Pacemakers?

My hospital is one of the few in our area that will perform an MRI on patients with pacemakers.

It makes me nervous.

I KNOW it’s supposed to be considered “safe” now. The newer pacers and defibrillators are being made to be compatible with MRI scanners.

It still makes me nervous.

I just don’t feel I should be throwing a person, with a magnet sensitive device, into a giant magnet. I feel like it’s a risk everytime I do it. Is an MRI of the wrist really necessary on this 79 year old man with a pacemaker/defibrillator combo? Like, is this life or death? Are you going to do surgery?

No?

Then why are we taking this risk?

I just don’t like it.

Do any of your facilities perform MRI’s on patients with pacemakers or defibrillators?

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“Exceeds expectations”

So, it’s evaluation season. Doing my own eval is uncomfortable for me. It feels like I am tooting my own horn, so to speak. I don’t like talking about myself. I don’t want to sit down and tell you about the great things I’ve done over the past year.

So, I sit down for my eval with my manager… As we start going over each section she tells me the ratings she has given me.

They were all “exceeds expectations”!

What?

I have been a nurse nine years. Every eval I have gotten was rated “fully meets”. I was always content with that. However, for the first time I exceed. My manager started mentioning all the things I’ve done that’s she’s noticed. She gave me compliment after complement for the care I deliver. I honestly didn’t know she paid that much attention. She manages over 100 nurses, she’s always on the move. However, she makes it a point to stop by our department and check in on us. She is always available. To be honest, she’s the best manager I have worked for. To know that with all she is doing, she still noticed my hard work, it felt great.

My actions are not so that I can be noticed. I just do what’s right for the patient. Ultimately, that who we are here for. I never thought I was going “above and beyond”.

It was a great feeling.

I’m in the right place. I’m definitely in the right place…

The Ativan isn’t working…

Hey doc,

It’s Fred, the MRI nurse calling about your claustrophobic patient detoxing from opioids.

The ativan isn’t working. ūüėí

I’m not sure why you thought 1 MG of ativan IV would get your patient to hold still for an hour inside of a tube that can sound like a jack hammer but THE ATIVAN ISN’T WORKING. It’s not going to work. He is detoxing… FROM OPIOIDS!

How about you let us do this the way we wanted to and let us complete this HOUR LONG STUDY under anesthesia? It’s propofol, you know, the same stuff you guys were using when you had him intubated? Remember how well that worked? Yeah, we can do that down here as well. We use just enough to get him asleep and only leave it on long enough to complete the study.

But no. Instead you would like for us to “just give it a shot” without sedation. He has pain medication and the ativan so that should keep him still. Oh okay. Well, I hope you get all the information you can from these blurry images we were able to get before we stopped the scan because he almost climbed off the table.

Let us know when you want to schedule him for sedation, I can do that for you…

That’s… unfortunate

A majority of my patients cannot read and know nothing about their medical care.

That’s… unfortunate.

In fact, it’s scary.

My patients have to fill out a checklist before having their MRI or CT scan. It asks numerous questions about prior procedures and certain health issues.

So many of my patients can’t fill out the questionnaire. In fact, a lot of my patients don’t even know why they are having the scans! They are here because they have an appointment. They don’t know which doctor ordered the scan, what is getting scanned, or what the particular doctor even does for them. It’s sort of the mindset that “if the doctor ordered it then I should do it”, no questions asked.

That is¬†frightening. Those of you that have been following me know I am big on patient education. With how fast paced my department is, I don’t have the time I would like to have to educate patients. And let’s be real, at this point I can’t teach someone to read. I guess what is so disappointing to me is the fact that it’s just glossed over. It’s accepted. The lack of patient education, understanding, and participation has become the new norm. I can’t stand it. I want patients to understand what is going on. I want patients to be a part of their plan of care. I want patients to be set up for success.

Apparently, I want to live in the NCLEX world where everything is perfect and everything runs smoothly.

I want my patients to be happy and healthy. Sometimes I feel like I am being unrealistic.

 

GFR

Now that I am in the radiology department I spend a lot of time focusing on GFR and kidney function. Why? Good question!

In MRI and CT we give contrast to a lot of patients. In CT the contrast is iodine based. In MRI the contrast is gadolinium (metal) based. Both types of contrasts are filtered out through the kidneys and thus the reason kidney function is so important in this department. The way we assess kidney function is by checking a patient’s creatinine level in their blood. Luckily for us we have machine called the i-Stat that can test the blood and give a result in two minutes. The result transfers into Cerner (our EMR) and the computer then uses that result to calculate the GFR. Great… except I didn’t really have an understanding of why we were checking the creatinine, what GFR really was, or why there is a GFR result for African Americans and non-African Americans. I decided to do a little reasearch and I figured, since this is a nursing blog and all, why don’t I share what I have learned?

What is “GFR”?

GFR stands for glomerular filtration rate. Basically, the GFR tells you the flow rate of fluids through the kidney. Your glomeruli are the capillaries in your nephrons inside the kidney. Blood is filtered across the capillary membranes helping to remove waste that can ultimately be excreted through the urine. Taking you back to anatomy and physiology in nursing school aren’t I? *shudders*

A simple google search will bring up lots of GFR calculators. Typically the GFR calculator takes into account serum creatinine, age, gender, and race (African American versus not) and then it will give you the estimated GFR. A GFR >60 indicates a generally healthy kidney. Less than 60 can indicate potential kidney disease. Less than 15 can indicate full on failure. Here is a little infographic that is patient centered.

Why creatinine?

Why does the GFR equation use creatinine? In the most basic terms, creatinine is a waste product of creatine. Creatine is used by the muscle cells for energy. Your kidneys help filter the creatinine out of the blood to be excreted in the urine. Low creatinine typically indicates good kidney function (which makes sense, healthy kidneys will filter out creatinine effectively). High creatinine indicates the opposite, kidney function is probably on the lower end because the kidneys are unable to filter out the waste product. Creatinine is primarily filtered out through the kidneys which is why it is a pretty good indicator of kidney function.

Why is the result different based on race?

Many, many times I have looked at my labs and wondered why the GFR had a result for African Americans and then essentially everyone else. It wasn’t until I started working here and paying attention to the GFR that I decided to look it up. Turns out studies show we have “higher than average” muscle mass so we generate higher levels of creatinine. Higher creatinine levels lead to higher filtration rates. The difference in results account for this.

Now I can actually explain to my patients why I am taking blood after I start an IV. I like to be able to asnwer my patient’s questions so of course I had to do a little learning on my end. Hopefully some of you will also find this information useful! (Also here is a great reference for frequently asked questions from the National Kidney Foundation because, why not!)

Constantly learning

A little while back, while I was still a STICU nurse, I decided to start a little notebook where I would right down new diseases/diagnoses/medications I came across during my shifts so I could look them up and learn about them. I was afraid when I transitioned into an imaging nurse I was not going to really be “learning” anything new. I’m just going to start IV’s and monitor for contrast reactions.

I was wrong.

People get MRI’s for all kinds of reasons. I have probably come across more diseases that I have never heard of in this position than I had the whole time I was in the ICU.

It’s been a constant learning experience. I start looking up the disease the patient is diagnosed with (which is the reason they are coming to MRI in the first place), and that leads me to another related disease, which leads to a new study, which leads to a med I have never heard of, and so on.

I’d never heard of MGUS, plastic bronchitis, or a syrinx. Came across all of those in MRI. I assumed that I need to be bedside to learn anything new in nursing. That’s not the case at all. As long as you are providing patient care you never really stop learning…

So you have to send your patient to MRI…

So your patient needs an MRI. Maybe you can just send them down with transport, maybe you have to come down with them. Here are 10 tidbits to help make it easier or yourself and us.

  1. THE MAGNET IS ALWAYS ON. ALWAYS. 
  2. Because of #1, don’t bring anything you don’t need on your¬†person. Majority of what you carry is not MRI compatible and you’re going to have to leave it somewhere away from the MRI room anyway.
  3. Also, don’t leave anything on your patient that they don’t need. The 4 blankets? Yeah, let’s consolidate that. The SCD’s? Leave those in the room. The stickers from their morning EKG? Take those off, they aren’t MRI safe. No, your patient can’t bring his/her phone with them. Your patient will need to be moved off of the hospital bed and onto the MRI safe stretcher, let’s make this easy on everyone.
  4. Coming down with your patient? Understand that you aren’t just going to walk into the MRI room when you get downstairs.¬†You may be in a rush, we aren’t. Safety is our number one priority. We have to make sure you don’t have anything unsafe on you and we have to check the patient for the same reason.
  5. ICU nurses please note: your ECG leads and pulse ox are coming off once you get here so be prepared to replace those. We have our own MRI compatible monitoring equipment, your patient will be monitored using our stuff not yours.
  6. Take a look at what IV fluids you have hanging, are they necessary? Your IV pump is not compatible with the MRI machine. No, seriously, it’s not. You are probably going to have to add like 30 feet of extension tubing to your drips unless your hospital has the MRI safe pumps and there aren’t many hospitals that have them. Do you¬†really need to bring the patient down on normal saline? Really? Can the TPN and lipids be paused for 30 minutes to an hour? Thinking of this while you are still on the unit is going to make the transition much easier. ICU nurses, take note because we are notorious for bringing down drips that could really be paused for this test. I’m not saying be unsafe to make it easier, just use your judgment.
  7. The magnet of the MRI interferes with the ECG monitor, you are NOT going to get a good rhythm while your patient is in the¬†scanner.¬†This, in particular, applies to my¬†ICU nurses. Please understand that there is nothing we can do about that. The monitor is wireless and whenever the magnet begins scanning it disrupts the signal so the rhythm that we see on the¬†monitor is garbage. In between scans you will see a normal rhythm but once the technologist begins the next part of the study you are going to see nothing but artifact. If your patient has been having unstable arrhythmias you may want to speak with your docs about the risk/benefits of coming down for the scan. You may want to wait until you can trust that they aren’t going to jump into some funky heart rhythm during the scan. That MRI of the foot can wait.
  8. Pacemakers no longer exclude a patient from having an MRI. It used to be having a pacemaker was an automatic “no”. That has since changed. There are now MRI conditional pacemakers and we are now scanning patients with MRI non-conditional pacemakers. That being said, let your physician know that an MRI on a patient with a pacemaker is NOT going to happen the day it’s ordered. Many steps have to be taken to assure we do this in the safest manner possible. We need paperwork from whatever company manufactured the pacemaker. We then have to set it up so that a technologist from the company can be there to put the pacemaker in “MRI-safe” mode.
  9. FYI: MRI safe mode does NOT mean we turn the pacemaker off for the scan! This was something I was not aware off until I became a radiology nurse. It’s the exact opposite. The pacemaker mode is actually changed from pacing only when needed to pacing continuously at a set rate determined by the doctors and set by the technologist from the company.
  10. Do not send your patient down if they are claustrophobic, altered, or in pain unless you have a plan. For a successful MRI, the patient MUST lie still for the ENTIRETY of the scan. If they move, that section of the scan must be restarted FROM THE BEGINNING! If you know they are claustrophobic, ask for something to help calm them. If they are altered and can’t hold still, ask for a sedative of some sort or reschedule. If they are in pain, please premedicate them. The MRI table is hard and uncomfortable, your patient won’t be able to tolerate the scan if they are already in pain.

Hopefully these 10 tidbits of info make your trip to MRI a tiny bit easier.

Humbled

Since I have become a radiology nurse I have witnessed something that has humbled me; cancer patients and the infallible strength that they have.

My role in¬†radiology is different from my role as a bedside nurse. I am still responsible for patient safety and care but in a more indirect way. I monitor the patients during their MRI’s and I am the one that starts the IV’s before the study begins. I encounter¬†a lot of oncology patients. In fact, I would say almost 90% of my patients some days are getting scanned to assess for metastasis,¬†diagnose new cancer, or stage some form of cancer. These are people from all walks of life. All races, all statuses, all religions, all education levels, all ages, cancer does not discriminate.

What has humbled me is their attitudes. Almost every cancer patient I have come in contact with in my department has had a bright smile and a sunny personality. Most of them come in¬†with the mindset that they have another battle to fight and they are going to win it. I love that! Their smile makes me smile. We end up joking and laughing during our time with each other. These are people that are getting a procedure that could potentially present more bad news and yet¬†they walk around with a smile. I wake up bitching and moaning in the morning about having to get up so early. I complain about my knees being stiff or my back causing me pain. I rarely wake up and just thank God for being alive and being *relatively* healthy. I am going to make a real effort to try and change that. If these oncology patients can still tackle life with such vibrancy then why can’t I? Every day that I am alive is a blessing. Every day that I am blessed to not have to experience the things that these wonderful patients are having to go through on a daily basis is a gift. I am humbled yet inspired by the strength and positivity these patients demonstrate. I’m going to live for them.

Full circle

I started working in a hospital on my birthday in 2007. In this particular hospital, there were two separate transportation teams. One did regular transports and discharges and the other only did transports to and from radiology departments. I started as a transporter in the radiology department. The hospital offered a free EMT-B course, all you had to do was pass. Of¬†course I took up that offer! I transported for over a year and in the process started nursing school. That’s when I decided to become a tech. After graduation, I worked on that unit (med-surg) for two years. I hated it. I am not a med-surg¬†nurse. I got frustrated very quickly with all the frequent flyers. I felt like I wasn’t making a difference. No matter how much teaching I did I knew I would see those patients in a month,¬†maybe two.¬†So I left the hospital to¬†take an ICU position in a smaller hospital. It was hell for me to go from a¬†teaching hospital where I was autonomous and a¬†part of the care team to a community hospital where I was supposed to just do what I was told. Yeah, no. They got two years out of me as well before I took an ICU position in another teaching hospital. I¬†loved it. I learned so much and got to be a part of things I had never experienced before. The only drawback was the commute. An hour and a half one way, and I was working night shift.¬† I managed to pull this off for three years. I kept telling myself I would move closer to the hospital but I never did. I love the city I live in right now. I love the diversity, something that was lacking in the area that particular hospital was in. So, I started the job search again. Guess what hospital and what department were in need of a nurse? Yep, my first hospital and the opening was in radiology! I jumped at the chance and luckily got the position.

Its been a bit surreal. Being back in the radiology department feels familiar and new at the same time. Most of the radiology techs and nurses were there when I first started. They remember me as a transporter from 11 years ago. Now here I am in their department as a clin¬†2 nurse! I’ve come full circle.¬† I am getting used to being the new kid without actually being a new kid. Maybe, just maybe this is where I was supposed to be all along…