July…

It’s July. For some of you that’s no big deal. However, if you work in a teaching hospital July means something deeper… Darker…

The “brand new” residents begin their rotations…

Chaos ensues.

If you have had the pleasure of avoiding the July rush, you’re lucky. For the rest of us, there’s a sense of impending doom.

So many orders. Most make no sense.

-pediatric doses ordered for adults.

-level one head CT for “AMS” on your 98 year old patient with known dementia.

-12.5 mcg of fentanyl q3hrs for your chronic pain patient.

-one unit of blood for an hgb of 5.

-MRI of the ankle to look for osteomyolitis of the toe.

Many, many more orders from an alternate reality…

In this moment, it is your time to shine! You are the only barrier between your patient and a doctor that is still getting their bearings. You’re going to have to speak up, a lot. You’re going to have to advocate. You may even have to knock a new doc off their self-appointed pedestal (when they tell you you’re “just a nurse” please refrain from punching them in the throat).

You can do this. Take a deep breath and remember: you’ve made it through many July’s and you’ll make it through many more…

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Arch nemesis

Classes have started for me. In fact, I’ve already completed one class. I’m liking the program so far but my fight with my old arch nemesis has reignited:

APA formatting 😒😐

I despise APA. I don’t even understand its point. Margins of this size, very particular page headers, citations that are done *just* so, reference pages with indentions done differently than the actual paper, references sited differently depending on what they are…

Why can’t I just write this damn paper and send it in?!

I get that APA formatting is to help maintain consistancy with how research is published and readability. What I don’t understand is why make it so damn complicated? It almost feels like the creators made it complicated because it made them feel smart.

I hate it.

APA has always been a thorn in my side. I’ve never been very good at it. I find the rules convoluted.

As you can see, I’m already over it…

Drug dealers

Sometimes I feel like the health care industry are some of the biggest drug dealers around.

Case in point, the largest drug bust involving medical providers happened just this month. I first heard about it on the news while at work. Of course I had to look into it because I didn’t want to believe professionals in the very field I work in would stoop this low.

I was wrong.

This NPR article gave some numbers that were astonishing. There were almost 60 individuals caught in this bust. The Appalachia region of the US has been hard hit by the opioid epidemic. It was discovered that over 32 MILLION opioid pills had been prescribed in this region. If you don’t know, that’s more pills than there are people in most of the states in the Appalachian area! Doctors, NP’s, pharmacists, even a damn dentist was part of the drug problem. The Washington Post article tells a little bit more about how absolutely unbelievable these “professionals” were. Some traded opiates for sex. One doctor operated a pharmacy in his waiting room. The dentist apparently unnecessarily pulled teeth to justify writing prescriptions! However, the article goes even further with all kinds of things these people were doing in exchange for writing prescriptions. It’s shameful. So many people are dying of overdoses. So many are in our emergency rooms getting narcan to try and save their lives. So many people are on our units going through horrible withdrawal symptoms. Why would anyone in the medical field want to contribute to opioid epidemic?

It seems like the DEA (Drug Enforcement Administration) is starting to crack down on medical field when it comes to opioids. The New York branch of the DEA just charged a pharmaceutical distributor with unlawful distribution. This case is one of the first of its kind in the country. If this works out as planned, I feel like we may start to see more companies held responsible as well as individuals.

It needs to happen. There needs to be some sort of accountability for the medical field. Some of us are a part of the problem, they need to be removed. We are here to save lives, not destroy them!

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. 😒

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…

April 1st

It’s coming.

April 1st.

No, I am not worried about April Fools Day.

I start graduate school. I make that first step towards my Master’s degree. I take that big leap back into school.

I. Am. Terrified. I don’t know why. I feel like I’m not ready. I feel like I have gotten myself in over my head. I feel like I am not good enough for this. I know this is my anxiety talking. This isn’t my first time dealing with the panic and self doubt that comes with anxiety. Anxiety stopped me from going back to school before now. Anxiety almost stopped me from taking the job I have now. Anxiety has awoken me from my sleep with my heart racing for absolutely no reason. True anxiety is no joke. It’s not easy for me to admit that I deal with depression and anxiety. I am the nurse that has it all together. I am the nurse that other nurses vent to. I am the nurse running a blog giving advise to other nurses. I am the nurse that has mental health issues.

I am not going to let anxiety win though. Yeah, I am scared sh*tless, I won’t lie. I feel like I might have made a mistake. However, I am still going to log into my student portal on April 1st and begin looking over my first assignment. I am the nurse that is going to have her Master’s in two years because I am the nurse that refuses to give up.

Unnecessary

I almost lost my temper.

One of the anesthesiologist does NOT know how to talk to people.

It feels like she is being condescending at all times. I get it, you’re a doctor. I respect that. However, it’s totally unnecessary to speak to people in that manner. I am a nurse. If you talk to me instead of at me you would know I have plenty of nursing experience. I know quite a bit more than you give me credit for. I am fully capable of the tasks that are required of me during this anesthesia case. I can do whatever you need if you just ask. Contrary to popular belief, nurses don’t read minds.

I’ll say this, she has one more time to speak in her condescending tone. One more. While I am going to be professional and respectful, I’m going to put her in her place. I’ve had to do it with plenty of residents and a few attendings. This isn’t new for me, I know how to get my point across. She needs to be knocked off the pedestal she placed herself on… I’m just the one to do it.

A la carte

I work with different doctors almost every day. What I’m doing depends on the doctor I’m working with or which doctor I’m on the phone with at the time. It can be super frustrating.

Doctor A wants things done this way when they are in the department. Doctor B wants to do it a totally different way. Doctor C doesn’t care how its done as long as it’s done. None of the docs actually communicate their wants with the nurse until the nurse does it the way they don’t like. Oh, and Doctor D on the phone wants the test done with contrast but Doctor E ordered it without. As the nurse, I’m just supposed to make it work. It’s as if I should be able to read minds.

Sometimes it feels like doctors order from a menu when they give orders to nurses. A little of this, some of that, a few of those… I just wish we could all get on the same page. Let’s pick a method and stick with it. Why is this so hard?

CIDP

In nursing, we are always learning something new. Sometimes we learn about a new med. Sometimes we learn about a new use for a med. Sometimes it’s a new side effect. Sometimes it’s a disease you weren’t aware of.

As I’m writing this, I just came across a disease I never knew existed: chronic inflammatory demyelinating polyneuropathy.

Say that five times fast!

I had a patient that had an MRI of the brain and complete spine ordered (that’s at least two hours) and the reason was “CIDP”. I have never come across this abbreviation before so I had to hit up good ol’ Google to find out what it is.

Turned out to be very interesting, at least to me.

What is it?

CIDP is rare. It’s a disorder where there is inflammation in the nerve roots and peripheral nerves. It also destroys the myelin sheath over the nerves. This inflammation and destruction interfere with signal transmission. Patients notice muscle weakness, impaired motor function, and it’s typically noticed on both sides of the body.

How is it diagnosed?

According to the rare disease database put together by NORD (National Organization for Rare Diseases), the symptoms of CIDP progress slowly. Patients notice “symmetric weakness of both muscles around the hip and shoulder as well as of the hands and feet”. These symptoms must continue for at least eight weeks without improvement to be considered CIDP. Patients may also undergo EMG’S, nerve conduction studies, lumbar punctures, and MRI’S to help lead physicians to the diagnosis.

Why do symptoms have to persist for so long, you ask? Great question.

Turns out, Guillain-Barré syndrome is kind of an acute form of inflammatory demyelinating polyneuropathy. With GBS there’s typically a preceding virus or illness. GBS progresses over three or four weeks. The symptoms plateau, get better, and don’t re-occur.

The extended period of time is to differentiate CIDP from the acute forms. With CIDP, the symptoms don’t get better without treatment. GBS is usually related to an illness while CIDP doesn’t really have a known cause yet.

How is it treated?

Corticosteroids and immunosuppresants are the standard treatments. According to the NORD article I linked to, IVIG has also been proven effective. It seems that plasma exchange has also been an effective form of treatment. However, both forms of therapy only last a few weeks and the patient may need intermittent treatments.

I spent about an hour reading about this disease because it was so new to me. That’s something I’m trying to make sure I do, read up and learn about the new things I come in contact with here in the hospital. I know I can’t learn everything. That isn’t going to stop me from trying though!

Pause and plan

All hell is breaking loose.

It looks like it’s not going to get better any time soon.

You are really close to the point of tears.

Pause. Breathe. Let’s plan this out.

It’s time to break out those critical thinking skills and use that time management you have been developing.

Look at the situation as a whole, is it as complicated as it seems? Can things be broken down into multiple manageable tasks instead of one giant ball of “what the actual hell”?

Start thinking. Which patient is the most critical? Can someone check on your other patient while you attend to the patient circling the drain? (You know what, the cup of ice is going to have to wait.) Which tasks are the most important? What tasks can be delegated? Do we really need to go to CT right now or can we see if we can push it to a later time when things are a bit more calm? So there are 5 patients in the waiting room, they all came at the same time. All of them are here for their scan. That’s great but you only have two scanners so let’s take each patient one by one.

The point is this: you are one nurse. One. Singular. Nurse. You CANNOT do everything at the same time and that does not make you a failure. Don’t panic. Take a moment. Pause and plan. Use your resources. Who can help you? Align your tasks from most important to least important. Tackle what is most important first.

More importantly understand this: there are only so many hours in your shift. There is only so much you can do. If you have to pass on a task or two, don’t feel like you failed for the day. Nursing is a 24-hour job. You are not super-human. Sometimes you can’t do it all. Understand that’s okay.

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.