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FranEMTnurse, LPN, EMT-I Pro 40,922 Views

Joined Jun 7, '02. Posts: 14,081 (24% Liked) Likes: 7,494

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  • 10:50 am

    Even though it is apparently "rare," I still had no idea it happened as often as it does. Thanks for the informative article.

  • Feb 5

    Pinkberry77, thank you for your kind words. I wish you peace and courage in your challenging situation.

  • Feb 2

    After a 20+ year career as a professional photographer, I started my pre-reqs for my ASN at the age of 40. I earned my RN license 4 days after my 43rd birthday. I'm now 47 and I just earned a BS degree in Health Informatics. I'm the first person in my family to ever earn a bachelors degree and I'm super proud of my accomplishments. Couldn't have imagined that I'd be where I am today when I was 20 something. Never think you are too old. Never believe you are incapable of achieving success. Never give up on your dreams. And never ever let anyone tell you you can't do it!

  • Jan 29

    I thought this was our break! Even out here we have to deal with impatiens.

  • Jan 28

    For most people, the holiday season is a special time of year, a time for shopping and decorating, attending parties, traveling to visit family, and doing all things celebratory. But for nurses, and for many medical professionals of all other specialties, the holidays are much like any other time of the year: unfortunately patients don’t magically get well just because it’s New Year’s Eve; emergencies don’t halt to a stop for Christmas. Working in healthcare is a 24/7 commitment to your patients, and only the most dedicated of employees can do it.

    So for all of the nurses who’ll find yourselves working while others play this holiday season, here are six tips to help make your own holidays a little brighter, a little less stressful, and hopefully much more fun.

    Plan your holiday schedule well in advance:
    If you know you’ll have to work specific days of the year, notify your family as soon as possible and make plans that will work around your schedule. For instance, if you work Christmas day, try planning your celebration for Christmas Eve. And remember, not everyone celebrates the same holidays. Communicate with coworkers early on and you might be able to find someone who’ll trade shifts with you.

    Bring the holidays to work:
    Just because you can’t be home for the holidays doesn’t mean you have to forget them altogether. Get permission to decorate your work area, and team up with your coworkers to literally “deck the halls” of your hospital, doctor’s office or other medical facility. Something as simple as some twinkle lights, an electric menorah (avoid fire hazards), a couple wreaths, or maybe even a little stocking for each employee, can go a long way. Have each person bring in just one decoration they would’ve used at home, and see what kind of holiday cheer you can create from it all.

    Hold an employee potluck:
    The holidays aren’t complete without food. And the best part about this food gathering is that it doesn’t have to take up much of the free time you do have outside of work. Hold your potluck in the break area all day long, so everyone can enjoy it at their convenience during breaks. Even though everyone may not be able to share in this together at the same time, it’s a wonderful way to come together as a community, what some might even call their “work family”.

    Be mindful and considerate of patients:
    Remember that you’re not the only one away from home for the holidays. But while you do eventually get to leave work and return to your family and friends, many patients are stuck in a hospital bed the entire season, some without any loved ones to visit them at all. You don’t need to go so far as to buy every patient a gift, but even small attempts to share the holidays with your patients --such as sharing your favorite holiday memories-- can lift both yours and their spirits.

    Know your limits:
    Work aside, the holidays can be stressful enough. Don’t push yourself to make everything perfect. Ask your family members if they can help prepare Christmas dinner. Simplify your shopping by doing it all online. Remind yourself that your friends will understand if you can’t make it to every Christmas party. You may not be able to prepare extravagant festivities, but you won’t be burned out either.

    Be proud of yourself:
    You care for others when no one else does. You work incredibly hard while most people relax at home. You dedicate your time to one of the most honorable professions of serving people in need. At the end of the day, never forget to take pride in your work as a nurse.

  • Jan 28

    We should all bow out,...on the same day. That MIGHT get someone's attention. No bleeding heart, what about the patients, malarkey. If "They who are not us" really cared about the patients, things would not be a bad as they are currently.

    Someone pick a National Bow Out Day,.....heck, I'll even volunteer to work that day and deal with the mayhem,...until my 16 hour work limit expires! That will give plenty of time for administration to become competent ICU nurses!

  • Jan 28

    When I helped admit Little Man on Friday, I had no idea that five days later I would be sitting by his bed praying he would hold on until his baptism that afternoon. Prenatal tests had indicated some possible genetic abnormalities and this was quickly obvious upon Little Man’s admission to the NICU. He had hydrocephalus, a small and asymmetrical chin, low-set ears, a webbed neck, clenched fists with overlapping fingers, and was unable to fully extend his arms. He was also having some respiratory distress so we quickly got him stabilized on NIPPV (CPAP with a respiratory rate) through a nasal cannula. A head ultrasound was performed that showed enlarged ventricles, which correlated with his large head size, but more tests would need to be performed before we truly knew the extent of his condition. I spent the rest of the weekend caring for Little Man and getting to know his parents, who were both in their early 40s. This was their first baby and they were so excited.

    When I came back to work on Tuesday, I was shocked to hear that Little Man’s parents had decided to withdraw support. I learned that Little Man’s MRI the previous day had shown large ventricles without a surgical option and very little healthy white matter. He was also continuing to have difficulty breathing due to his underdeveloped lungs and enlarged heart, and he was close to needing intubation. Because of all of this, his parents decided that they would remove his respiratory support the next day. Since I had gotten to know him and his parents all weekend, I requested to care for him that day, even though I was scared. This was going to be my first experience with a patient death and I wasn’t sure if I was ready for it, but it felt like something I had to do.

    The next day, Wednesday, represents one of those “defining moments” of my nursing career, even though I didn’t perform any crazy procedures, run a code, or save a life—I didn’t even give any medications! What I did do that day, though, was arts and crafts with a family who was about to lose their baby. We made prints of his clenched hands and his feet, I took pictures of him with his family, and I helped his parents get him dressed in clothes for the first time. My only real “job” that day, was to help him make it to his baptism that afternoon. When I had talked to the neonatologist that morning, she had said it would likely take Little Man hours or even more than a day to pass away since he wasn’t intubated at that point and was breathing mostly on his own (with support of the NIPPV). However, as the day progressed, I knew that it wouldn’t take him that long to die once we removed the respiratory support. He started having more and more episodes of bradycardia and oxygen desaturation as the day went on, but he would recover on his own each time. I kept slowly turning up his FiO2, hoping it would help until it was time for the baptism. His parents just wanted that one little thing—to have him baptized by their pastor—and I was determined to give them that.

    I stood in the back of the room during the baptism, my eyes trained on his monitor. I kept the monitor paused using a remote so the alarms would not disturb the baptism, and I cranked up his FiO2, just hoping to get him through it. At one point during the baptism, his heart rate dropped severely and I had to give him a couple manual breaths on the ventilator that was providing the NIPPV. One of Little Man’s aunts, who was also a nurse, caught my eye, and it was obvious that we both knew he wasn’t going to last much longer. After the ceremony was complete, there were a couple family members who still had not held Little Man, so one by one, we got them settled into the chair with him. I stood out in the hallway carefully watching his monitor while Little Man’s family held him, entering the room only to transfer Little Man into the next family member’s arms. Less than an hour after the baptism, I was leaning against the wall across from Little Man’s room while the last family member was holding him. All of a sudden, his heart rate plummeted. His dad met me at the doorway to the room, and it was obvious that he knew—it was time. I quickly picked Little Man up and his mom sat down in the chair. I placed him in her arms, turned off the respiratory support, and carefully removed the nasal cannula from his face. Little Man passed away only minutes later. I knew at that moment that he gave his parents the best gift he could have. He didn’t make them have to decide when to remove support; he decided he was ready all on his own. This family didn’t want their little boy to suffer, and I think he didn’t want them to suffer either.

    Little Man’s parents adopted a baby girl a few months later, and I know that they wouldn’t have been able to do this if they had still been trying to care for Little Man. My coworkers kept telling me that I would never forget my first patient death, and they’re right—but not just because he was my first. I will never forget Little Man because his death was something that I never though death could be—beautiful.

  • Jan 28

    It was Christmas Eve and I was in the ER working a 11am-11.30pm shift. I eyeballed her across the ER. She walked in with her son, an old frail lady. I looked at her pallor and shaky steps and knew in my gut that she was deathly ill. "She's not going to make it out of here alive," an unbidden thought sprang to my mind as I walked towards her.

    Cindy was the charge nurse and as she looked to see who was on next to take a patient, I reached her. "I'll take her Cindy," I said smiling easily at mother and son and taking the paper chart from Cindy.

    "Hi, I'm Annie. I will be your nurse today," I said as I deftly got her on a stretcher and closed the curtains of cubicle #4. I helped her change into a hospital gown, hooked up to the cardiac monitor and got my first set of vitals. Her name was Mary. She had been feeling more tired, fatigued and had lost her appetite for over a week. She was a little short of breath. Her vitals were normal. Her BP was border-line. I listened to her lungs and abdomen while my mind raced. I suspected that she was septic and so drew 2 sets of blood culture along with other labs and got a urine sample that was a tad cloudy. Probably a UTI that turned into sepsis, I thought. By the time the doctor came in to see her 15 minutes later, and EKG and CXR was done and I had normal saline running. The doctor agreed that she could be septic and I monitored her vitals carefully.

    The lab called back half an hour later with her blood count. Her WBC was 37. Bingo! I thought. Right on the money! I had antibiotics running and we kept pushing fluids. Her pressure began to drop and she started becoming tachycardic. I knew that she would crash pretty soon and wanted to make sure I was prepared. So I gently broached the subject with her son James who had no clue how sick his mother was or what her wishes were in case of an emergency.

    I talked to Mary in her son's presence and asked her. She looked at me, with wise knowing eyes and told me, "If you can save me, go ahead and do what you need to do, but at any point if you see it not going to help me, then let me go. I do not want to be hooked up to machine and it is futile." I told her, we would follow her wishes.

    I took James aside and talked to him. I asked him if he had any other family. He said he was the sole caretaker of this 87-year-old mother. His dad had died many years ago. He had a sister, who he had not talked to or seen for 20 years. She lived in the same city but they had a fight and stopped talking. I told him gently that it would be a good idea to call her as his mom was very sick. It would only be a matter of time before her systems collapsed due to the overwhelming infection in her blood. He was bewildered and said, "But she walked in! She can't be that sick". I told him that UTI and sepsis signs in the elderly were very subtle and that she might take a rapid turn for the worse very suddenly. I encouraged him to call his sister Ella.

    "After all, wouldn't you want to know if your mom was very sick and you were not with her?" I asked. He readily agreed to that and dialed her number (I got it from the patient) as I held my breath. They talked and Ella asked to speak to me. She told me that she was an RN and so I was able to give her an update on her mom’s clinical status. She had just picked up her husband from another hospital after discharge and promised to be there in half an hour. "Try and keep her alive for me, Annie" she begged. I stayed by Mary's bedside but she was rapidly going downhill. I looked at her and marveled at how her dying was bringing her two children together one last time. I now had her on multi drips. She crashed. We intubated her.

    Five minutes later her daughter rushed through the ED doors. I took her and her brother to our tiny family room where they talked for the first time in 20 years and hugged each other. Tears and laughter rang as they reconnected. Later Ella came to me and told me that her sick husband was sitting in the car and she had to take him home. She gave me her number and left. James came to me and told me that he could not watch his mother die. By now she was made a DNR after they talked to the doctor. He gave me his number and left.

    Another nurse relieved me for break but I stayed at the nurse’s station drinking my coffee and writing my notes playing catch up. A few minutes later I heard a voice in my ear, "It is time”. Probably my guardian angel Providence, I thought to myself. I quietly got up and went to her cubicle. I sat down near her and held her hand. I spoke to her softly, "Mary, you did it. You got them back together one last time. Now it is up to them. Go in peace." As I recited the Lord’s Prayer, she flat lined and was gone peacefully. I sat at the nurse’s station and made the calls to her children.

    Mary had gone leaving her final gift behind; the gift of peace to her two children. I walked out of the ER at 12 midnight on Christmas day marveling at a mother’s final act of love where she used her dying to bring her children together. Merry Christmas and God bless us all!

  • Jan 28

    I had a wonderful resident, who allegedly has multiple personalities, tell me the other night that she wished she hadn't married me.

  • Jan 21

    RSV. Those three little letters are enough to strike terror in the hearts of PICU nurses everywhere. It’s like a bad penny, turning up without fail every autumn; by mid-winter, virtually every PICU in the northern hemisphere has admitted at least one case. Some years are much worse than others and, at least in my part of the world, 2017 is shaping up to be one humdinger. What’s the big deal with this bug, anyway?

    Respiratory syncytial virus is the leading cause of lower respiratory tract infection in infants and small children in the world. Most children will have had at least one bout of it before their second birthday. For children older than 4 and for adults, it’s little more than a nasty cold, but for those people with tiny airways, it may cause severe bronchiolitis and pneumonia.

    A syncytium is, at its most basic, a multi-nucleated giant cell, often resulting from the fusion of several uni-nucleated cells. This virus, in creating syncytiae, essentially becomes self-replicating by transferring its fusion proteins to the surface of the host cell, which then allows the host cell to fuse with other cells around it. This single-stranded negative-sense RNA virus is medium-sized and has a lipoprotein coat; it was first isolated in chimpanzees in 1956, the same year it appeared in a human infant for the first time. In the last decade, reverse transcription polymerase chain reactive (RT-PCR) assays have transformed the diagnosis of RSV and allows for rapid isolation of the patient and appropriate treatment.

    RSV has an incubation period of 2-8 days, but typically takes only 4-6 days to present. It spreads easily by direct contact, remaining viable for 30 minutes or more on hands and up to 5 hours on hard surfaces. Active infection typically lasts 2-8 days, but effects may last up to 3 weeks. Infants present with cough, wheeze, tachypnea, retractions, poor feeding and perhaps cyanosis; fever is low-grade when present by very young infants may be hypothermic and experience intermittent apneas. Sepsis from concomitant bacterial pneumonia can be life-threatening. Based on the American Association of Pediatricians’ Bronchiolitis Algorithm sicker infants will be admitted. Those requiring more than a little supplemental oxygen and fluid will be admitted to the PICU. Children who were born prematurely, those with chronic pulmonary disease or cardiac compromise and those with immune system dysfunction are at higher risk for severe disease.

    On physical exam, the PICU-admitted child appears ill, with all the usual manifestations of increased work of breathing. They are often dehydrated and require aggressive fluid resuscitation. Chest auscultation reveals coarse crackles and wheezes throughout, with a gurgly, bubbly sounding cough. Secretions tend to be moderately thick, frothy and clear. Moderate-to-severe respiratory distress is accompanied by tracheal tug, head-bobbing, nasal flaring, intercostal, subcostal and substernal retractions and cyanosis. Inflammation and secretions reduce the luminal diameter of the bronchioles and cause atelectasis throughout the chest. If high-flow nasal oxygen is insufficient to maintain pulse oximetry at least 90%, the child will require intubation and mechanical ventilation. These are the infants you do not want to turn your back on… they tend to wake up with a bang, stimulate their vagus nerve with both coughing and ETT movement, desaturate and drop their heart rates to <60 in the time it takes to turn back around. Rapid deployment of generous hand-ventilation with 100% oxygen is literally life-saving for these peanuts. Actual treatment is usually supportive; supplemental oxygen +/- intubation, fluid, nutrition, antibiotics if bacterial infection is present and bronchodilators for some patients who have shown a response to them are the mainstay. Suctioning of intubated children should be accomplished in the most cautious and judicious manner, again to avoid that hair-raising vagal spiral. Most hospitalized children recover within a week or so and are home again in less than two.

    For those children falling in the premature/pulmonary/cardiac/immunosuppressed category, immune globulin prophylaxis has shown to prevent infection or reduce the severity of illness. Palivizumab (RespiGam or Synagis) given IM once monthly for the typical duration of RSV “season” is prescribed for these children:

    • Those under 24 months with hemodynamically-significant congenital heart disease or have chronic lung disease and are off oxygen and/or medications for less than 6 months at the start of RSV season
    • Infants born at <28 weeks gestation who are chronologically under 1 year at the start of RSV season, with prophylaxis to continue to the end of the season regardless of when the child turns 1
    • Infants born at 29-32 weeks gestation who are less than 6 months old at the beginning of the season, again with prophylaxis continuing to the end of the season and not when the child is 6 months old
    • Infants born at 32-35 weeks who are less than 3 months old at the beginning of the season and who either attend day care or have at least one sibling or other child under the age of 5 living in the same home who does

    These prescribed guidelines exclude older children who are immunosuppressed following organ transplantation or treatment of malignancy. This omission may have dire consequences, particularly in a child who becomes ill with more than one virus concurrently. While overall mortality for RSV in children is only about 1%, these children are at high risk of such severe disease as to need extracorporeal life support; they are the sickest of the sick and at dramatically increased risk for death, regardless of age.

    Long-term complications of RSV bronchiolitis in infants aren't common. Some children will go on to develop reactive airway disease but evidence of its association with a past RSV infection is weak. The combination of RSV and respiratory adenovirus has a higher rate of complications which can include bronchiolitis obliterans. Most children recover completely.

    RSV is SO much more than just a cold. Treat it with the respect it demands!

  • Jan 21

    I myself have worked as an ER nurse in 3 different facilities and I have to say to you that we do not like sending patients up on top of each other or at change of shift. I have had the floor say to me, " I can not take that patient right now". The sad truth is when a sick patient or one whom thinks they are sick (patients with no PCP so let's get it checked at the ER) comes in through those doors we can not at to them hold on we can not take you right now; we must triage them and place them with a priority then go on to the next one that walks through those doors. I have said all along that we as ER nurse's should work a shift in each unit as well as each nurse from another unit work in the ER. There is seldom times in the ER that we have nothing to do. Hope this clears some things up and believe me we do feel bad when we send the unit multiple patients or very sick ones. We as nurses all have to remember we all have a patient load. Imagine have a code in one room while getting a chest pain patient in another along with someone SOB due to severe CHF or asthma. We as nurse's will continue doing our best for those they put their lives in our hands. God Bless.

  • Jan 21

    Quote from Here.I.Stand
    My question is who are these admitting docs who are sending unstable pts to the floor vs ICU?
    Amen. Our hospital requires ALL septic patients go to either PCCU or CCU depending on how septic. Our problem has been our hospital closing one med surg floor to enhance productivity (make them more money)! All it has done is caused the other 3 floors to burst at the seams. They only open the other floor when there is finally no where to put anyone. Then PCCU and CCU start flushing out people to floor status when they aren't really ready to be floor status. End result is half of them get a MET call and transfer back down. It's incredibly frustrating.

  • Jan 19

    So I wanted to run something by everyone. I realize at my hospital, the ER try to push their patients out of their unit and onto the floors. I work on a med surg tele floor. Last night I walked into work and right off the bat had an admission. Well this admission was very unstable and was going into septic shock and my first hour was stuck attending the needs of the patient. This meant I was neglecting all of my other 8 patients. Were they alive? I couldnt even tell you. So a few hours later I transferred the patient to ICU. So yes this patient was my admission but the ER is so quick to rush patients onto the floors that they end up sending unstable patients to the floors and then cause chaos to us because then we need to do the documentation for the assessment and then all the transfer work for a patient we only saw for a few hours. Idk if this is more of a management issue on getting patients up to the floor quickly but it is very unsafe and it is a reoccuring theme at our facility. I understand patients statuses change and stuff happens but it feels like it is getting out of hand. My one co worker walked into work when I did and right off the bat had a patient that passed away on shift change (thats just bad luck I guess). But I really just wanted to know what is the real reason behind this? Last night was too much for me and my stress and anxiety level is thru the roof when I need to go to work. I left work at 10 this morning and am going back at 7 for another 13 hours so I dont know how I am going to manage this night. Just needed to vent! Thanks for listening!

  • Jan 17

    "I am going to pick the flower that best represents my level of stress and anxiety from working here and give it to human resources!"

  • Jan 16

    You know it's a bad shift when even the flowers are scowling at you!