I participated in a podcast about healthcare reform.  We first listened to a Q&A between Dr. Val and Dr. Bob Goldberg at CMPI-Advance.  After that we were invited to ask questions.

Dr. Goldberg is into policy, not bedside healthcare, so I think my question threw him for a loop.  I asked about futile care and how it fits in with healthcare reform.  His answer took on a very strong “ethics” angle, which is not the direction I had intended for my question to go!

Despite my derailment, the other bloggers that participated in the call asked excellent questions – they are Kim, RN from Emergiblog, Dr. Wes Fisher,  Dr. Edwin Leap, The Happy Hospitalist, and Dr. Brian Vartabedian.

You can listen to the podcast at Better Health.  Thanks Dr. Val for the opportunity to participate!

Just in case you’re following this flu business, I’ve found this feed to be the best source thus far.

I know.  It’s getting a little tiresome to read about all this flu business, but the first confirmed death in the US was reported today. A very young confirmed death.  :(

(hat tip to Better Health for the link)

Moreena at Falling Down is Also a Gift live-blogged her daughter’s third liver transplant. If you want to read from the beginning, here is where she gets the call.

Annika is out of surgery now and is in PICU but not yet out of the woods. Please keep this family in your thoughts and prayers. I’m sure a comment or two of support would not be unappreciated!

ERNursey wants to know: What do you people do with the christmas trees off the flo-meters anyway? Why do you take them off?

Not a comprehensive list by any means:

1. Take them off the flow meter, add some beads, and you can make a kick-ass ID Badge lanyard.

2. A naughty little addition to that voodoo doll you made.

3. As, well, Christmas/fir trees for your kid’s miniature doll house yard.

4. They go for about a buck apiece. They’re always in demand. I think patients steal them and sell them on the black market.

5. Respiratory Therapy hoards them.

6. Add a little ball on top, some wings on the back, a little halo: instant green angel finger puppet.

Okay, so the real reason we take them off the oxygen flow meters is so that we can put them on the portable oxygen tanks when the patient goes off the unit. Why don’t all the portable oxygen tanks have them? I don’t know. See above.

The other reason we take them off is because when someone is on a high rate of oxygen (my own personal threshold is about 4L/min) we like to add humidity so the flow doesn’t dry the patient’s nose so much. Adding the humidifier requires us to take the adapter off the flow meter so that we can screw the water bottle directly on to it. The little green tree gets set down and the next RT that goes into the room scoops it up.

It’s like a compulsion for them. Kind of like RN’s and pens.

I hope that answered your question! Anyone else??

Over at Nursing Voices, there was a recent post about working the night shift as a new grad.

I worked 11p-7a right out of school. I trained on evenings (3p-11p) for a few weeks then switched to night shift. There were no day/evening shift positions at the time. I’d worked nights during school on the weekends as an aide, so it wasn’t completely new to me.

But it still completely sucked.

I sleep best at night. I like it dark and quiet. Sleeping during the day, for me, was horrible. Room darkening shades helped, but nothing much helped the noise. The majority of the world is awake during the day, and there are lots of traffic sounds, lawns to be mowed, and doorbells to be rung. At first it was kind of neat, being a full-time child of the night… but the novelty wore off quickly. Driving home in the new day’s sunlight made my brain resistant to sleep. Even if I slept 8 hours, I still woke up groggy. And trying to keep up with the rest of the world (friends who kept “normal hours”) was hard. I found myself staying home on my days off and vegging in front of the TV or computer. I gained weight by eating carbs during the day, trying to perk myself up. I used to fall asleep again when it got dark outside and have to wake up again to go to work and literally cry because I could not fathom staying up all night again.

Once I got to work, though, I was usually fine. I worked on a very busy unit and there was plenty to do to keep me occupied. After 6 months, though, I moved on to CVICU, where there were only two shifts – 12 hour days and 12 hour nights. Of course there were no day shift positions. The plus was that I’d only work 3 nights a week instead of 4 or 5. The minus was that I was no longer able to take that nap at night when it got dark. I had to get good quality sleep in during the day, which was hard for me to do. I tried to sleep for only a few hours on my days off in order to sleep that night, but that just made me groggy and again I found myself vegging on the couch instead of out and about.

I jumped at the chance when a day shift position opened up. I had been watching the job board for months, and even secretly wished that someone working days would transfer to a different unit or hospital. A few of us put in requests for it, but I managed to snag it with only a few weeks seniority over the others.

It was a different world for me from then on. Never again will I work night shift. Day shift is much different from nights with all the comings and goings, but I wouldn’t have it any other way. Within a month after starting days, it was like a fog lifted from my brain. I felt so much better. I was so thankful to be able to sleep at night again. Unfortunately, one of nursing’s occupational hazards is candy and goodies brought in by family members and former patients – so the weight situation didn’t change much. Everyone knows that day shift eats all the good stuff before the night shift comes on anyway :)

What’s your story? There’s a poll up at Nursing Voices. Were you forced to work nights starting out? Did you immediately switch to days when you could, or did you discover that you liked being up at night?

A few years ago, I was working very closely with a physician to figure out what was going on with the critically ill patient we’d just admitted. I was in near constant contact with him for hours as we drew labs, got results, added meds, etc. When things started to settle down, I said, “Thanks for being so available, Dr. S” to which he replied, “You’re welcome. And call me Bill.”

That was the first time in my entire career (~7 years by that point) that a doc had “invited” me to use his first name. It felt strange! I tried it out a few times over the next few months and it really took awhile to feel comfortable with it.

But then I got to thinking. Why don’t we call doctors by their first names? Is it a sign of respect to say “Dr. Jones” instead of “Fred?” Or is it a throwback to the era when nurses used to scramble to give up our seats when a physician walked onto the unit? These days, nurses work more closely with physicians than ever. We call ourselves the “healthcare team.” Do teammates have to address other members with a title?

I have never again been asked to use a doctor’s first name. With some (mostly women), I spontaneously said their first names one day and since they didn’t seem to mind, I kept with it. Lots of nurses who have been on the unit for decades working with the same doctors use first names. But I don’t know if they were asked to, or if they simply started one day and never stopped.

It still feels weird, though. I would always try to call the doc “Dr. S” in front of a patient or family member. But why is that? Clearly doctors have had way more training, years of school, internships and residencies than nurses. (Adding 8/30: Also some rough working conditions, too) But I don’t expect the people with less education than I (CNA’s, students, etc) to call me “Nurse Geena.” Eh – saying that sounds silly, like it’s not a fair comparison. It isn’t, I suppose, but I cannot think of a better one off the top of my head.

I’ve started a poll at Nursing Voices. So if you’re a nurse, head on over and let us know what you do. And I’d truly love to hear what the docs have to say about this topic. Feel free to leave a comment… Would you be surprised/offended if a nurse called you by your first name without being asked to? What if you’d only been working with him/her for a few weeks? Or a few years?

I read a lot of ER nurse blogs. I know I’ve seen a lot – and I know they’ve seen much more. You think it’s an some kind of urban legend when you hear about patients coming in with a
broken nail (by ambulance no less! Where do these people come from?) but no – apparently it happens.

I’ve also noticed that some blogger ER nurses are frustrated by floor nurses. Girlvet says that floors in her hospital “refuse patients” or won’t take report because the admitting nurse is “busy” or “at lunch.” This causes a delay in getting the patient to the floor and ties up the ER bed even longer, causing patients to back up in the waiting room, patient dissatisfaction, the whole sequelae.

And ERnursey says, “Plenty of times when we are holding patients due to staffing there are nurses on the floors with all their work done sitting around the nurses station.” The title of that post is Why Nursing Ratios Are Failing Patients.

I won’t lie. I have seen charge nurses refuse patients to ICU (let’s see… supervisor calls over wanting to send us a 70 year old man who originally came in with low BP and low oxygen sats, but is tuned up after some IV fluids, is on no pressors, stable on some nasal O2 and yet he still has to come to ICU? Why?? Sorry, but I only have one bed left, and he ain’t takin’ it.) Tell me – what are the reasons given for floors refusing patients? I honestly don’t know.

In the past, I have seen instances of the nurse not being available to take report from ER. Yes, sometimes they’re at lunch. Before nursing ratios were actually enforced in my ICU, the person covering the nurse at lunch ALSO had their own patients in addition to watching the other two. That’s 4 critically ill patients. ICU patients are supposed to be at a ratio of 1 RN to 2 patients max. And those patients were wives, husbands, mothers, daughters, etc. Would you want your critically ill beloved family member being watched by a nurse who also has to watch 3 other critically ill patients? When they finally decided to start honoring staff ratios, we got a “break nurse.” This nurse watches patients for RN’s who are on a break, at lunch, etc. This means that when ER calls over to give report on a patient we’re getting, there is someone there to take report.

Nurses are also busy sometimes. Too busy to take report, even. I know ER likes to say that it doesn’t matter how busy they are, the patients still roll in. It also doesn’t matter how busy we are when there are critically ill patients in the hospital. We’ve had patients come over on balloon pumps from the cath lab with about 5 minutes notice, and code blue’s can happen any time. We have to respond to those and shift our staffing accordingly. So we are aware of what it’s like to receive very sick patients at a moment’s notice. But honestly – if we’re stuck in a patient’s room, elbow deep in poop, are we really supposed to drop everything to come and take report? I know in our unit, if the admitting nurse will be more than a few minutes, someone else will take report on his/her behalf. Sometimes there simply is no free nurse to do that. We do the best we can. It’s drilled into our heads on a daily basis that the ER is backed up and whenever they “go red,” all of the charge nurses find out about it and we try to help however we can.

As for nurses who are just sitting around on the floors while the ER is holding patients – come on now. I do believe you when you say that you’ve seen nurses sitting around, and when the opportunity arises for me to actually sit down and shoot the breeze with my coworkers, I take it. I also know that I have gone over to ER to borrow equipment to find them sitting around doing nothing while we’re 50 feet down the hall drowning in sick patients. It does go both ways. Are there patients backed up and waiting because the ICU is drowning? No, not always – but I say this to demonstrate that we do know what it’s like to be busy while other units are twiddling their thumbs. It happens in almost every unit.

Another reason for back-up is late transfers and discharges that go home later in the day. Docs discharge patients, but their ride can’t come and get them til the afternoon. Or placement has to be arranged, including transportation. ICU can have 5 patients that are able to transfer to the floor, but there will be no beds to transfer them to until later in the day. That causes back-up on our unit. I’ve also had this situation to deal with more times than I can count: ICU is full to the brim, with several patients to transfer out to med/surg, but there’s not a bed to be had by anyone. The supervisor will tell us time and time again: “Nowhere to transfer patients, all units are full (no beds) or no nurses to take the patient.” Then ER has a patient for us and viola!!! Somehow a bed has opened up on med/surg! Yes, a bed has just appeared out of nowhere, complete with a nurse to take the patient. Where was that bed/nurse combo 5 minutes ago? Who knows. We’re told, “Hey, ER has a patient for you, so go ahead and send bed 5 up to med/surg.”

All I know is that ER has been notified that ICU now has a bed and 30 seconds later calls to give report, but I haven’t even gotten the patient out yet! Why? Because I have to get the patient on a gurney, call the flex nurse to accompany if necessary, call transport to take the patient up. And I have to try to call report, too. I also used to get a lot of “the nurse is busy, she’ll call you back” or “the nurse is at lunch” before break nurses (ie, keeping-us-within-ratio nurses). I still get it when the nurse is there on the floor but is truly busy with one of his/her other patients. Maybe she’s in the middle of an important conversation with a family member, discharging a patient, teaching someone about how to prevent pneumonia, drawing up insulin, whatever. Am I supposed to insist on disrupting patient care? Well, sometimes I have. Sometimes I’ve begged someone, anyone to take report and give it to the accepting nurse when she gets a chance. Sometimes they’ll do it, sometimes they won’t.

And THEN we have to wait for housekeeping (sorry, Environmental Services) to come and clean the room. There are so few of THEM on the off-shift that you could wait up to an hour… and don’t even ask them to come when they’re at lunch. Forget it. You can say that you need the room cleaned emergently to admit an ER patient and if they’re on minute 5 of their lunch, the rest of the 25 minutes will be taken.

And it sounds bitchy to expect someone to come back early from their lunch. But I can guarantee you that almost every nurse has done it when the need arose. As a nurse, I have taken the patient up to the floor myself when flex and/or transport is tied up. I have even seen other nurses take a mop to the floor when EVS won’t or can’t come.

My point is that if we could have just transferred the patient when we got the orders, the patient would be out of the room and the bed cleaned and ready to go by the time ER calls with report.

There are many pitfalls to this system. Every unit experiences frustration with how things are done. I like the idea of having a person on-call to deal with admissions, but honestly? Sometimes we don’t even have enough nurses to deal with the patients already on the floors. Please don’t knock ratios, though, until you’ve walked in a mile in our shoes. You wouldn’t want your family member’s nurse to have 7 other post-op patients to take care of when research has shown lower rates of mortality if that nurse only has 4 other patients.

I’m not trying to pick on the ER nurses… we all have our perceptions. I appreciate reading about the frustrations of their jobs and hope they don’t mind hearing about the frustrations of mine. Any med/surg nurses want to chime in?

I don’t post frequently. When I do post, I’ve often thought about what I’m going to say for a long time – days, weeks. The topic sits in my mind like a spiky rock. My mind tumbles it until the remainder is smooth and coherent. Then I post.

But the article I’ve just read has set many many spiky rocks tumbling in my mind and it hurts.

This article, from the UK Times Online, describes a physician who withdrew treatment from two neonates when their conditions were discovered to be terminal. If you’ve read this blog since the days when I went on and on (and on) about end of life issues, advanced directives, and withdrawing treatment on terminal patients, you know that I fully and unabashedly support letting people die. I feel that in the majority of the cases I’ve seen and participated in, the family of the terminally ill patient is unable to let go and thus selfishly allows the patient to go on day after day, week after week – sometimes month after month.

I know it’s hard. It’s so hard to watch. It’s so hard to give up and accept that things will never again be the way they were. It hurts and it’s a horrible decision to have to make, but in some cases, it has to be made.

The physician in question decided in conjunction with the parents to “withdraw treatment” on 2 separate cases of very premature infants – both very sick and not expected to survive.

The infants were taken off life support and morphine was administered.

I’m totally with the good doctor so far. It’s all appropriate.

Death can be really ugly. When someone is removed from life support, it can be heartbreaking to watch. Often, the entire body is motionless except for the breathing motions that the patient makes. It appears as though the patient is gasping for breath (”agonal breathing”). I have always been told and taught that this is a very normal part of death and the patient very likely is not necessarily suffering. The reason is because they are dying and are not typically conscious (I’ve never seen anyone with agonal breathing conscious). Do I know this for sure? I admit it – no. I don’t think anyone does.

So what we do during this withdrawl of life sustaining measures is to give the patient morphine. Morphine suppresses the respiratory drive, relaxes smooth muscle of the body and has a sedative, as well as a pain relieving, effect. We start the morphine before even taking the patient off of life support. Despite getting this drug, some patients still exhibit signs of agonal respirations. If they do, I give them more. It’s (in my experience) widely acceptable to treat the patient’s symptoms, even if that treatment for their apparent suffering causes death. I have never given what I would consider to be a massive dose. I’ve always given small increments, assess the response after a few minutes and go from there.

So back to the babies. It is here that I start to disagree with the good doctor. I have not been in the situation, but it doesn’t take a stretch of one’s imagination to realize that watching your baby die is probably the hardest thing anyone would ever have to go through. It would break my heart and haunt me for the rest of my days to watch my dear sweet baby have agonal respirations. I would advocate for lots and lots of morphine to help alleviate any perceived suffering. Knowing that agonal respirations are normal in dying people does not go very far in comforting one having to watch them.

Apparently, presumably to treat the parent’s discomfort rather than the baby’s, the good doctor administered pancuronium. I found it laughable that the author of the article described it merely as a “muscle relaxant.” Pancuronium is a paralytic agent. Injecting this drug into someone paralyzes them, but does not sedate them. Sometimes we need to paralyze patients in the CCU (to treat them), and we ALWAYS give both a sedative and a pain reliever when this is done. Still… I always feel very uneasy about these patients because I’m never sure that they’re totally sedated. I’m fairly confident that they are, but that’s as far as it goes.

Thus, it makes me almost physically ill to think that those babies might have had one teeny tiny bit of consciousness… and were then paralyzed. I know what I said above – those patients with agonal breathing are likely not conscious. And the babies were getting morphine which would further the case for likely unconsciousness. But it just doesn’t sit right in my mind to actively stop them from breathing. Why couldn’t they just give more morphine? When giving enough morphine to relieve suffering, the purpose is to do just that – relieve suffering. There is a possible side effect of death. That last sentence sounds ridiculous, but the one and only goal is to make the patient more comfortable, not cause death. Giving a paralytic agent leaves no room for any sort of interpretation. If you give pancuronium to someone without respiratory support, you are doing so with the full knowledge that you will kill them.

The kicker quote of the entire article, for me, was that the doctor said that he was giving the baby a drug that “was on the verge of what society finds acceptable.” That sounds iffy at best. If some doctor told me that, I’d feel very uneasy. I mean – there’s experimental (maybe this will work, maybe it won’t) and then there’s socially unacceptable (unethical behavior?) Apparently the parents not only felt quite easy, they “fully supported the doctor’s actions and were grateful to him.” Goody for them, but I just can’t quite get it out of my mind that the “treatment” was done to comfort the parents and not the baby.

I’m sure that when it was not acceptable to give enough morphine to relieve a patient’s suffering, the mere thought of giving “too much” was enough to send spiky rocks in lots of other people’s minds. For all I know, someday giving a paralytic agent to someone having agonal respirations will be the standard of care.

I just might have to pass on taking care of those patients, though. I’m really quite sure that I could never do it. As I said – I didn’t take the time to mull this one over and it won’t surprise me in the least to discover that there are holes in my logic. I just had to get it off my chest.

Adding on – well isn’t this interesting. The Journal of Medical Ethics advocates the rare usage of paralytic to “allow a peaceful and comfortable death.” Sorry. Still can’t wrap my spiky rocked little mind around it. Judy at Tiggers Don’t Jump agrees, perhaps a bit more eloquently, too.

Hat tip to Kevin, MD for the article.

Someone gave me mono for Christmas this year. Since I was scheduled to work, I had to go in with mono. I carried it around with me and eventually others learned that I had a stomach-ache as well. Then they demanded to see my athlete’s foot!! Ew.

All in all, my maladies ended up amusing almost everyone who was exposed. And I’m actually kind of looking forward to acquiring an ulcer. I wonder if they take requests… an MRSA or clostridium difficile mascot would look great in the isolation rooms….

I know it’s been awhile since I’ve posted. Sorry – was back home in the midwest last week.

My hospital has installed a Linear Accelerator. I’m sure it does all sorts of things, because it cost about $1.5million. (I won’t tell you how much the vault it is encased in costs) I also know that what it does has something to do with zapping cancer with the utmost accuracy.

The administrators and radiology departments have been pretty excited about getting this thing. It’s finally finished, and yesterday when I went into work, there was a huge white tent taking up half the doctor’s parking lot. Not connecting the two at the time, I wondered as I walked into work what the white tent could be for.

I needn’t have wondered for long, however. As I approached it, I could see that there was a big banner which said, “The Hospital Welcomes The Linear Accelerator” or something just as goofy. [It got its' own banner!] Later, the operator announced over the intercom that a reception was being held outside under the big white tent to celebrate the Linear Accelerator. [It got its' own reception!] I walked out about an hour later with a coworker and found tables catered with hot hors d’oeuvres and “pretty food.” [It got its' own... well, you get the picture.]

My coworker and I got a plate (A see-through plastic plate with a lovely design etched into it. The nicest plastic plate I have ever seen, in fact.), took some food then sort of stood back and watched. Someone dressed in a nice suit was offering tours of the new Linear Accelerator. I decided to go see what the big hubbaloo was about, so followed the nice lady downstairs to the radiology department. We walked into a big vault (which was disguised as a room; in fact, I did not notice the 6+ inch thick door to the vault on the way in; just on the way out) and we got a little presentation. The machine itself is quite impressive and someone behind me actually called it beautiful. After a few minutes, I decided to return to my unit as I had some medications that were due.

Upon exiting outside to go back to CCU, I heard very lovely music when I passed the white tent. Can anyone guess where that lovely music was coming from?

Why, it was coming from the Linear Accelerator’s very own harpist, of course.