Recent Blogging Hiatus

has been brought to you by Halo 3.

Yes, I did it.  I finally went out and bought an Xbox 360 and it has been comsuming quite a bit of my time.  And you know what?  It’s been throroughly refreshing.  Nothing says stress relief like blowing away people you don’t even know from across the globe in an on-line deathmatch.

Hopefully it will be out of my system by the time I come back from my work weekend and I can regain the ability to bring you the fine bloggerific posts y’all expect.

Oh, if anyone wants to meet up and go toe-to-toe, drop me a line and we can set something up!  Just promise to be gentle, I’m just a n00b.

What I Didn’t Learn in Nursing School

It’s 6am in the morning.  I have my arm laid out on a Chux pad on a table in the Pharmacy office with a 20 gauge angiocath sticking out of my AC.  The angiocath is held by the shaking hands of a new nurse trying valiantly to stick the needle into my vein.  A bead of sweat rolls down her forehead as I say, “You’re doing good.  Just keep advancing the needle.”

“I’m not hurting you?” she asks with a worried frown.

“Nope, just fine.  Keep going.” I said, distracted by the phone ringing on the desk.

“I think I missed.”

Looking down at my arm and the angiocath, “Yup.  Looks like it.  Do you want another go at it?”

So why am I subjecting myself to the unskilled ministrations of this nurse?  Other than the fact I’m a nice guy and an awesome preceptor and charge nurse?  Because her nursing school education failed her.

I’m not saying that her education was sub-par or that she was unable to pass the NCLEX, but that the essential technical skills of a nurse were glossed over.  Nursing school is supposed to be a chance to learn.  Learn pathophysiology, disease processes, the nursing process and a load of nursing theorists.  It should build a theoretical and knowledge based foundation to base one’s practice upon.  In addition to knowledge, it is an opportunity to learn the technical skills that one has to call upon as a nurse.  Things like inserting Foleys and nasogastric tubes, restraining patients, changing beds (with the patient still in it) and starting IVs.  The basic technical skills.  I’m not talking about drawing ABGs, performing EKGs, dealing with chest tube drainage systems or interpreting rhythms, skills that are unit specific and taught in relation to that unit, but basic/slightly advanced nursing skills.

As we were about to begin, the nurse confided in me, “I’ve never started an IV.”

“Never?  Like never at all?”  I ask incredulously.  “Not in school, not in your preceptorship?”

“No.  We weren’t allowed.”

“Why on earth? (actually thinking WTF) not?”

“They said it was something we would learn on the job.”

That’s delusional thinking on the part of the faculty.  Like many other hospitals, ours has an IV team, a dedicated crew of nurses whose sole duty is to place IVs, whether peripheral, midlines or PICCs.  During the day this isn’t a problem, but after 2300, we’re pretty much S.O.L. (shit out of luck).  Sure we still have an IV nurse, but 9 out of 10 they’re busy placing a PICC or at another facility across town.  A new peripheral site does not top high on their priority list.  It comes down to the floor nurse to step up and place a line themselves.  Frequently though, the patients we get the “practice” on in the middle of the night are not the best subjects, hence why I was on the table.

There are not enough educational opportunities to teach our multitude of new nurses the skill, no, art of inserting an IV.  Hell, there’s not enough opportunity for the rest of us to keep our skills sharp (no pun intended…).  I was a lucky one.  I did my preceptorship in a relatively busy ER, where I had multiple opportunities to poke needles into folks in varying states of consciousness and I got adept, not great, but able to start lines.  However, that skill is pretty much rusty and as out of shape as I am due to a lack of practice.  How then are we supposed to provide that opportunity to newer grads?

It seems a large disservice by that school to deny the opportunity for their students to learn such a vital and practical skill.  I agree, it’s not always the best thing to have legions of eager students roaming the halls to stick unsuspecting patients with large bore angiocaths.  It’s a great way to deter frequent flyers return if they were greeted with such a sight, but alas it isn’t going to happen.  But what happened to starting it on each other?  That’s how we learned.  I won’t soon forget having my classmate John digging around my hand with an 18g trying to poke my elusive dehydrated vein.  That didn’t feel good.   But it was how we learned.

So why the vitriol Wanderer you may ask?  It’s because we recently hired 9 nurses to the the night shift, most of whom are new grads, most without the previous experience of starting IVs.  Some never dropped an NG, placed a Foley, given charcoal or done a large time-consuming dressing change.  It leaves gaps in the team that places a larger impetus on the experienced nurses on the unit to step up and fill the holes while trying to figure out how to get these folks up to technical speed.  And when not everyone is willing to step outside their norm, it makes it a little more stressful.

“So, OK, figure out what you did wrong?” I ask as she arranges a new set on the table.

“No.  No clue.  Any suggestions, words of wisdom?”

“One thing, go in steeper than you did.  My veins are a little deeper, so go in steep, when you get the flash, go just a little further then flatten it out.” I replied demonstrating what I meant.

“OK, you ready?”

“As I’ll ever be.”   Wish I could say it was a successful ending, but I would be lying.  We work together soon, so I’ve resigned myself to be a pin cushion.  If it helps, well, then it’s worth it.  Just wish her nursing school would had delivered so I wouldn’t need to be that pin cushion.

If it ain’t gas…

It’s something else.

The wife and I decided to go out, spend some quality time ensconced in front of a large movie screen.  Have some laughs, enjoy some previews, gorge on popcorn and drown it all in gallons of Coke.  In honor of this auspicious event, I present my version of a Mastercard Priceless commercial, based on my night.

Admission to first-run movie: $20.50

Large Popcorn, Large Coke: $12.00

Sneaking in Churros from Costco: $2.00

Having the twit working the ticket booth give you tickets for the wrong showtime: free (see #1 above…)

Watching Brad Pitt say, “That’s some serious sensitive shit!”: just about Priceless.

Yes, we saw “Burn After Reading” and laughed our asses off.  Seriously odd, demented fun.  We thoroughly enjoyed it.  While waiting we saw a preview for “W” a movie about our Pres.  Isn’t it a little early for that?  And it’s real.  Not a farce, not a satire, not a “Disaster Movie” version of his life, but a real Oliver Stone biopic.  I may have to go to the second-run theater where I can drink heavily to get through that.

But seriously:  go see “Burn”.  It’s really great.

Aerial C.Diff?

Another entry into the “Holy shit!” files of scary drugs, diseases and conditions, add aerial C.Diff.  In this article: Aerial Dissemination of Clostridium difficile spores.

Adding airborne transmission to the standard contact transmission just increases the pucker factor.  The article goes on to note that aerial spores were captured on several tests showing samples of C.Diff in wards where there had not been active cases of C.Diff for weeks.  The authors postulate that this could be an explanation for the sporadic cases of CDAD (Clostridiun difficile associated diarrhea) that spring up seemingly out of nowhere.

While not surprising, it is enough to knock you back a bit.  Operating on the idea that it is solely contact based transmission has been the basis for everything we do when treating CDAD.  From terminal cleaning of the room post occupancy of a C.Diff patient to the gown and glove isolation we practice may not be enough to combat spread around a unit.

Combine aerial transmission with the over-abudance of PPI use (which studies have shown to be a  factor in C.Diff infection due to the breaking of the gastric acid barrier protection from reduced gastic pH) in a population already at risk of CDAD and you have a poop-strewn nightmare ready to happen.  While the article does not definitively note any cases where areial transmission is the sole cause of CDAD, it raises the specter that it proably does happen and that we need to adjust the way we protect our patients.  Terminal cleaning with bleach is one step, espeically for surface cleaning, but the cleaning of air remains another aspect all together that could require extensive revamping of HVAC systems hospital wide.

It’s hard to guage the true impact of this and the fallout it may have on protocols, but it could go some way to explain a lot of cases of CDAD.  Still it scares the poop out of me!

Sheath Pulls

One of the unique procedures we do on our unit is the removal of arterial and venous sheaths.  A sheath is a large bore (7-11 French) tube inserted into the vein or artery, usually the femorals, that allows the insertion of a variety of instruments to perform procedures like stenting, diagnostics and ablabtion.  It used to be the docs would pull the sheaths in the cath lab, or in post-procedure.  Since we split our unit, the step-down side is set with a 3:1 ratio and any intact sheath goes there.  Consequently we’ve been getting a lot more.

Many times, the day shift pulls these, but as the docs are adding more procedures and they’re taking longer, the night shift is getting more to pull.  Lately I’ve been drawing a lot of ablation pulls.  In other words, many holes to plug. They need so much access to thread the multiple tools into the heart.  In this particular view you can see 4 tools inside.  4 tools equals 4 sheaths, if not more.

The other night I had a doozy: 6 to pull.  3 in the right femoral vein and 1 in the right femoral artery, 1 in the internal jugular vein and a giant honkin’ 11 French in the left femoral vein.  The pic below is a visual representation of the size of the typical catheters.  French sizing is basically sized in milimeters, so an 11 French is 11 milimeters in diameter.  Not exactly small.  Luckily it was venous.  I shudder to think of one that size in an artery.

The nice thing with venous sheaths is that it’s just hand pressure for 10 minutes and you’re good.  It was just the sheer number that is daunting at times.  The IJ came out good, like pulling a CVC.  Just have to rememeber not to put too much pressure on the neck.  Wouldn’t want to stop any blood or air flow!

By the time we moved to the left venous, we had literally gathered a crowd. There was me, my second, my preceptee adn my second’s preceptee.  We always have another nurse in with us when we pull just to have another sets of hands in case things go south.  And this night, both of us had preceptess with us.  Since we don’t have sheaths all that frequently, and rarely in this number, I like to make sure any new folks to the floor can at least watch the prceedings.  It all goes with the mantra: see one, do one, teach one.  Besides the 4 of us, my charge nurse popped in as well.  I think we had it covered if things went to shit.

Out the sheath came and there was a gasp of amazement.  Think about the blue BIC pens so ubiquitous to any office.  Yes, it was the size of the end of one of those pens.

“We don’t see many of this size very often.” my charge said.

I bite my tongue thinking, “Yeah, I get that a lot!”

Finally we’re down to the arterial sheath.  Being an artery, it’s a little different.  I tend to use a Femostop pressure device that exerts direct pressure on the puncture site to achieve hemostasis.

Usually it takes me an hour from when I pull the sheath until the Femostop is off.  Now some nurses on the floor take less time, but I have my reasons.  I’m conservative, but *knocking on wood* I have yet to have a re-bleed or hematoma when I pull a sheath.  It’s not like we’re just hanging out.  We’re grabbing vital signs every 5 minutes, checking distal pulses, sensation and color to the foot and generally distracting the patient from the large amount of pressure being exerted on their groin.

The best thing about our new unit is that we can take the time needed to do this.  Now, I’ve done this ncredibly time-consuming procedure with 4 other patients.  It ain’t pretty, but can be done.  Now though, I can take the time I need.  Besides the cath lab, we’re the only ones to do this in our hospital.  Granted, now that the sheaths are out, we have to bug the patient every hour to make sure there is no hematoma or bleeding and they still have good distal circulation.  I always joke, “You’re going to be sick of me by the end of this.  And not get any sleep at all.” And it’s true, they’re sick of me, and I’m sick of doing it.  But it’s the job.  And I love my job.

Redneck Cardioversion

I was taking care of a patient the other night who was in for an atrial fibrillation ablation.  In quick and simple terms, they go in, find where the ectopic fib beats are originating and then burn them out.  As we were chatting the typical run-of-the-mill history questions came up.

“Did they ever cardiovert you?  Or have you been managing with drugs?” I asked.

“Nope, whenever I would come in to have it (a cardioversion) done, I’d be in sinus by when they hooked me up to the monitor.”  he replied. “But there was one time though.”

“Go on.”

“I was working around the house doing some remodeling work and noticed myself go into fib.  I had been in it for a couple of hours, but wanted to finish what I was working on.  It was some electical work…” he related.

I saw where this was going…

“And I touched one of this the wires.  Guess I had forgotten to switch the breaker off!  Got a shock, but my fib went away!” he finished.

It’s perfect, a redneck cardoversion!

September 1st – Bits & Pieces

Doe that mean even if my hospital decided to require us to wear whites, does wearing them after Labor Day make us uncouth?  Just a thought.

Never truly understood the whole “no white after Labor day or until Memorial day” thing.  Just not part of the that social strata I guess.

Oh yeah, hint of advice: if planning on leaving town and calling in sick, make sure you call in sick.  We had a nurse not call in for the morning shift, no-call.  So the charge nurse calls his house, wife picks up and says, “no he’s not here, he’s in Astoria.”

“Yeah, this is his work”

“Ummm….I mean he’s sick.  In Astoria.”

And after getting him on his cell phone he admitted to being in Astoria and forgeting to call in sick.  Dumbass.  Not saying he should lose his job, but he is gonna’ have to do some major pennance.

Oh yeah, and I’m really starting to hate clipboard nurses and our residents.  A blowout is brewing…