Code in Dialysis

Midwest4me · Oct 8, 2004

:uhoh21: It is beyond me how anyone works dialysis. I knew absolutely nothing about it and went and interviewed at a dialysis clinic a week ago.

(It's located next to a fire station ~ convenient?)

Anyway, I shadowed one of the nurses for over an hour.

I came out of there vowing I would never work dialysis.

I'm sorry, no disrespect intended; but hooking somebody up to a machine is not my idea of nursing.
Yes, they deserve the care and it needs to be done. I'm just not going to be the one to do it.
I would go insane working dialysis.

The Mgr. told me it was very stressful ~ I believe her.

Dialysis nurses, kudos to you.....

First of all--I like the fonts you used--my eyesight is getting worse the older I get!:) So it was nice to see the big lettering!

Second --good for you that you were able to "shadow" a nurse for an hour! I didn't get that luxury--but if I had, I may not have stayed with it for as long as I did--4.5 yrs one place and 5 mos. another place...--it is INDEED STRESSFUL--most nsg jobs are--but very rewarding(specially when your pt gets that needed transplant and you know you helped keep him/her alive for a time to receive that gift)--you see the same pts. all the time for years so are able to establish close relationships--but you really run your tail off(not as much as you do in a nsg home but almost). I wouldn't have minded making the $80-90K/yr but then I'm not an RN; still I was very thankful for the experience I obtained in that field--just adds to a nicer looking resume and makes me more "well-rounded"!:)

nosonew, BSN, RN · Oct 9, 2004

I have been a dialysis nurse since 98, Charge Nurse in my unit since 2000...so...every facility/company has different policies. First and foremost, you need to understand that what you experienced is not normal where I work, nor for the company I work for (that I have ever heard). I am not familiar with that companies policies, but am sure that it was not the status quo. Our facility is a small unit. Our doctors come 1-2 times per MONTH! We do NOT have a crash cart, we have an ambu-bag, suction, and an emergency med container for reactions to renalin or antibiotics. Our emergency med box has Epi, solu-medrol, and benadryl. that is it.

Sorry about that patient...I really don't know what to say...YOU could not have done anything else...please don't blame yourself...NOT YOUR FAULT.

bobnurse · Jan 3, 2005

Most dialysis clinics in my area perform BLS only........No ACLS, No Defib, No tube.....

You would be amazed at the ACLS requirement in dialysis clinics.......Wait, in most there is no requirment....But the delay in BLS....Seems like a liabililty to me...

Nurseboy1 · Jan 4, 2005

In our inpatient dialysis unit, the code team is responsible for codes.

In the outpatient unit, the charge nurses are ACLS and run the code until EMS arrives. The unit is less than 1 mile from the hospital.

So very sorry for the horrible situation that you were put into.

Pamilina · Jan 4, 2005

I am so sorry that you had an experience such as this. Please don't think that dialysis is like that everywhere. Working in Dialysis in the hospital is so much more different, for obvious reasons. You get one to one patient care, and you work with so many highly experienced, highly educated, and trained professionals. In a clinic setting, there are more patients per nurse, with techs running the majority of the machines. It's a very political environment, as well as chaotic. A lot of egos running around! Doesn't mean that they aren't good. Just that it causes more grief in the workers lives.

With your experience as an ICU nurse, you should find a hospital that will offer the training in the Acute Dialysis department. It's very rewarding. Sure, there is stress in all jobs, but you really get to know your job in Acute Dialysis, and get to know the patients one on one. You even get to go to the ICU to run a patient on Dialysis as those patients don't come out of those rooms to the department. You get to talk with the ICU nurses and work with them a little with their patient. You have plenty of time to read, and talk with your patient or patient's family, and best of all, you get a great pay and great environment.

The clinic setting has so many limitations, and again, knowing what their policy and procedures are is essential in knowing what to do first hand in a Code. If they only provide BLS, till 911 arrives, then that is what they do. Unless, there is an M.D. in the house, that is all they really can do. With a patient that is on Dialysis, there are multisystem failures that can result from long-term dialysis, diabetes, cardiac problems, can play an integral part in the breakdown of systems. It isn't too unfamiliar to realize that this is a highly dynamic area of nursing. Unfortunately, you experienced a lot of drama there. This may have been a preventable scene. Maybe it wasn't meant for you to be there. So, my words of advice are either go back into ICU nursing, or find a hospital that will put you through a superior training program, as the demand for Acute Dialysis nurses is great. It will be a growing field, as the rise in diabetic's, and high blood pressure problems continue to be a problem for the majority.

All My Best!

babs_rn · Jan 14, 2005

I agree with Pamelina. I have a long, LONG background in ER and ICU myself - but remember....ACLS protocol is a protocol that applies in the hospital and pre-hospital environments where I guarantee you there is something signed by the hospital medical director that allows the ACLS certified personnel to implement it. To do so outside of that is practicing medicine without a license and you can't do that. I agree that as you relate it, it was mishandled by the staff above you, BUT as an orientee, you legally can NOT do ANYTHING you haven't been checked off on no matter what your background is. O2 via BMV and CPR would be standard, as is putting the patient back in Trendelenberg - and if the monitor is present then its condition should be addressed (and that has to be documented or the state - AND Gambro, I"m sure - would have a field day with them. But rest assured that any time a patient codes in-house there is a reporting system the center is legally bound to follow. That chart WILL come up under review.) Most chronic dialysis nurses who have been in it for a long time have not had too much recent experience in code situations and since you were only two weeks into the job, they haven't had time to trust your skills and your care - and there are other implementations that may be necessary from a dialysis/fluid/electrolyte replacement standpoint that a two-week dialysis nurse wouldn't have been exposed to yet, no matter how much critical care experience that nurse may have. Hemodialysis is a totally different world in which a critical care background is immensely valuable, but that background alone isn't sufficient to understand the complexities in what is very complicated (much more so than just "hooking up to a machine") and is also the most regulated form of healthcare that exists in the nation. So while morally and ethically you are certainly to be commended for wanting to do the right thing, remember that legally you are limited in what you can do as an orientee, and in an outpatient chronic facility. It is not acute care. You just utilize BLS and the AED if available, and yes....the MD has to run the code or specifically order ACLS protocol if it is to be implemented. Some centers do go so far as to have EKG machines if needed and some require its nurses to be certified in reading them, but not all. Some have Lifepaks but most that I have seen stick to the AEDs (again, liability issues - the more capability you have in-house, the more liable you are). Hopefully the EMS system responds in a timely manner. That's what THEY are there for. For the record, this year Gambro Healthcare will cease to exist in the US, as Davita is buying them out - the deal is expected to close the first half of this year. I know Davita's P&P almost by heart, and I can tell you that Volume II has an entire section devoted to interventions in cases of complications and in cases of emergencies - and the P&P is supposed to be maintained on the treatment floor to be referred to regularly and prn.

To quickly answer the young lady who suggested that hooking a patient up to a machine isn't nursing, Sweetheart, I'm afraid you got very little exposure in that hour to what is really involved in the patient care, the complexities of it, the assessment of the access and the understanding of what's going on inside, finding and intervening early as complications develop with the access, preventing and intervening in times of complications, all the relentless hours spent on patient education and support, anemia management, osteodystrophy management, adequacy management, and the multitudes of safety checks (there are so many ways a dialysis patient can be killed as a result of just a little bit of neglect or a shortcut) as well as nursing the WHOLE person in that chair. I lament the fact that nursing has become so task-oriented and that the person receiving care is lost in the mix, that "healthcare" seems to have lost the concept of "care". Not with me, and not in my center (come Monday I will be a Center Director :) ). I care for the whole person who trusts me with his or her life....because in dialysis, we GIVE life. The person in that chair would die if not for what I do for him or her. And a relationship develops with each of them over time (I was even asked to speak at a patient's funeral once). There's nothing more fulfilling than that.

renerian, BSN, RN · Jan 15, 2005

Wow scarey and horrible for you. My aunt/Godmother gets dialysis and I hope someone doesn't have a policy like that where she goes........

renerian

imperial · Feb 21, 2005

This should be reported to the licensing agency. THE END>

Everyone's license would have been on the line. The nurse who directed you away would have been held responsible as well as you for allowing the patient not to receive CPR, when you were qualified to do so. Additionally, all RNs should be CPR certified. Unless the patient was a no code, CPR should have been done. Report this anonymously, if you do not want to give your name. Another patient could die and then what? This type of behavior and practice needs to be halted. Glad you have morals and ethics.

I am two weeks into a new Dialysis career. I come from a Critical care background and happen to be ACLS certified. There was a patient that coded at the center today. I was the first one to the patient no pulse and not breathing. I called for O2 and the crash cart which were both brought by a Rt. the Center Director Rn and the charge Rn came at that point. I started directing the code and was asked to leave. Long story short....... the crash cart was never unlocked no 02 to the patient no CPR started no blood sugar obtained. Needless to say I quit but, before I did I wanted to know why the patient wasnt put on a monitor Charge responded by saying ti was broke. I asked why we had a crash cart if nobody knew how to use it, the CD response was that was in case a Dr. was making rounds and wanted to run the code. WTF? Come to find out I was the only person in the building that was ACLS certified and I guess since I had no dialysis experience that would rather have let the lady die to save face. Anyone that has dialysis experience care to explain what the policy concerning a code in their center is? I left out of there distressed that they would not let me do anything for the patient when it was apparent these people didnt have a clue. Thanks!!!!!!!!!!!!

imperial · Feb 21, 2005

KUDOS to you, you sound like a great nurse and wish there were more like you. Are u with a large corporation or a privately owned small co.

imperial · Feb 21, 2005

Unfortunetly, I am guilt ridden. I feel like I should have knocked the CD down and insisted on the care I could have given. The patient was not a no code. I dont think the nurse at the clinic would have known one way or the other. This is a Gambro clinic BTW. I intend on finding out the policies because my mom dialysis at one of the clinics. Nurses like that scare the heck out of me, Hey if I dont know it I just say I dont. Thanks for listening everyone. I am still crying and I cant sleep.

Don't beat yourself up, you did what you could of done under the circumstances, but I would still report to the licensing agency. If it happens this time, it will happen again and again. ((hugs))

jnette, ASN, EMT-I · Feb 22, 2005

I agree with Pamelina. I have a long, LONG background in ER and ICU myself - but remember....ACLS protocol is a protocol that applies in the hospital and pre-hospital environments where I guarantee you there is something signed by the hospital medical director that allows the ACLS certified personnel to implement it. To do so outside of that is practicing medicine without a license and you can't do that. I agree that as you relate it, it was mishandled by the staff above you, BUT as an orientee, you legally can NOT do ANYTHING you haven't been checked off on no matter what your background is. O2 via BMV and CPR would be standard, as is putting the patient back in Trendelenberg - and if the monitor is present then its condition should be addressed (and that has to be documented or the state - AND Gambro, I"m sure - would have a field day with them. But rest assured that any time a patient codes in-house there is a reporting system the center is legally bound to follow. That chart WILL come up under review.) Most chronic dialysis nurses who have been in it for a long time have not had too much recent experience in code situations and since you were only two weeks into the job, they haven't had time to trust your skills and your care - and there are other implementations that may be necessary from a dialysis/fluid/electrolyte replacement standpoint that a two-week dialysis nurse wouldn't have been exposed to yet, no matter how much critical care experience that nurse may have. Hemodialysis is a totally different world in which a critical care background is immensely valuable, but that background alone isn't sufficient to understand the complexities in what is very complicated (much more so than just "hooking up to a machine") and is also the most regulated form of healthcare that exists in the nation. So while morally and ethically you are certainly to be commended for wanting to do the right thing, remember that legally you are limited in what you can do as an orientee, and in an outpatient chronic facility. It is not acute care. You just utilize BLS and the AED if available, and yes....the MD has to run the code or specifically order ACLS protocol if it is to be implemented. Some centers do go so far as to have EKG machines if needed and some require its nurses to be certified in reading them, but not all. Some have Lifepaks but most that I have seen stick to the AEDs (again, liability issues - the more capability you have in-house, the more liable you are). Hopefully the EMS system responds in a timely manner. That's what THEY are there for. For the record, this year Gambro Healthcare will cease to exist in the US, as Davita is buying them out - the deal is expected to close the first half of this year. I know Davita's P&P almost by heart, and I can tell you that Volume II has an entire section devoted to interventions in cases of complications and in cases of emergencies - and the P&P is supposed to be maintained on the treatment floor to be referred to regularly and prn.
To quickly answer the young lady who suggested that hooking a patient up to a machine isn't nursing, Sweetheart, I'm afraid you got very little exposure in that hour to what is really involved in the patient care, the complexities of it, the assessment of the access and the understanding of what's going on inside, finding and intervening early as complications develop with the access, preventing and intervening in times of complications, all the relentless hours spent on patient education and support, anemia management, osteodystrophy management, adequacy management, and the multitudes of safety checks (there are so many ways a dialysis patient can be killed as a result of just a little bit of neglect or a shortcut) as well as nursing the WHOLE person in that chair. I lament the fact that nursing has become so task-oriented and that the person receiving care is lost in the mix, that "healthcare" seems to have lost the concept of "care". Not with me, and not in my center (come Monday I will be a Center Director :) ). I care for the whole person who trusts me with his or her life....because in dialysis, we GIVE life. The person in that chair would die if not for what I do for him or her. And a relationship develops with each of them over time (I was even asked to speak at a patient's funeral once). There's nothing more fulfilling than that.

Well, intelligently, and beautifully written Babs... thank you ! :)

bobnurse · Feb 22, 2005

Excellent post babs