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Joined Jun 6, '07. Posts: 2,000 (46% Liked) Likes: 2,918

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  • May 19

    Hmmmm, let me think.... work as a nurse? I know, it's crazy. You should spend 2-3 years learning your craft. Then, you can probably answer your own question. Good luck.

  • May 17

    When I met Army private Jamie Salvedo he was being loaded onto our C17 cargo plane at Joint Base Andrews (near Washington D.C.). It had been nearly two weeks since he was injured and almost killed in Afghanistan. This was the last leg of his journey home. He gave me a smile and thumbs up as I introduced myself and did a quick assessment. He had three wound vacs, one each to the amputated stumps of his legs and right forearm. He also had a peripheral IV, epidural PCA, IV PCA, NS infusing through a pump, and a Foley catheter. I asked how he was doing and he struck me completely speechless when he said with a wink "my feet are kind of hot".

    Our day begins several hours before flight. Our five-person crew (2 nurses and 3 med techs) will brief on the mission and get the number and type of patients. Based on the patient load we create a positioning plan that is tailored for each flight. After briefing we load our sizeable pile of equipment (about 800 pounds of ACLS and nursing supplies) onto a truck and head to the hospital where the patients are being housed. There, we get patient report, pick up narcs, and head out to the plane to set up. We hustle to put up the stanchions that hold the litters, electrical systems, oxygen lines, and all of our own flight emergency gear. When the patients arrive, they are loaded, secured, and briefed.

    Jamie was on patrol with his unit in Afghanistan when he stepped on an IED (improvised explosive device). The explosion blew off both his lower legs and right hand, and peppered him with shrapnel. Jamie was treated in the field by US Army medics who put him in spinal immobilization, placed tourniquets, and started IVs. He was choppered to a field hospital at a US base for emergency surgery. He was then flown to Germany for more surgery and stabilization. After nine days there, he was heading home.

    Aeromedical Evacuation (Air Evac) is a large, complex system designed to bring American casualties back to the US and take them anywhere the US military operates. Run by the US Air Force, it transports service members from all branches of the military, their family members, US military contractors, and occasionally foreign nationals. These patients all require in-flight nursing care that is delivered by Air Force flight nurses, flight med techs, and Critical Care Air Transport (CCAT) teams. (A CCAT team has a physician, nurse, and respiratory therapist. They transport ICU patients on the ground and in the air.)

    Once our patients have been loaded and assessed for safety and pain levels, they are prepared for flight and all equipment is secured. We give them a briefing similar to that received by anyone who has taken a commercial airline flight. Jamie's PCA pumps are operating normally and his pain levels are acceptable. I know I will need to check his pulse ox especially once we reach altitude. Based on the patient report we received prior to the mission, we have affixed an electrical outlet and an oxygen regulator to the stanchion where Jamie is loaded.

    Flight nursing care has a number of considerations not found in most nursing environments. Air Evac utilizes cargo aircraft, which are not ideal for transporting people. They are noisy, hot on the ground, cold in the air, and are by no means considered a "clean" environment. They operate at high altitude, which can significantly reduce available oxygen. Privacy is difficult to provide and resources that are normally taken for granted like medical supplies, oxygen, electricity, and medications, are all in a limited supply. Additionally we have to always consider mission security, manage the patients' luggage, and assist passengers.

    Flight nursing training focuses on these "stresses of flight". They are; decreased oxygen, decreased barometric pressure, temperature changes, decreased humidity, noise, vibration, fatigue, and G-forces (AFI 41-307, 2011). These factors impact patients with respiratory issues, cardiac problems, pain medications, closed head or eye injuries, burns, fractures, TBIs (traumatic brain injuries) and others.

    As expected, once we reach altitude, I check Jamie's pulse ox and find it to be 81% with him dozing lightly and easily arouseable. I place him on 3L O2 via nasal canula and he is fine at 91%. We now have to complete assessments, take vitals, document, administer pain meds, give scheduled meds, and provide food, water, and toileting. In short- typical nursing care.

    In addition to Jamie we have 7 other litter patients, (2 of whom are intubated and cared for by a CCAT team), 11 ambulatory patients, 2 family members accompanying 2 of the patients, 1 medical attendant accompanying a psych patient, and 22 passengers, some of whom are children (the aircraft is not exactly child-proof and we must watch them for safety). It can get pretty hectic, like any nursing shift anywhere.

    During flight, one of Jamie's wound vacs is alarming because it has become unplugged and the battery is dying. I can't hear the alarm over the engine noise but I see it during an assessment and plug it in. I reposition him twice during the four-hour flight, empty his Foley and help him eat. He insists on opening his water bottle without assistance using his teeth to hold the cap.

    At our first stop in California we off-load about half our patients and take on one new one, but Jamie is continuing on to Washington State. During our stop, with the engines off, I'm able to talk with him more and he tells me about his injury. Newly a triple amputee at 22 years old, I was again humbled by his amazing attitude and outlook. He feels lucky that he will still be able to go fishing, one of his favorite things to do.

    After an uneventful flight to Washington State we off-load our patients, give report, secure our gear, and check into a hotel. We will fly back the next day, restock, recharge, and repeat in a few days.

    Nursing in flight is full of challenges. One of the biggest is that you can't just head to the supply closet if you need something. If you didn't bring it, you don't have it. It can be as simple as a power cord for a pump. Planning ahead and being meticulous are two important skills. Keeping organized is a constant challenge when you don't even have a flat surface to write on.

    The best thing about this job is that these wounded warriors are the most amazing patients! I respect them so much for volunteering to serve their country. They are polite, tough, don't complain, and looking forward to be going home. Most of them display either quiet strength or a bit of bravado, like Jamie. It is truly an honor to take care of them.

    (Details have been changed to protect patient privacy but represent real events.)

  • May 15

    I hope you have some education in adult educational practices. Really use that to develop effective education. The most important thing is that the education is meaningful. Selling the "why" is sometimes essential. Just because the boss says so will NOT win the hearts and minds. If the boss wants something taught that is BS you need to say so (diplomatically) and defend your position. Be sure to research the steps of change theory to develop your plan. Too often education is pushed through in a ham-handed fashion that is not well received by staff. A lot of our educational needs come from the top down, but you can have some control over how it is delivered. Good luck.

  • May 6

    I was a paramedic to RN. Accept it. Most people have no idea what the capabilities of EMS are. Put your energy into showing them what an awesome NURSE you can be. It's like fighting racism. You can rant and rave but that doesn't solve the problem. I take every opportunity to praise EMS, but it's not nurses' fault. They just haven't been under that car with you, or in that tiny bathroom, or in that drunk crowd. Suck it up, get through school, and sooner or later someone will notice that you rocked it when your patient went down the tubes. And don't forget, you have a ton to learn about nursing. Good luck.

  • May 2

    Your impression is incorrect. The directory of the hospital is NOT protected by HIPAA unless the patient chooses to be confidential. Any further information about them, except their general condition, is protected.

  • May 1

    Quote from SuesquatchRN
    I sneak the med into ice cream or something the resident likes.
    I find this unethical, although none of us were there and don't have the full picture. The patient has the right to refuse a medication. Forcing or sneaking are just about the same thing. If it is something they really need, then another mode of delivery must be sought. If the patient is at all rational find out what the problem is. I know there is a lot of work to be done and time is money, but it might just be quicker to satisfy her issue or come back later. I would carefully document the refusal of care. One good way to do that is to say to the patient "is there anything I can do or say to get you to (insert desired outcome here)". Then just document, move on and try again later.

  • May 1

    Your impression is incorrect. The directory of the hospital is NOT protected by HIPAA unless the patient chooses to be confidential. Any further information about them, except their general condition, is protected.

  • Apr 22

    As a victim of poor orientation I applaud your idea. I personally like an orientation that somewhat mirrors the nursing process. First you start with your outcomes. Then assess your learners (no one likes to repeat stuff they are good at), then create a plan to best impart the information. Then implement your plan. Evaluate regularly throughout and at the end. Then reassess (perhaps by QA for a few months). As for your idea of computer versus classroom, I would pick the mode that best achieves the outcomes you seek. That will vary depending on your learners and available resources.

    My unit is working on a multilevel orientation process which will both shorten and lengthen it. Nurses will be cleared for lower acuity patients first. This orientation should be relatively short. Once they are comfortable, and doing well by either QA or some other assessment, they go back in for moderate acuity patients and are evaluated there as well. Then they hit all the specialty training and assessments for the highest acuity patients. The advantage to this system is that if they can't handle the first stage, you haven't wasted a lot of time and money training them for things they can't do anyway. Hopefully this type of employee will be few and far between, but not everyone works out. Experienced nurses will be passed through this process quickly based on their abilities. New grads will have the time they need to absorb a lot of new information. Good luck!

  • Apr 21

    I've thought the same thing myself. Let's say they have 30ml in there. You roll them for a linen change which might take 3 minutes. In that time, your TF running at say 30ml/hr would have infused 6ml. But, what if you get called away and come back to find TF drooling out of their mouth? My interpretation is that it is just a good habit. By turning it off you don't have to take the time to think what was their last residual, how fast is the infusion, how long will they be supine? It's like putting your seat belt on for a short trip. Hopefully it is just a habit to minimize the risk of aspiration, hope this helps. So, I see your point, but on my watch I try to do everything to maximize safety.

  • Apr 19

    Just say "no thanks". No elaboration, just let the silence hang there uncomfortably until they close the conversation. No one ever asks "why?", but if they do, make it game to come up with the most cringe worthy response. Such as:
    1. We are trying to get pregnant, I'm ovulating at 1000 tomorrow. If I come in, I need my break then.
    2. My significant other is getting out of jail then, I need to pick them up.
    3. The man who murdered my family is having his parole hearing and I need to be there.
    4. I'm almost finished with a bottle of bourbon, I don't think I'll be sober by then.
    5. My purification ceremony is then and I can't be around the unclean.
    6. I'm having my *** bleached.
    7. That's my vulvoplasty appointment.

  • Apr 18

    I hope you have some education in adult educational practices. Really use that to develop effective education. The most important thing is that the education is meaningful. Selling the "why" is sometimes essential. Just because the boss says so will NOT win the hearts and minds. If the boss wants something taught that is BS you need to say so (diplomatically) and defend your position. Be sure to research the steps of change theory to develop your plan. Too often education is pushed through in a ham-handed fashion that is not well received by staff. A lot of our educational needs come from the top down, but you can have some control over how it is delivered. Good luck.

  • Apr 17

    Just say "no thanks". No elaboration, just let the silence hang there uncomfortably until they close the conversation. No one ever asks "why?", but if they do, make it game to come up with the most cringe worthy response. Such as:
    1. We are trying to get pregnant, I'm ovulating at 1000 tomorrow. If I come in, I need my break then.
    2. My significant other is getting out of jail then, I need to pick them up.
    3. The man who murdered my family is having his parole hearing and I need to be there.
    4. I'm almost finished with a bottle of bourbon, I don't think I'll be sober by then.
    5. My purification ceremony is then and I can't be around the unclean.
    6. I'm having my *** bleached.
    7. That's my vulvoplasty appointment.

  • Apr 11

    Standing orders are a nice idea. We can order tests and medications, including narcotics. It sounds like it would be a big reach for a facility that doesn't seem to care much about patient pain though. But every challenge is an opportunity!

  • Apr 3

    I think it is essential to keep working at the bedside, although it can be almost impossible to balance the schedule and time commitments. I'm lucky to have an educator job 24 hours a week, which allows me time for a 12 hour shift. I find most educators are not able to do that. You will fall further and further behind the constantly changing practice over time. There is not an easy fix for this problem. Perhaps if you could find a place that would hire you back during school breaks, like summer, you could stay current. But of course, who wants to work on all their time off... Good luck.

  • Mar 28

    Quote from deni_an
    I've thought about the "What are your weaknesses" question a lot.

    My weakness is I can't stand people who don't vaccinate their children, with their ignorance they are literally hurting society (herd immunity) and therefore hurting me or my future children.

    But I realize that is their freedom, and just because I don't respect you or your decisions doesn't mean I won't treat you with respect. I'll give you (and your children) the same care that I would give any other patient. But I won't be happy about it. :/

    I'll have to figure out a way to portray that in an interview. I think it is a valid answer though, at some point we'll all have to treat child molesters, murderers, drug users, or simply just rude people - our level of care cannot change when if we don't like someone. Luckily we don't have to be their friend we just have to help them get well.
    I would say you are passionate about being an advocate for immunization. "Can't stand" a paying customer is not a strong quality to show in an interview.


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