I’m learning that there is only so much that you can write about on a daily/weekly/bi-weekly basis without getting into things like religion, money and politics – all subjects I learned long ago to steer clear from while at work and the dinner table. Thees are things that I wish I could write intelligently about and eloquently enough to make a valid argument, but I have neither the time or the inclination to deal with the kooks that would stream from under the rocks if I did. So instead, every time I get the urge to blather on about the inequities of tax policy, over-reach of global multinational, invasion of privacy, the corruption of our government and political process among other things, I will just post a picture. It works for me.
Some deep thoughts, random reading and questions…
Where do you draw the line between a pause and aystole? I figure if the heart starts back up again, it’s a pause. Looks bad though to have 5, 7, 10, 15 second pauses. I’m going to copyright the phrase “gravitational precordial thump©” based on the following: patient is up in the bathroom, on the way back to bed, they have a 7 second pause and fall. On the rhythm strip you see the moment they hit the floor and it causes them to return to normal sinus rhythm, thereby self-correcting the issue. Guess a pacemaker can do that with out the falling part.
How much booze do you have to drink to get your EtOH level >400?
In a related bit, according to Wikipedia, the legal limit to operate a sea vessel in Norway is 0.15%.
“You gotta let me go outside to go see all the ladies.” and “See those bottles of Scotch on the wall? Bring me one…” and “Get me out of this box! (bed).” quotes from drunks last week. That would be great site, “Drunks from Last Night”.
How is it that most hospital-related educational events are always in the morning? I know no one cares about night shift, but it really sucks to work 3 nights in a row, have 1 night off and have to be at a training event at 7am. Really, do people want to come in/get up early on their days off?
Is it wrong to have a beer at lunch when you’re in class for work?
Is it so hard to wait the 10 seconds it take for the occupants of an elevator to get off before pushing your way in? It isn’t going anywhere until the doors close any way. Same goes for public transit.
If you are going to try and commit suicide by giving yourself insulin, why use Lantus (very-long acting)?
I’m thinking that if you made $17 billion a year, it couldn’t hurt to pay a little bit of taxes on it, or at least not getting a refund from the government.
Could you imagine if this was your commute to work? Watch out for the dog at 00:019!
Perusing my stats last night before heading to work I realized something: I had broken the 100,000 visits mark someday Friday. I know, big deal. Yeah, there are blogs that do that in a day or even an hour, but they aren’t mine. This little creation that started as a place to vent, educate and regale keeps growing. And all thanks to you folks, my loyal readers, or at least the one that has visited 100,000 times.
I know this rant has been making the rounds on Twitter. It is full of rage, a touch of woe is me and the grim reality of the situation we place so many new grads in. A quote (shield your eyes if easily offended…)
Well, after a year of getting rejected I have finally decided to give nursing the bird. FUCK YOU NURSING FIELD! Too bad the schools and media are still insisting that people go to RN school. Believe me THERE IS NO FUCKING SHORTAGE! New grads are considered garbage. On top of that, the degree serves no purpose in any other setting. BSN is a complete waste of time and money. …And it is not just the economy. Hospitals turning huge profits stopped new grad programs and hire foreigners.
Wow. The rest continues on in a rant that she (assuming a she) will never get a job, never put her degree to use and that she wasted 6 years of her life.
First gut reaction: she’s right. It sucks to be told there is a ready market of jobs just waiting for new grads. Read too many job requirements of “at least 2 years experience” and raged at the screen saying, “How am I supposed to get experience if I can’t get a job? WTF?!” I know many, many grads who have cycled through our unit for practicum who have yet to find jobs. We have nurses on our unit who jumped at the first offer (methadone clinic anyone?) but persevered and got the jobs they wanted. In fact that was me. I got lucky. I can empathize. The betrayal of it all is painful, kind of like when you realized Santa was not real, or your girlfriend was banging your best friend.
Second reaction: buh-bye. Maybe we’re (as a profession) better off not having this person in our ranks. Nursing is not easy…what happens the first time they get a difficult assignment? Or have “one of those days”? Run out? Quit? Nothing in this profession is given to you, one has to work for it. Take for example NurseXY, who landed his dream job in a world-class CVICU. Seriously, go read his stuff, he worked his ass off for it. Nothing was easy. No one ever promised (at least anymore) that a job would be waiting right when you passed NCLEX – and if they did you should make sure they aren’t selling a pile of hooey. Just because there is a nursing shortage does nothing to guarantee you a job just because you passed the boards. Anyone who degrades their education to this degree and doesn’t realize that sometimes sacrifice is a needed part of our job has no place being a nurse.
Final reaction: no seriously, buh-bye. If you want to work as a nurse enough to devote 6 years and thousand of dollars to do so, giving up isn’t an option. She never says that she looked out of state for jobs, into different avenues than the traditional hospital based nurse or for other ways to be a nurse. Our system interviewed over 500 grads for spots in our residency program and they came from all over the Northwest. They tried to make it work. There is nothing to say she did this, just a whiny, “why isn’t it given to me!” rant. We have too many toxic personalities in nursing and truly don’t need anymore.
I know this is harsh. Maybe this person is a amazing nurse, top notch clinical skills with empathy to boot, is driven far beyond belief and tried EVERY avenue to make things work, but based on what I’m reading, what they posted onto the internet for everyone to read, I doubt it. And with this rant, I doubt any but the most desperate, worst, idiot recruiter would ever even consider asking for a resume. I know it sucks, but maybe it’s for the better.
Every now and again my wife and I go to our “crazy Goodwill“. While most Goodwills (a for-profit company that provides training, education and employment for the disabled through their thrift stores) are an adventure, but on a whole the merchandise is useful, well organized and in true thrift store fashion priced ranging from “wow! that’s cheap” to “you want how much for that?!”
Our “crazy Goodwill” is a totally different beast as it is an outlet. If it didn’t sell in any of the retails stores it ends up here. It is is the thrift store of thrift sores. Organization? Yeah, not really, only in the following categories: stuff, clothes/fabric stuff, books/old media stuff. All loaded into big blue bins on wheels. To find what you want, one rummages through the piles of stuff searching for the hidden diamonds of the rough. It is the epitome of “one person’s trash is another person’s treasure.”
Every now and then you can come away with some cool stuff. I found a copy of the Lippincott Manual of Nursing Practice, 2nd edition from 1979 – that was a little different, and a copy of Dale Dubin’s Rapid Interpretation of EKGs in German – very different. We even found a pair of Bob’s Big Boy Figurines by luck. And yes, that is an ashtray, get over it.
The best thing about going shopping here is the experience. It is surreal. First, the space is intimidating. Large is an understatement. Second, the odor. You know that funny thrift store funk? Add in unwashed humanity, dust, mold and you have a pretty good sense. I imagine it is what the inside of a hoarder’s house smells like. Third, the feeding frenzy. In order to keep the stock fresh they periodically rotate bins on some preset interval. They start pulling the old bins away and folks start to line up next to where the old bins were in anticipation. A crowd will gather, more as each old bin is removed until they start bringing in the new bins. People are jostling, pushing for a place next to the new bins, eagerly vying for the best spots based on what they can see in the bins. But until the entire row of bins is in place it is look, no touching. When the attendant walks away from the last bin, all madness breaks loose. You’ve seen film of piranhas going after hapless prey, or a school of sharks with blood in the water, right? Yeah, like that. People are digging like their lives depend on it, throwing elbows, frantically rummaging like old miners searching for the elusive flecks of gold.
The people , like the stuff run the gamut. The are the eBay hunters, hipster folks trying to get stuff for their stores, bored housewives, hoarders, people buying stuff for their next yard sale and then some. It is amusing. Some walk out with cart load(s) of stuff, so much they have issues loading their cars! It is the consumerist American Dream distilled and crystallized into sharp focus. I’ll admit, there is a rush when you find something cool and it can drive you back for more if you let it. And it’s fun. See you at the bins soon!
A code last week reminded me that the biggest problem with classroom ACLS is that it is too clean, too managed, too un-chaotic. Here’s a couple of recommendations to the AHA for inclusion in the next set of guidelines for ACLS curricula.
1. More people, smaller rooms. Codes almost never happen in big rooms, so you end up with 20-30 people cramming into a 10×10 (or smaller). I swear besides the code team, everyone else tends to show up. Housekeeping, dietary, looky-loo nursing staff with nothing better to do, extra docs not involved in the case, maybe a couple of pharmacists and an administrator. To best simulate that feeling of claustrophobia and having to work under such conditions, the schools hosting the classes should hire extras to crowd around you so there is barely enough room to work.
2. Auditory competition. It’s usually a cacophony of noise as people are barking orders, shouting back values, yelling at each other and general noise in a code. ACLS mock codes are just too quiet, like a quaint afternoon tea in the country. They’re full of thoughtful contemplation, “Hmmm…we gave Epi, CPR is in progress, let’s see what the next step should be.” Where usually it is, “What!!! Did you give EPi yet?!!!” and “GET ON THE CHEST!!!!” To solve this, using the extras mentioned above, have them loudly carry-on conversations to provide a sort of white noise effect and teach students to think with 10 different voices giving you information all at once.
3. Smell-o-vision. Think it through.
4. Realistic dummies that either poop, pee or vomit during the code. Ever done CPR while trying to keep your scrubs out of vomit? Yeah, it’s difficult, the hands slip off of their position as the gloves slide over the vomit on the chest so it’s kind of like hitting a moving target. Also, the training should incorporate identification of emesis into the H’s & T’s differential diagnosis. Maybe call it T-H-Es? We’re trying to look for a causative reason, ID’ing dinner might be a good start, it’s usually easily viewed. One of the extras could smear chocolate pudding on the dummy with each rhythm check to add that extra layer of realism. To make it better, the manufactures of the dummies could add an optional module that uses the force of the compressions and triggered by breaths to spew liquid material out of the dummy’s mouth.
5. Re-organize the algorithms by using a drunken dart toss for each step, say every 2 minutes. Many times the actions are just so random it is like that. This way by using the toss method, random changes to the procedure would be accounted for and awaited thus allowing practioners to think ahead. Besides, wouldn’t playing darts in ACLS be awesome?
6. Teach clean-up as part of post-recusitation care. We’ve all seen rooms after a code. Wrappers everywhere, boxes from meds strewn about, random pieces of detrisius tossed to the side of the bed, pieces for the intubation tray lodged in the computer keyboard, sharps hiding under piles of plastic and the puddles of body fluid. What should be taught is that everyone goes on break, leaving one person to clean up the mess. That job should be assigned with as much if not more importance than the compressors to ensure the rest of the team gets to take a break post-code.
If the AHA would consider incorporating these elements into ACLS training, it would make the providers so much more capable in handling the realities of the true in-hospital codes. Just sayin’.
editors note: your results may vary, data is compiled from triple-blinded, beer-goggled, non-placebo, peer un-reviewed observation of events on medical/telemetry/geri-psych nursing floors over a 5 year period of time.
You’re talking to the patient, carrying on a normal conversation whilst finishing some mundane task. Abruptly in the middle of a sentence they stop talking to you. You turn in time to see their eyes roll back in their head and them slump lifeless back into the bed. What goes through your mind?
First, denial: “Maybe they’re just messing with me.”
Sternal rub and nothing.
Second, more denial: “Oh Hell no, they better not be playing with me now. Wake the Hell up!”
Third, even more denial: “That was a twitch…ahhhh shiiiiit.”
Slam the head of the bed down, take one more attempt at noxious stimuli. Nothing, nada, zip.
Finally, acceptance: “Someone call a Code!!!!!”
All in less than 10 seconds, probably only 5. The longest 10 seconds of the night.
It was night three, about 3am. I had just gone down to the cafeteria to get something fried and salty to satisfy the ravenous beast in my gut. I had about 5 of the fries while still warm as I walked into near pandemonium. It was like someone turned the crazy on the minute I left the floor.
Compared to the previous two nights, this one hadn’t been too bad. While earlier in the week it had been “grab your ankles and hold on!” tonight was a little better controlled chaos. Instead of a rapid response we calmly sent the patient with a pH of 7.19 and a pCO2 of 95 to ICU for BiPAP. Instead of getting hit with a CVA admit with no orders at shift change, the only patient we admitted came with orders and hours after shift change. It was better. Kind of.
While technically we weren’t short, we were. We had two floats filling in for the one we were short and the one we floated away to step-down, but strong they were not. They had the easiest patients on the floor, but were barely keeping head above water. In essence we were short as they couldn’t help the rest of us. And the scheduled aide? Yeah, stuck in close observation with the paranoid, impulsive, delirious ICU transfer out.
I don’t remember a whole lot after 3am, it’s just a blur as we ran putting out one fire after another. Your previously calm patient is now fucking nuts? Hey isn’t that your patient trying to escape out the fire door? Hey, my patient sounds like a stridorous 3 year old and has that “oh shit” look in her eyes as she uses every muscle in her body to breathe. Bed alarms to my left, call lights to my right and I’m stuck in the middle with you all.
Our only saving grace was the 3 of us left from our core staff formed a tight team, picking up where each left off, answering call lights and bed alarms without the petty stuff that gets in the way. What, you need meds on 97? Got it. Can you tuck 93 back into bed? No problem. Tight teamwork saved the night and got us through until 0705.
No falls, no restraints and chaos reigned in by the time day shift rolled in the door. It’s how we do it. It’s how we did it.
“Uh, hey Wanderer? You said the super-pube would just easily come out after we deflated the balloon, right?” the nurse asked me from across the hall.
“Yeah, might have to tug a little, but should just be able to remove it and swap in the new one.” I said.
“It seems like it’s stuck…can you come take a look?” he said.
Gown up, glove up (isolation rooms are the best!) and head in. The catheter is in the stoma the nurse looking at me with question marks above his head. “You have all the saline out of the balloon?”
“Yeah, can’t pull any more back.” he confirms.
I reach down and grab it, give it a good tug. Nothing. Twist it a little around. Still no dice. Twist and tug. It’s not going anywhere. Short of putting my foot on the patient’s chest and pulling, which probably is a bad idea, we’re not getting it out without expert (read: someone with an MD to take responsibilty) help. I say as such tot he nurse and suggest he call the intern on duty.
The intern calls back and the nurse explains the situation. She proceeds to ask, “Well, did you deflate the balloon?”
It’s a good thing it was him and not me. He was cordial and didn’t roll his eyes too much. Me, at that point it would have been, “Really? Do you think I’m that stupid to not deflate the balloon? Really? I’m not some novice who’s never done this. For f*cks sake, give me at least a little credit here!” That’s why he called, not me.
Be careful of who you ask stupid questions of…