid extra for keeping a straight face when they hear some of the names given to babies.   I've met babies named, "Knives", "Rumor" and, "Murder".  I'm still waiting for "Spoon", "Gossip" and "Manslaughter".

I also see names spelled in all kinds of strange ways.  Many Americans think if there is an accent mark, an umlaut or a circumflex thrown in randomly it proves they are erudite and cosmopolitan.

So, here's a combination of names that aren't really names AND creative spelling!

Can you read these names?

*Toenail, Carpet, Stripes, Leather Jacket, Fungus

The Doctor's Paw

The Monkey's Paw is a short story by W. W. Jacobs about a gruesome talisman that grants three wishes.  The moral to the story is, "Those who interfere with fate do so to their sorrow". 

Modern medicine has a lot of parallels with The Monkey's Paw.  All the elements are there:  meddling with natural order, unreasonable expectations and horrific consequences. 

Here's my medical version of The Monkey's Paw.  I'm calling it, The Doctor's Paw. 



Once upon a time, there was a man named, "Ernest".  He lived in a typical house in a typical town in a typical state.  He worked hard as a fireman, saving people and property.

Ernest married a wonderful woman and they had two adorable children.  He had a great life!

But Ernest grew older.

One day, Ernest couldn't get his breath.  Faint and gasping, he went to the hospital.

In the hospital, he met Dr. Duno Goode.

Dr. Goode told Ernest about a charmed amulet--the Doctor's Paw.  Dr. Goode explained that The Doctor's Paw could grant three wishes.  But the wishes would come true at a terrible price.

 Ernest was too scared to understand that.  He couldn't breathe!  He grabbed for the Doctor's Paw and made his first wish-- he wished that his breathing would be made easier.

He was placed on bipap at 15/8 with 100% bleed-in.  To provide nutrition, a stiff plastic nasogastric tube was poked down his nose into his stomach.  Sticky, smelly liquid was pumped into it.

 

Now, Ernest was very uncomfortable.  The bipap's strong air pressure felt like his head was hanging out of a space shuttle on its way to Jupiter.  The feeding tube down his nose made him gag constantly.

Once again, Ernest reached for the Doctor's Paw.

"I want this mask off my face and this tube out of my nose!"

Dr. Goode cut a tracheostomy into his throat.  A PEG tube was crammed into a hole sliced into Ernest's abdomen and stomach.

"I don't want to live like this!" he wrote in a shaky hand (he could no longer speak with the tracheostomy).  "Let me die!"

It was his last wish.

His code status was changed to "DNAR".   The hospital shipped him off to a nursing home where he lived for eleven years lying in bed on a ventilator, wearing a diaper, being turned every two hours and fed through a tube in his stomach.

The End

 

 

Nurse's Note:  evaluate your code status carefully