Safety first

I feel like safety may be starting to take a back seat to profit and productivity. Nursing is increasingly being pressured to move patients from ICU to the floor quicker. Discharge the patient quicker so that another patient can be admitted. Get patients to this scan or that scan faster. It’s not safe.

As a former ICU nurse, I have witnessed patients being moved to the step-down or the floor before they are really ready. Two days later they were back in the ICU do to a decline in the patient’s status. Typically they were in worse condition than they were when we moved them out. As a former floor nurse, I have seen discharges be rushed because they needed the bed for the next admission. Patient education was minimal at best. As a radiology nurse, I am seeing patients come down to MRI that are in no condition to be inside a scanner for an hour. There is a constant rush to get the outpatients on and off the table.

I understand hospitals need to make a profit to continue providing care. I get that we need to treat as many patients as possible. However, when you rush your medical personnel you open the door for mistakes and safety events. I became a nurse to provide the best care I can provide. I don’t see my patients as just a medical record number and a hospital bill. I see people that are here for our help. I see people that are bracing themselves for a potentially devastating diagnosis. I see people that need my care. I don’t like feeling like I have to rush this person through the process.

What happened to the so-called “culture of safety”? When did safety take a backseat to speed? I refuse to place anything before the safety of my patient. So, continue to look at your numbers, your productivity charts, your profit margins. I will continue to take care of my patients as I was taught and give each patient the time they need.

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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?

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…

Set up… To fail

So, the higher ups have decided to implement new changes in our department to make us more “efficient”.

😒🙄

Are the changes going to work?

No.

I say no, not because I am against change. I embrace change and fully believe medicine is an ever changing field.

I say no because the changes are rigid.

Our department is very fluid. We may not have a single patient one minute, and the next minute 6 outpatients are here and there is an vented ICU patient on the way down and a patient waiting to go back to their room. Our patient flow changes throughout the day and unfortunately the decision makers don’t recognize that. They see numbers. They see productivity. Pie charts and bar graphs.

Patient care just doesn’t work like that.

However, we are going to implement the changes. We will go along with what management wants. We will grumble and groan as we see how poorly the changes work. We aren’t afraid to speak up. The speaking has been done. At this point, we are going along so we can watch the changes fail and create more problems. We are doing this so that they can see how inefficient their decisions are.

Sometimes the only way to get through to someone is to stop talking.

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!

ABG’s, what do they mean?

Arterial blood gases… Chances are if you work in a progressive care or intensive care unit you have seen ABG results or you will.

If you’re like me in the beginning, you have no idea how to interpret the results. For the longest time I had no idea what I was looking at. I knew the pH was indicative of acidosis or alkalosis, and that was the end of it. Once I started working in an ICU I wanted to really understand what the results meant. I made one of our respiratory therapist teach me how to understand the results (he was awesome and was happy to help). It turns out ABG results are not too terribly difficult to interpret. You are trying to obtain three key pieces of information:

  • Is the patient acidotic or alkalotic?
  • Is this a respiratory or a metabolic issue?
  • Is the body fully compensating, partially compensating?

While there is plenty of information on the ABG slip (or in the chart if your unit doesn’t have an ABG machine available) you can come up with the answer by looking at three key results: pH, paCO2, HCO3.

One of the ECCO learning modules I did had this handy little chart that made it easier to interpret the results. I thought I would share it with you all in case there is someone out there confused like I was, but may not have a quick resource available.

That’s it. This little handy chart has helped me a lot. It took what was, for me, a larger amount of overwhelming information and broke it down into something I could use. Here’s how to use it:

Look at the pH, is it <7.35 (you’re acidotic) or >7.45 (you’re alkalotic) or is it normal? Circle which side of the chart your value falls in. Then look at the PaCO2. We are looking at carbon dioxide in the blood here. Repeat the previous steps and circle where your value falls. Then look at your bicarb, HCO3. Circle where that value falls.

Remember pH tells you if they are acidotic or alkalotic. Now that you’ve figured that part out, it’s time to figure out if this is respiratory or metabolic. Look at your chart, is the CO2 circled on the same side as the pH? If yes, it’s respiratory. Is the bicarb circled on the same side as the pH? If yes, then it’s metabolic. Now, are we compensating? If you are partially compensating then you will have one value on the other side of the grid. If you are fully compensating then your pH will actually be normal.

I’m a person that needs to see something in action so let’s do a couple of examples:

Note let’s break out the chart:

pH is low so we know the patient is acidotic. The CO2 is on the same side as the pH. The bicarb is on the opposite side of the grid so the body is trying to compensate. We have respiratory acidosis, partially compensated.

Let’s do one more:

Bust out the handy dandy chart!

The pH is high so we know it’s alkalosis. The bicarb is on the same side of the chart as the pH but the CO2 is on the opposite side. Here we have metabolic alkalosis, the respiratory system is partially compensating, that’s why the CO2 is high.

I would like to mention one thing, if all your values are on the same side of the chart then it most likely means the one of the systems of the body aren’t compensating.

Hopefully this post is able to help someone out. If you have any other hints, tips, tricks let me know!

Vitamin C and sepsis

You may or may not have heard about some new studies coming out that show some positive results adding vitamin C to sepsis treatment.

If you haven’t heard anything about it, don’t worry, you will.

This is what really kind of started it all. It was a retrospective study, not one you could really take back to your ICU and make evidence based changes on, but it provides some interesting factors to think about. This study gives some information about some of the preliminary findings. So far, (cautiously) it looks positive.

However, don’t think doctors around the world are ready to jump on the vitamin C boat just yet. There hasn’t really been a what I would call a “large scale” scientifically sound study completed just yet. It’s safe to say the idea remains controversial. Here is a really good article addressing the controversy surrounding the treatment. I did notice one thing when I read this article: while doctors may not be ready to jump on board do to a lack of evidence, most of them really hope vitamin C treatment does turn out to be beneficial. The health care field as a whole really wants a better treatment for sepsis, especially since what we are doing now is only partially successful.

I am hoping someone decides to do a large scale study and really put vitamin C to the test. I would love to know if this could potentially be an adjunct sepsis treatment or if it is time for medicine to go back to the drawing board. Trying new things is what helped the medical field advance this far, let’s not stop now!

PALS is not my pal…

I took PALS this week. If you aren’t familiar with that acronym it stands for Pediatric Advanced Life Support. It’s ACLS for kids.

I don’t like kids.

I don’t want to work with kids.

Thanks to my new job, I occasionally work with kids.

I’m in MRI now and I have contact with individuals of all ages from one week old to 99 year olds. This is new to me. I’ve worked with adults my entire career. That’s been on purpose. I don’t like kids and I don’t know what to do with them. Everything dealing with pediatrics is intimidating to me and I commend all of you pediatric nurses.

Honestly, it’s the math. I SUCK AT MATH!

EVERYTHING with kids is weight based and that just throws me off. Everything I’ve learned in PALS involves the weight of the child as a basis for how to treat. With adults it’s typically a general dose. Don’t get me wrong, there are some weight based meds for adults but typically a miscalculation isn’t going to kill them quite as quickly as it could a child. Children are so much more fragile and I’m afraid I’m going to do far more damage to a sick child. I couldn’t live with myself if my poor math skills resulted in the death of a child. I’m just going to keep my hands off.

So why was I sitting in a PALS class?

It’s mandatory for me. Radiology nursing is considered “progressive care” and we are required to have PALS and ACLS since I come in contact with all ages. We do sedation on our claustrophobic patients and recover them afterwards so the potential for an emergency is absolutely there. I mean, I needed the class. I learned quite a bit. I had no idea just how different it is caring for a child when compared to adults. I now feel a little more prepared to handle a pediatric emergency. I will probably still freak out completely but at least I will know what to do if someone can calm me down.

PALS made me realize I will never be a pediatric nurse. Rock on pediatric nurses, rock on!

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.

“It’s ok, we’ve got it”

I don’t trust this phrase whenever it comes to my patient any other medical professional or anyone for that matter.

Why?

Because I’ve seen it come back to bite people.

The patient needs to go to the bathroom, you go in to help. The family says “it’s ok, we’ve got it”… Annnnnnnnd your patient is on the floor.

They want to place a central line at the bedside so you go in to assist. The fellow tells you “I’ve got my med students so it’s ok we’ve got it” annnnnnnnd then they proceed to place a femoral central line in the right subclavian because the student didn’t know the difference between the kits (this is a true story).

X-ray comes in for the morning film and needs to reposition the patient, you offer to help. They tell you “it’s ok I’ve got it” annnnnnnnd now your IV is ripped out and on the floor.

As far as I’m concerned, you don’t “got it”. Don’t you touch my patient without me being there. I’m going to help whether you like it or not. I do NOT have time to fill out safety events. I’m probably not even done with my regular charting.

It’s ok, I’ve got it.