Turn the Other Cheek

  I've heard somewhere that it's more effective to just turn the other cheek, and I will tell you in nursing I have learned to do it not to say that I like it, but is it really more effective? 

  The other night we were getting killed and PACU sudden calls in a panic, no surprise they are bringing over another patient and it's mine, of course.They come over and I am trying to triage the situation when I hear my charge nurse talking to someone with a very loud voice outside my room, a very loud, angry voice. I step in and introduce myself as this patients nurse and proceed to get blasted about the lack of communication and how we have kept the very worried family out in the waiting room way too long. I bite my tongue and swallow the tart response that wants to jump up, I take a deep breath and then another and explain in my calmest voice that the unit is very busy, their family member just arrived 20 minutes ago, all of which I have spent at his bedside trying to stabilize his condition. I tell them if I had had someone who could have gone out to update them I would have and apologize but we are a bit busy tonight.

  What I wanted to say was that I wasn't sorry, I have been working hard to fix your loved one and if you think my time is better spent talking to you then at their bedside then they wouldn't be here! I wanted to tell them to look at the board, see all those spots filled up and not one empty? That means we have a ton of sick people here who are more important than you. 

  But I didn't, I turned the other cheek. 
  I settled their fears and sent them home knowing their family member was safe and cared for. As is often with these sorts of encounters I promptly forgot about it.

  A week later my charge nurse handed me a small white envelope while making her rounds someone had left it for me a few days ago. Curiously I opened it to find a small pastel card inside with an unfamiliar handwriting. The card was addressed to me, thanking me for my care of their loved one and my ability to make myself available to them in such a busy time. It also apologized for their "terrible" behavior and explained that not too long ago a family member was in the same situation and did not have such a good outcome, so if I could please understand they were very very emotional, and since they knew I worked long nights please have a coffee on us. Inside was a gift card to Starbucks. 

Suddenly I knew who this was from.

Is turning the other cheek more effective? I don't know, but in this instance I am very, very glad I did. 
  
  

Growing

 It's been a nearly a year since my hubby set up my garden.

 The growth that I have seen has been incredible,

 and  has made me see 

 how much my garden has mirrored my journey in nursing.

Things start out slow.

Small things are both exciting 

and 

intimidating.

Then things start to take shape.

You begin to see amazing things in places you never imagined.

Things begin to blossom.

You find beauty in the everyday

and 

appreciate what you took for granted before.

The smallest, mundane things 

become the most satisfying rewards.

Enjoy the journey,

find wonder in the small things,

and

reap all the rewards no matter how small.

Grow your garden.

Hello, Is It Me You Are Looking For?

  Yep, it's been a little while.  I can't say that I am sorry for being away from my computer for so long, there have unfortunately been a ton of things that have taken priority lately, but I am glad to be back.

   The New Year came and went for me almost un-noticed  in the midst of a couple crazy nights on the unit, short staffed and crazier then usual and it has been full steam ahead ever since then. It seems like there hasn't been a night I've had off that my phone hasn't rang with Staffing begging for some help. Some nights I've had the energy and the mental fortitude to do it, other nights I have literally ignored the phone all together and deleted the message without listening to it. 

  With the new year has come new challenges and goals, I am, according to my charge nurse,  no longer a newbie nurse and I have been pushed to step up to the plate and accept more challenging assignments and more responsibility on the unit. My director has also echoed the sentiment by pushing me to write for my Critical Care Certification. I am now staring at a dauntingly large pile of books that sit here next to my computer. Contained in these pages are all the knowledge that is somehow supposed to reside in the head of a CCRN and I am expected to somehow cram it all in there and NOT lose an ounce of it. 

  It is funny because I don't feel any wiser, stronger or smarter yet and I keep waiting for that magical moment when everything will click and I will know  that I have it "all down pat", then at the weirdest times I have a sudden moment where it feels like I am standing outside of my body watching myself. It's at these times that I watch my hands move smoothly through the task at hand and it hits me, I see just how far I have come in this past year. I have learned by watching the people around me that in nursing you can never know everything, a good nurse never has "everything down pat". The real skill is to learn how to learn and adapt.

  So there is a ton of "firsts" still to come and I look forward to everything that has yet to happen and is still to come. So onward and upward as they say.

IV Insertion Tips

  A couple of days ago a reader asked me for some tips on IV insertion, unfortunately I was in the middle of a three day stretch and I wasn't able to get a post up in time. It got me thinking though and I began going over all the things that I have learned in the last few months that have made putting in an IV much easier for me. 

  So here is what I could think of, I hope it helps.

Feel, don't look.  

  I know every instructor has said this and it makes about zero sense, but trust me, this is one time in nursing that your eyes can lie to you. It makes sense that every new nurse (and even some seasoned ones) will go for an easily visible vein, but often these veins are very close to the surface and will blow easily, deeper veins are often stronger, less fragile veins.  

  Palpate veins with your fingers tips and feel around for a springy feeling vein. It will feel vaguely like  pressing down on an under inflated balloon, it will "bounce" a little under your fingers. Avoid "mushy" or soft feeling veins, these can be more delicate and blow easier. Select the largest vein you can find, they are way harder to miss, you can use a nice large catheter and they are less likely to "go bad". No point in putting in an IV that only lasts a few hours. 

  Once you have a found a nice big, bouncy vein follow it up about an inch or two and make sure it feels pretty much the same all the way up. A hardened area can indicate a valve or sclerotic area that will not allow the catheter to advance. If you find one of these area's be patient and follow the vein further up or down until you find a nice stretch of clean vein.

Hold on!

  Now that you found that vein, anchor that sucker!  You went through all the time to find it now make sure it doesn't run away when you try to poke it. I hear a lot of people say that a patient has veins that roll, all veins do roll to a certain extent so hold em down!

 Everyone does it a little differently

For really roll-y veins try stabilizing

between two fingers.

Spread your fingers wide and hold the skin 

very taut.

OR

Anchor the base of the vein close to your puncture site.

Apply pressure and pull your thumb towards yourself

pulling the skin taut

  The key to anchoring a vein is to apply pressure,  so don't be shy about pushing down on your patient and to pull their skin nice and tight. Apologize and let them know the discomfort will only be for a few seconds, it's a way better option than having to poke them a second time. 

Don't go deep!

  It's tempting to puncture the vein at a 30 to 45 degree angle, especially if you have drawn blood a lot, then drop your angle and attempt to advance the catheter, don't do it!  Going in on a steeper angle than 15 or 20 degrees increases your chance of going straight through the vein, and I find that when I drop my angle after a flash I flub the insertion almost 50% of the time.

  An IV nurse I work with gave me these tips, go in at an angle that is only slightly steeper than parallel with the vein and then check for your flash. If you don't have one advance slightly at a slightly steeper angle.  As she put it veins aren't that deep and your aren't drilling for oil.

Don't be shy

  OK so you got a great flash, but as you advanced the catheter you lose it. Sound familiar? It happened to me over an over again until my friend the IV Nurse commented that I am "bashful" in threading the catheter.

  What she meant is that when I was advancing the catheter I would do so slowly because I was worried about losing my IV. Problem was that my caution was what was causing me to lose my IV sticks. She reminded me that advancing a catheter quickly would not cause any damage.

  What I learned to do it insert the IV and check for a flash, 

then wait and see how well the flash chamber is filling. 

When I see that the chamber is nearly full, 

 I am sure the IV is in the vein.

Now in one smooth quick motion I advance the catheter.

  I know it sounds way too simple but honestly it has worked like a charm every time. Oh yes and don't worry, if there is a valve or sclerotic area that you did not find prior to inserting the catheter won't advance, promise.

And remember....

If you don't get it the first, second or even third time

it's OK.

Don't beat yourself up about it, 

stop and think about what you learned from the experience.

Then let it go.

Remember,

 none of us were born with these skills.

We all have had to learn them

and

YOU WILL TOO!

Things I have Learned

  When priming a line for albumin it is inevitable that the dang stuff never wants to flow.

It just sits in the bottle refusing to come out

even though you have opened the vent 

and 

pierced the vent with a large bore needle.

I have learned a trick,

it's so simple you won't believe me.

When hanging albumin just let the bottle hang for several minutes.

Gather your tubing and such and just let your albumin sit there and chill.

Then spike your bottle in one quick motion and pop the vent.

If you do this I promise you will never have a problem priming a line with albumin again.

Paging Dr. Grumpy

 "Page the Doctor." 

  The three words that seems to strike fear into the heart of every new nurse. In nursing school I cannot tell you the number of time that when the teacher said;

  

  "You'll need to call the Doc if this happens."

  "But what if he yells at you?" someone in the class would pipe up and ask every time.

  Why is this the gut reaction of every new nurse? Are doctors really terrifying creatures that put on a human skin when they come out of the lounge but in reality are snarling beasts when there are no prying eyes to see? Or is it that every doctor has an inner ear condition that is painfully exacerbated by only the exact pitch of the cell phone or pager ringer that sends them into a fit of pain induced rage when ever a nurse calls?

  All kidding aside, as a new nurse I have found it daunting to call a doctor, especially in the middle of the night. I don't like talking to some disembodied voice, that I have no face to attach to. In the end I did have to get over this irrational fear of talking to doctors, what helped me through this phase was to have a formula when I called the Doc.

  Remember SBAR? Yes it felt like I was pulling that one from the depths of my brain, but I guess they taught it to us for a reason. A charge nurse suggested that every time I contacted the Dr I should write my report down in SBAR fashion so that it was organized and I had all my information in front of me. OK for those of you who have forgotten lets review.

  SBAR stands for SITUATION, BACKGROUND, ASSESSMENT and RECOMMENDATION. This format is often used in giving report to help the nurse give a full picture of the patients status in a short, concise manner to someone who would not be familiar with them. Let's face it, Dr's see hundreds of patients everyday, if you just call them about Mrs Smith it might be the eighth Mrs Smith they have seen, you need to give them enough to jog their memory about the patient so they can make the right call. SBAR report may be awkward in the beginning but with enough practice it will become second nature.Here's a little taste of how it often goes.

 "Dr. Grumpy, I'm calling about Mrs Smith. She is a 57 yr old female who came to us with sepsis, since 8pm her BP has been going down and now I notice she has inadequate urine output. (That is your situation) She has a history of CHF and hypertension. (This is the pt's background, don't give a life story just what is relevant) Right now her BP is 80/45 and she is tachycardic at 110, with only 50mL urine output in the last 2 hours. (Your assessment) Would you like me to give a bolus of normal saline and start a pressor of some sort?(Your recommendation)" 

  If you read that aloud you'll notice it took under 5 minutes and gives the Doc a nice picture of whats going on in your neck of the woods. Not only have you clearly stated the problem that you are calling about but you have given the Doc enough info to make an informed decision. Here are some other tips:

• Keep the patients chart open near by, the Doc may want to know the most recent labs. This way you are prepared, not fumbling around, they appreciate that.

• Take five minutes and write your SBAR down so you have everything you want to say in front of you. I have blanked a couple of times when the Doc got on the phone, it saved my butt!

• Don't take is personally if you do get a cranky Doc, they are people too and like us nurses can have bad days. Just be polite, get what you need and hang up, then vent to your fellow nurses, no point getting too upset over it we have more important stuff to attend to!

  When a patient starts to take a turn for the worse it can often be pretty scary especially for a newbie. The best advice I ever got was from my charge who reminded me that a patient rarely goes downhill so fast that you can't take a minute to organize yourself. Taking a second to clear your mind and focus on all the important things not only improves your patient care but will also make communicating with those Doctors even easier.
  

Being a Nurse Has Made Me Better At....

  I used to roll my eyes every time one of my instructors gave the class the "nursing isn't just a profession  it's a lifestyle" speech. Right, how on earth was learning about drip rates and lab values going to change my life? Amazingly they were right, here are a few ways being a nurse has changed my life.

Cooking

I used to be the worlds worst cook. Honestly, ask my husband, I have given him food poisoning on several occasions. My cookies always came out looking like tiny cakes and my cakes came out flat as a pancake. 

  So what changed? First, I finally have a handle on measurements, Remember all those seemingly pointless conversions they made us do in first semester, how many teaspoons are in a tablespoon, how many mL's are in an ounce? Now instead of trying to guesstimate how much something is, I actually do a real conversion. Guess what, that 1/4 teaspoon REALLY does make a difference. 

  Second, I learned to be patient. I was always poking at whatever was in the oven, flipping things constantly on the grill or popping the lid off the pot. Now I have learned things need time, just like you can't rush a patient into taking their meds or giving you that urine sample you needed an hour ago, you can't rush food into being done. 

  I also learned that timing and time management in cooking is pretty much the same as in nursing. When I begin my night I sit down and look at what meds I have to give and when, I look at my timed lab draws and plan out when I'm going to do things and cluster my care so that I am in the room disturbing that patient as little as possible. Cooking requires the same skill, what can be in the oven at the same time, when to start cooking what so that everything is ready at the same time. Now that I have mastered this you rarely see overcooked meat being served with under cooked sides anymore. My husband has never said anything, but I notice that he's asking for seconds now.

Babysitting

This one should go without saying or surprise, but it still caught me off guard. I have never really had a love for kids, as can be seen by my lack of them, but I was also never really good at entertaining them or controlling them. Perhaps this was due to a lack of interest. 

  Working an ED will teach you that the best way to keep a kids parent from bugging you is to keep their kids from bugging them. Because of this I always keep a small box in my locker full of crayons, cheap coloring books and stickers, and yes it's all bought by me with my own cash that's how much I value my sanity. Now when I head out to spend time with friend and kids I always toss one of the "sanity packs" into my purse, it's amazing how long  4 crayons and some stickers will keep a little one happy. My friends seem to think it's funny that the gal with no kids always is prepared for them.

  Oh yeah and I've learned kids aren't dumb, not even the little ones, so don't treat them like it. In the hospital they know exactly what is coming, so I never lie and tell them it won't hurt when it will and I never try the ambush tactics some nurses think actually works. When I'm around kids that I am not treating I have learned to apply that principle too, I talk to them, guess what a couple questions directed at the kiddos over lunch generally leads to less screaming for attention, go figure. If the screaming does occur I have learned that a well controlled tone of voice goes WAY further than yelling, just like with the patients, honestly kids and patients aren't all that different in the end , they just want to be treated like people and included. Weird huh?

    Complaining

  I've always had plenty to say and never held back in delight or in displeasure, but nursing has taught me there is an art to doing it right. In the past I have been know to just go off and heaven help anyone in my way, now I've learned to do it better.

  Meaning what? For starters I usually take a moment to step away from the problem, take a deep breath and compose myself, just like I do when I want  to tell a patient what an unreasonable jerk they are being but instead explain with a sweet smile on my face that the reason I can't give them any food is because they are going to have surgery in the AM and you can have food in your tummy when that happens in case you throw up, aspirate and die. I use that moment to order my thoughts in a logical manner so that I sound like a reasonable person not a raving lunatic, astonishingly it gets you way further.

  I also learned to take the mail to the right address. I no longer complain to the poor sod at the cash register for the long wait, he/she is probably just as ticked off about having no help, but you betcha I will take it up with the manager. Just like I hate fielding complaints over things I have no control over, I bet anyone else hates it too.

  So yes I will give my instructors their dues and say, yes they were right. There is something about being a nurse that changes you, it gets into your blood and you will never really be the same person you were before you started. 

  What has nursing taught you?

Overtime or Overworked?

  Sorry for the layoff folks but that whole "Real Nurse" thing got in the way of...well everything this week.  This week I worked SIX shifts straight, because I can't say no when the staffing office calls  looking for someone to come in extra. Don't get me wrong here, I'm happy I made a load of overtime this week, but I am exhausted, which leads me kinda to the point here. When does overtime just become overworked?


  Let's be honest, being fresh out of school I still have very vivid memories of what it is like to not know how you are going to make ends meet. So kinda like a stray cat that eats whatever you put in front of it, I will take any chance to pad my bank account. Whether it means floating to any floor in the hospital to avoid being called off due to low census, working holidays without a complaint, or picking up pretty much any overtime shift that is offered to me, regardless of how insane it is. I'm sure plenty of new nurses reading this know exactly what I mean and plenty of you nursing student who are set to hit the workplace soon are planning to do this too, the money is good and it's there for the taking if you are willing to do it, but should you?


  There are always pros and cons to everything you do, and now that I have done what I really thought was impossible I can sit back and go over in my head how smart or stupid this little exercise of my endurance and love of a fat paycheck really is. 


  Having done it once now I'm not sure I'll do it again and I am not sure how much I recommend it to any nurse. To be quite honest my whole body hurts and I think I have totally undone the work the massage therapist did on my back last Saturday. My sleep schedule is now seriously messed up having gotten used to sleeping in the AM and being awake in the PM , that it's going to be tough to revert back to being a "normal" person on my days off. 


  More concerning is the how my ability to handle stress went slowly down hill the further into the week I got. No matter how you slice it, working 12 hours a day is rough. Now when you are into your 48th hour in 4 days you may find that it has some toll on your emotional endurance. Yes, I was a little crabsy this week, and was that really fair to my patients? I'm not sure, I guess one could argue that with the way things were going, having a nurse was better than the outlook had been at the beginning of the night. At the same time I may have been a better nurse if I hadn't been on day 5 of 6. Also, my concentration was not great by day 5, when I began to notice I got super cautious with everything I did, double and triple checking meds to be certain that I wasn't making an error. Sure I get a gold start for being careful, but it really slowed down my productivity and was a little nerve wracking at times.


   On the flip side, there ARE upsides to picking up some overtime besides the big paycheck. I have made friends for life with he staffing folks for saving their butts and my co-workers all think I wear a halo for giving up a couple days off to help them out. My boss, our director, thanked me for being such a great team player and probably has a touch more respect for me now. For a new nurse it's really important for me to establish to the higher ups that I am a team player, I have a connection to my unit and show them that I am willing to work, I think I established all these goals this week.


  So, was it worth losing a week of my life? Yes. Would I recommend you do it? I can't speak to that in a yes or no way. Instead this is what I suggest, nursing is about total honesty. Be totally honest with yourself. Take some self inventory and ask yourself if you REALLY can handle that extra shift. Don't think about it in dollar terms, just be honest about your limits and if you have even an inkling of a doubt in your mind don't do it.  If you are worried about feeling guilty or caving to pressure, don't answer your phone and talk to your staffing person, let them leave a message, they always do. Then take a moment to take a personal inventory and decide for yourself if you can handle it, only you can figure that one out. Remember, another opportunity will always pop up down the road to pick up a shift, just because you don't feel like you handle one in the here and now doesn't mean you won't be able later, another day, another time.


  In the end I am glad I did it. I learned that I can handle way more than I thought I could, but I also learned a few things about my own personal limitations. I also learned that limitations are not a bad thing, or even written in stone, but just like road signs, they are something that you really need to pay attention to.

Things I Have Learned...

The last 20 minutes of a shift in the ER is like the last 2 minutes of an NBA game. 

It lasts forever and all kinds of crazy shit happens!