Monday, October 31, 2011

It's here! Hooray!

50 Things Your Nurse Won't Tell You

Two of my ideas made it into the list, so that's pretty cool. I liked hearing what the other nurses came up with. So true, so true...

It was a very interesting process being included in a magazine, especially when the fact-checker called to see what my opinion was of what some of the other people said, like fudging the dosing on pain medication to keep your patient comfortable.

Friday, September 16, 2011

Quick moment of horror...

So there's going to be a sympathy strike in our region coming up, and the administration is trying to figure out how to cope with a few thousand nurses missing.

One of the things our Chief Nursing Officer said they'd do was "perform a few extra C-sections on the weekend before" so there would be fewer people delivering on Strike Day.

Talk about unnecessarean....

Friday, July 22, 2011

A short illustration of the difference between Mom/Baby and Telemetry.

While assessing a new admission, you notice a set of shallow, scabbed-over scratches on your patient's calf. You ask the patient the story behind them, and you are informed that the patient's cat was bad about retracting its claws when it wanted to climb up her leg to sit on her lap.

On Telemetry, this short exchange is immediately followed by you writing a nursing note mentioning the scratches, as well as charting it in the flowsheet. You get the camera out to document that the patient arrived with said scratches, and so you can have a basis for comparison should they change. You upload the pictures to the system in case someone needs wound care to see them. You also write an incident report, to CYA in case someone tries to say that they were incurred on the unit. You waste a fair amount of your shift.

On Mom/Baby, this short exchange is immediately followed by you extending your sympathies and sharing your own cat-related-injury stories. You and your patient share a laugh. You move on with your day.

Sunday, July 17, 2011

I do not understand some people....

Here in my state, you have the right to refuse any and all treatments offered to you or your children in the hospital. I don't know if it's a universal/federal deal, but it is how it is here.

So last night, I had the interesting experience of taking care of a set of brand new parents who refused everything. I mean everything. Mom was not tested for GBS (a bacteria that can cause fatal sepsis in the newborn), hepatitis (which can also be passed on during delivery) or rubella (which can cause mental retardation), which are all standard parts of prenatal care.

They also refused ultrasounds on the baby, except to determine gender. Because dad had read somewhere that the sound waves can cause developmental delays. Based on a study done on the cell division in mice. Having done some googling, it looks like the study itself admits that there is need for further investigation, and that they themselves cannot formally correlate anything to human babies. They finally agreed to one when the mom's fundal height at 34 weeks didn't correlate with the baby's age, which is a sign of IUGR, just to make sure the baby wasn't severely undersized.

While in labor, according to the notes, mom wanted IV pain medication, but didn't want an IV in place. Sorry hon, but they are not going to inject directly into a vein every time you need some fentanyl. Multiple breaks in the skin are just asking for infection risk. Or you'd look like a heroin addict.

When the baby is born, they refuse the "eyes and thighs," which means erythromycin eye ointment, a Vitamin K shot, and the Hep B vaccine. Ok. Here's my beef with this particular issue. I understand refusing the eye ointment if you are certain that mom does not have any dangerous vaginal bacteria (like GBS). I'm totally fine with that. But since they refused GBS testing, and GBS can cause blindness, it seems like a foolhardy risk to take. If they'd tested mom for GBS and she was negative, sure. Skip the eye goo. I'm not sure why they refused the Vitamin K. Probably to avoid the baby being poked. Again, it's their right to refuse things, but the baby had a rather large cephalohematoma. I would be *so* worried about continued bleeding into the space because of lack of clotting factors. And of course, the vaccine refusal was related to autism risks. Don't even get me started.

They refused the jaundice test. They said if the baby turns yellow, they'll just put it in the sun for awhile. She's a small baby, not eating very well, with a hematoma. Jaundice can cause brain damage if it's untreated, and this baby had so many of the risk factors for it.

They also refused the newborn screening which tests for treatable but possibly fatal metabolic and endocrine diseases, like the inability to digest milk sugar. Wouldn't you want to know if your baby could get brain damaged by breastfeeding?!

In addition they refused the hearing screening. I guess also because of dad's fear of sound waves? This is the most benign test we do. We put squishy rubber headphones on the baby and little sticky wires on the forehead and measure what the brain does in response to sound. It takes 15 min and the baby stays asleep through the whole thing.

I guess the thing that baffles me about all this, is why bother coming to the hospital in the first place if you don't want anything the hospital provides? I will defend people's right to make their own choices in medical care, but it would be *nice* if they were based on reality and sound scientific fact rather than "shit I read on the internet."

When you come to the hospital armed with information from Dr Google, while categorically refuting everything an actual MD tells you, it does not look good for you as a rational human being.

And when your stubbornness could impact the health of your baby.... ooooh not good. I just hope that the things they take for granted (the baby won't get an eye infection, the baby's hearing is just fine, the baby doesn't have any metabolic disorders, the baby will not become jaundiced) end up being true. They have a really sweet baby.

But for me, it seems so bizarre to refuse testing/treatment on the remote chance they may cause problems, when the chances are fare more likely that refusing these things will lead to problems.

It would be like spending all your money on alien-proofing your home, while neglecting to put locks on the doors. Sure, there's a *possibility* that ETs will invade your house, but it's far more likely that someone will waltz right in and steal your TV.

Monday, June 20, 2011

New dads are great....

Last night was a fairly strange shift for me. I was on committee for most of it, to finish up some computer-based training. Then I hung out in the nursery to help out a little, because we had 4 babies under bili lights and one on the blanket. It's too much for one nurse to handle, especially when they're screaming at the same time.

Around 0530, I finally took an admission, and then another around 0630.

The latter one was a c/section, first baby. Mom, understandably, not moving around a whole lot. I got them settled, and told them to call me if they needed any help. At 0700, when I'm giving shift report, I go into the room with the oncoming nurse.

I see a light on in the bathroom, hear water running, and don't see the baby's crib anywhere. I poke my head in the bathroom, and dad is trying to change the diaper.

He has obviously never changed a diaper before. He's wearing gloves (cute! lol), wiping haphazardly. He's trying to dodge the baby's kicking feet, which have poop on them. There is poop everywhere.

I try to suppress a grin as I ask him if this is his first-ever diaper change, and if he needs some help.

I clean the baby's feet, and show him how to do the one-handed grip to keep them from spreading the mess. He didn't set up any wipes ahead of time, so pretty much I started from scratch trying to explain the process.

He told me he didn't want to call for help because he knew he'd have to be able to do it when he got home. I told him that we are there to teach, and that our job is to make sure they can take care of the baby:
"You can do it by trial and error if you want, but it's generally easier to just learn from someone who's already made the errors...."

Sunday, June 19, 2011

Awww. *gush*

I've been taking care of a particular family for 4 nights now, and they've been through a lot (mainly jaundice/bili lights hell).

Last night they bought ice cream for the unit. Really sweet of them. I am a sucker for ice cream. It's always cool when patients give us snacky-things.

But tonight was the first time I've had a letter written to me. The dad handed it to me, in an envelope made of a sheet of printer paper held together with paper tape lol.

Dear PurpleRN,

Thanks for all the care, support and guidance that you extended during the most anxious and memorable time. We truly appreciate your dedication

- [family]

I'm feeling super good right now. It's a nice thought to fall asleep to.

Friday, June 17, 2011

Gah. Circumcision rant again.

So I had this unfortunate baby yesterday that was born by vacuum-assisted C-section after a failed vacuum-assisted vaginal delivery. Apparently he got good and stuck.

After a vacuum delivery, it's pretty common for the baby to have a good-sized circle of bruise on the head (like a giant hickey) where the suction cup was placed.

This poor kid had actual scabbing and exudate (ie, "goo) on his head around the edges of the bruise. I'm guessing they tried too hard with the vacuum and broke the skin.

So naturally, the kid is kinda grumpy and fussy. His head hurts.

Then the parents decide to get him circ'd. This poor baby was inconsolable. I would be two if I was hurting from both ends. I wish someone would've tried to convince them to at least wait until his head was healed up a bit.

I ended up calling the NICU on-call doc to beg for a tylenol order for the kid. He was finally able to sleep for a whole hour and a half at least. That's all the sleep he got during my 8 hour shift. And they only gave a one-time order :(

Then I had some parents last night who asked about getting their son snipped and when they should do it. My brain immediately went "Never!" but I told them that if they can wait 24 hours until he has a chance to improve breastfeeding, it'd go better for them. Mom's a c-section, she'll be here a couple days. No skin off their back.

And then I go to change the kid's diaper. Poor thing has a mostly-buried penis. I think if they get him snipped, there won't be much of anything left! We'll see how things are when I go back tonight, if they've done it or not yet.... Mom seemed a little on the fence about it. Fingers crossed for them.

According to the latest data, only ~35% of West Coast babies are circ'd now ( ). It'd be nice if we could get it a little lower...

Monday, June 13, 2011

50 Things Your Nurse Won't Tell You....

I was contacted recently by a writer for Reader's Digest who was putting together one of their famous "50 things" lists. She found me through a comment I posted to one of Head Nurse's blogs ( ) back in April.

Apparently she liked my quip, "I may not decide whether or not you need an injection, but I do decide the gauge of the needle involved..." and decided to ask for some more ideas for the project.

I won't share any of them here, of course. That would ruin the article.

But the request got me thinking. It was actually really hard to come up with good "sound bites" within the topic, because, as a nurse, I live for telling my patients things.

Nurses are educators and advocates, and one of the keys to our job is keeping our patients well-informed. Communication skills are right up there with "how to take vital signs" in the list of important things we need to do.

So I answered the topic more along the lines of "Things Your Nurse Wishes You Knew" or "Things Your Nurse Wishes She Could Tell You" with a bit of a twist in the wording.

I'm very curious to see how the article comes out.

Also curious what my readers (all 4 of you lol) would write for this topic? Anything you really wish your patients knew? Or that you'd never tell them?

Thursday, June 9, 2011

A short happy :)

This happened a couple weeks ago, but I just remembered it and it made me smile.

[Setting - almost end of shift]

Patient: Will my next nurse be as nice and helpful as you?
Me: [laugh and grin] Nope. I'm the best one here! All the others are terrible!
Patient: You really are the best one here. I hope you're coming back again tomorrow.

Makes a girl feel good at the end of the day....

[I would *never* actually downsell my colleagues. I work with an amazing bunch of nurses! It's really nice that we have each others' backs, and we always try to upsell the oncoming shift when we do handoff in the room]

Saturday, April 23, 2011

A short rant about communication skills.

In a hospital setting, good communication is crucial. It can literally be a life or death issue. And even in the cases where it is not, a lack of communication can seriously Fuck Up Your Night.

Last night I was assigned to work in the Overflow Unit, a section of rooms in Pediatrics where we put the Moms that don't fit on the main unit.

I was originally assigned 3 patients, but one of them was halfway out the door. I just had to finish the last of the discharge paperwork and snip off the baby's security tag. Okay, cool. Down to two.

The Break Relief nurse told me to get Room X ready, because I was going to get the next admission. Didn't tell me the name, or when she delivered. I had to do some sleuthing and guess-work to figure out who was the next likely candidate. Okay, fine. It happens.

Then I get a call from L&D asking if Room Y was clean for my new admission. I explained that X was clean and ready, because that's what I'd been told to set up. She said "Right, pt A is going into room X, but she's not ready yet. Pt B is going into room Y." Huh? Who is pt B? "Also, make sure room Z is clean as well." (apparently for the other nurse on overflow with me).

So we scramble to get Y ready, and call housekeeping to clean Z (where I'd DC'd my other patient from). I'm trying to read up on my incoming patients when all of a sudden I see the room number for incoming-patient-B switch from L&D to the Main Floor, not Overflow as expected. Huh?

Apparently one that *they* were expecting was not doing well, and being kept in L&D longer, so they decided to move my patient to the main unit and give me the next one that came along.

It's 0445 when Patient A shows up, strangely lacking her baby. Apparently he was cold and they kept him under the warmers for a bit? Her husband was strange, maybe Asperger's? Obsessed with taking photos ("the lighting in here is terrible, and the white sheets are washing out the picture") while mom was clearly exhausted. Got her settled (the other nurse's patient came in while this was happening) and finally got to go on my break at 0520.

Back from break at 0550, got a 10-minute head's up, and then my New Patient B came to the floor. Did I mention I had 6am meds to give on practically everyone? Got B settled, managed to pass my meds mostly on time and waited for the Day Shift to arrive and rescue me.

And not *once* did my Charge call us to let us know what was going on. I had to call her. I understand what it's like to be busy as Charge. I used to do it on Tele. It sucks when you've got admits on all sides. But I made *sure* to call my nurses and let them know "You've got Mr Smith coming in, he's going into room 1234" as soon as I figured it out. There is nothing more unsettling to me than getting a call from the other unit going "Is the room ready?" and you having to ask "Which room and for what patient?"

I cannot handle not being kept in the loop. And I know that the Charge Nurse knows that this stuff is going on; she's the one making the decisions about who goes where. She changes the information on the L&D "Chalkboard" on the computer, but I am not sitting in front of that screen all shift waiting for information to pop up.

It is *not* that hard to call me and say "Miss Jones delivered at 0100, she'll be going into room 4321" It takes 30 seconds, and makes my night run sooooo much smoother. I know it's doable.

Apparently word got to the Charge that I was not happy, and at the end of shift I got an apology/excuse but no reassurance that it won't happen again.

Looking at what I've just wrote, I realize this is not a short rant. It is a long rant, and for that I am sorry. I just value thorough communication :)

Monday, April 11, 2011

An overheard conversation....

As a fix for our staffing problems, the management has decided to cross-train L&D nurses to float to Mom/Baby if we are short. One of those L&D RNs was having her first orientation day on the unit. Our scene finds us sitting at the station; they are discussing the pertinent info for shift report, and I am charting about 10 feet away.

[a muffled scream filters down the hallway]

L&D RN: Um, what was that?
MB RN: Sounds like a natural childbirth to me. *grins*
L&D: You guys can hear that all the way down here....?
MB: Yep. Especially if it's one of the rooms at the end of our hallway here.
L&D: [looks concerned] We had no idea you guys could hear things over here. I'll make sure to close the doors next time I have a mom without an epidural.

I dunno why but this brief exchange made me giggle like crazy.

Thursday, April 7, 2011

I may have a problem....

Ok, so this might be kind of stupid.... I'm watching through all of Xena right now on Netflix, and I'm on the last episode of season one. One of the side characters is in labor, spending most of her time sitting off on the sidelines while the main action is occurring.

Cut to her lying on her back with her legs bent, and another character is telling her that the baby "hasn't come down at all" and I'm thinking, "Dammit, woman! You're an Amazon! Get off your back! You're better than this!" (also, since when did ancient greek warlords know anything about childbirth?)

And then they determine that the baby (apparently a half-centaur!) is breech and she has to have a C-section using candle-related hypnosis as a method of anaesthesia and the baby that comes out could *not* have fit inside that woman and then I realized I need to stop taking things so seriously.....

Wednesday, March 23, 2011

A quick story

Was helping out with a procedure on the Mom/Baby Unit that involved the pt getting a little bit of fentanyl beforehand to help chill her out beforehand.

I don't know exactly how it came up, but the other nurse I was working with said something about the doctor having to give it. I dunno, I guess we don't give fentanyl on our unit? *shrug*

So I do the doc a favor and draw it up using a cannula access needle
and put the plastic covering back on to keep sterility while we got everything else together.

The doc comes in and pulls the plastic cap off, exposing the red-hubbed blunt needle and asks (confusedly) "So, um, I just put this into the IV?"

I take the syringe away from her and put the plastic cap on so I can unscrew the access needle. "No, it's a needle-less system. Just screw the syringe into the luer-lock on the IV"

She turns to the patient and tries to figure out how they go together (without even alcohol wiping the IV port!). "Um, I don't usually give medications......"

"How about I give the med and we'll just say you did, okay?"

"Sounds good to me."

I don't think this incident is limited to this one particular doctor. My guess is that most wouldn't know how to give an IV med if you asked them to. Which is why my blood boils when I see doctors doing nursing jobs on shows like House.... If it were realistic, they'd have no clue.

Party Pitfalls....

Beyond, "Can I get a little help in here?!" there is only one other phrase that strikes terror in the hearts of nurses everywhere:

"You should talk to PurpleRN. She's a nurse!"

I was at a party this past weekend and heard the words careen out of a friend's mouth, hitting my good-time-spirit like lead weights. Before I had the chance to avoid eye contact and slip away, I was pulled into the conversation.

Friend: "This guy here is afraid of having surgery."

Me: "Oh? What surgery are you having?"

Guy: "I'm not having surgery."

Me: "Um.... okay..... Then how did this come up?"

Friend: "Tell her about your brother."

Guy: "When my brother was a kid, he had appendicitis and had to have emergency surgery cuz it burst"

Me: "Uh huh....."

G: "So now I'm really worried I'll get appendicitis and have to have surgery."

Me: (Why am I talking to this guy instead of having fun? *sigh*) "I'm guessing he had stomach pains for a few days and your parents didn't take him seriously until it was too late. Generally appendices don't burst without warning.

G: "Yeah, I do remember that happening."

At this point I hoped that our conversation was over, but for the next 20 or so minutes (felt like F O R E V E R) I had to reassure him that no, he was not likely to get appendicitis, that it was even less likely it would burst, educated him about "rebound tenderness" as a classic sign, told him that *if* he had appendicitis and it wasn't an emergency, he could likely request a spinal block rather than general anaesthesia if that was one of his concerns for surgery (at which point I had to explain what a spinal block was...) and I think I'm *finally* done with this guy when he asks again "So you don't think I'll get appendicitis?"

"No. It's not very likely. Judging by your hair color (it was grey) I'd say if you were concerned about something happening to your intestines, I'd get a colon cancer screening."

"People with grey hair are more likely to get colon cancer?"

[facepalm] " You're supposed to get a scope done at age 50 to check for colon cancer."

"Ohhhh.... so you think I'm going to get colon cancer?"

At this point I was interrupted by someone wanting to know if I'd like a drink.

Yes. Yes I did.

Wednesday, March 2, 2011

Back..... to Telemetry!

I was briefly excited when I didn't see my name on the census board. "You're not on my list...." said the Charge. Took a brief look at the list from Staffing, and handwritten off to the side was "PurpleRN - Telemetry."

Good thing I just renewed my ACLS.

As you may recall, my old unit converted to 12hr shifts, so I'd be coming to them a full 4 hours after everyone else started. Apparently I was to take over the patient load of one of my no-longer-new grad comrades. As far as a first assignment after such a long break, I lucked out.

There were two alert CHFers, a new admission (that had just been done by the previous RN) who was super fun and talkative, and only one confused fall risk patient.

It was hard remembering all the stuff I was supposed to do for the shift. Totally forgot about all those stupid skin notes and turning notes. Still good at identifying rhythm strips at least.

They got new Dynamaps, which totally threw me off. You have to take them out of standby mode and respond to prompts on a screen, which is very weird.

The most interesting/annoying new thing is a different style of bed alarm. It looks like and it works by clipping a tether to the patient, and attaching the magnet at the other end to a contact point on the pager-type-thing. And it is only effective if the tether is, say, adjusted short enough so that it rings if the patient sits up. If it is long enough for the patient to get to the edge of the bed without alarming, it's not good....

This pt had been given Zyprexa before bed, with the intention of knocking her out. It did a great job, and I managed not to wake her up until I had to around 0530 for a vital sign check and BP meds. I hadn't noticed how long her tether was, as she was more or less sleeping on it.

The alarm went off around 0600, and two RNs managed to catch her before she slid off the side of the bed. The pt thought she had to go meet her husband. Tried to reorient her (with minimal success) and readjusted the lead. Also set the main bed alarm again.

I forgot how much fun that part was.

All in all, though, it was a pretty good experience going back. And it was hilarious seeing people's surprise when they realized I was working there.

Monday, February 21, 2011

Update on the last post I made....

I would not have thought it possible, but miracles do happen.

She survived.

We got more details of the ordeal after she was transferred to ICU. Apparently she developed abdominal compartment syndrome and had to be opened stem to stern to relieve the pressure. Someone manually massaged her heart while they had her open. They had to wait >24hrs before closing her back up because it took so long to stabilize her.

And yet she made it. With no major neurological deficits. There was some issue with her placement in the hospital after she no longer needed ICU-level care. They transferred her straight back to us, because they were not quite honest about her condition. Normally we don't take care of practically-immobile full-care patients with 3 abdominal drains. She shoulda gone to Tele or something at least. It's hard to turn a patient every 2 hours when you don't have any CNAs on your unit, and the House Supervisor isn't willing to budge....

But she made enough progress that 2 weeks after the ordeal, she's going home. I know there will be some drama for awhile, because no one goes through that sort of trauma unscathed. Especially since her family didn't tell her what really happened to her (it's a cultural thing) after the delivery.

Regardless, I wish her and her family the best of luck.

Monday, February 7, 2011

The rumors came in hushed tones at first, as they often do....

As if speaking them more loudly would make them truer. Which we all hoped would not happen. The first of them came when the baby was wheeled, alone, into the nursery.

"I heard the mom lost 6 litres of blood."
"They're going to have to do a hysterectomy."

Then even more quietly.... "They say she might not make it......"

Whenever there's an emergency with a mom in L&D, they bring the baby to our nursery so that everyone, including dad, can focus on mom for awhile. We became more concerned when dad showed up in the nursery to visit.

He had so many questions, a wide-eyed first-time father. To us seasoned vets, some of the questions were funny:
"How often does a baby poop? Every 3 hours?" "Well, you can't really predict that...."

Some were strange: "Did he cry when you fed him?" "Do you mean did he cry before because he was hungry, or during the feeding?" "During the feeding." "...No... he was pretty happy about it."

And then there was an overhead page. "Code Blue. Labor and Delivery. OR"

You could practically feel everyone in the unit's hearts collectively stop.

Dad then asked the question that we all hoped he wouldn't: "What does Code Blue mean?"

The break nurse and I exchanged a brief glance of panic, before I gently said, "It means there's an Emergency." I didn't want to tell him the truth. The dad said, "It's probably my wife. There were some problems after the delivery." The break nurse suggested that he go back to L&D to check in, but he stayed in the nursery for an agonizingly long minute or two before finally leaving.

The mood on the unit was funereal and somber. You could see the prayers on peoples' faces.

Another overhead page, specifying that a certain doctor come STAT. One nurse turned to me and said "I hope she's not gone."

Down the hallway we see a doctor and a security officer talking with dad. You can't hear from so far away, but you can only imagine the conversation. Dad looks like a small, lost little boy, with his hands clasped tightly in front of his chest, as if he's trying to keep his heart from falling out and shattering on the floor.

A doctor/nurse/tech (didn't see his name tag) in green scrubs came by to offer some information to our charge nurse. "We lost her pulse twice. They're working on getting her to the ICU. We poured so much blood into her, but it all kept just coming right back out. We didn't even get to finish stitching her back up all the way"

I was in the hallway when they wheeled the mom towards the elevators. A sea of green scrubs like waves carrying the bed along, with a person kneeling at the head of the bed, rhythmically pumping the ambu-bag while someone else followed, carrying the bed's headboard.

The person in the bed looked like an intubated wax mannequin, no signs of life whatsoever, and a horrible damp sheen over the unreal ashen skin.

Another doc came by the nursing station and uttered the most terrifying acronym in the maternity world: DIC. The body uses up all its clotting capabilities and just bleeds and bleeds and bleeds and there's not a lot you can do about it.

The last of the information comes from the janitorial staff. "They say she was fine for the first hour and a half, and was holding her baby. Then after that she started having problems."

"It took us two and a half hours to clean up all the blood."

I know I don't have a huge blog readership, but if any of you out there reading this could spare a moment, I'm sure prayers/happy thoughts/good vibes would be greatly appreciated by the family, even if they don't know it's happening.