hotdog19d 2,427 Views
Joined Aug 5, '05.
Posts: 126 (6% Liked)
For the latter half of this year I've had the wonderful opportunity of being deployed as the only ER RN with a Forward Surgical Team (FST). One of the interesting things about being with these folks is the "forward" part. That means we're a little further forward (i.e., in austere locations) than your typical Role 3 facility, which is a Combat Support Hospital (CSH). CSHs tend to be located on larger Forward Operating Bases (FOBs) like Bagram and Kandahar, where they even have cafes and sit-down restaurants and crazy things like paved roads. Heck, even our transient base in Kuwait had a McDonald's and a Subway, among other things. But even the larger FOBs have their drawbacks, despite a few extra amenities. It's still a war zone.
Out here on our compound we don't have much. It makes life very simple because our choices are so limited. We have an awesome gym, a plywood hospital that the Navy SeaBees built for us from scratch (love those guys and gals!!), a dining facility (DFAC), an MWR room (that's Morale, Welfare, and Recreation) with computers, and ... yeah, that's about it. We have toilets that flush and showers with warm water (bonus!). There's no Post Exchange (PX) where we can shop, so that cuts down on spending money. We don't get mail that often - maybe once or twice a month, surely to decrease in winter - so mail day is like a holiday. We walk on the most awkward and unforgiving gravel you'll ever encounter; most of us have left a fair amount of knee skin on the ground here. There is never silence, for it is always broken by the hum of generators.
With the grace of Amazon.com and friends and family, I've made a comfortable room for myself. I have a small Keurig for coffee, a water kettle for tea, a string of lights of warm LED lights around my room (much nicer than the harsh fluorescents), a washable/cleanable rug made of woven recycled plastic, a super-comfy Sherpa/fleece blanket, and other small amenities that add up to a lot of creature comforts. When we have a day off (once a week we are excused from showing our faces in the building), it's a nice place to relax and watch movies on my laptop.
Speaking of laptops, we do have wifi in the building, but it's not free. It costs $99/month for unlimited access, but in terms to being able to chat during the day with our significant others via Skype or Google Hangouts or whatever, it's worth every penny. (Though I do groan each month when I have to pony up the next $99.) For a while in July, when we were moving from our tents and the FST at the former FOB next door (closed and bulldozed), we weren't sure if we'd even have internet at the new place. Yikes! But luckily the internet company sent a guy to move the equipment and hotspots over, and we cheerfully paid up. It's been pretty reliable and the customer service is great.
I've discovered that nursing is pretty much an international language. Our patients who don't speak English still respond the same way to our care, be it a friendly touch or a tetanus booster. When they enter our ER, they seem to know that they're in capable hands, and they trust us. I have finally beat the urge to speak Spanish to the Afghan patients, too. Haha. Respira profundo!
In an FST, the ER is also known as the Advanced Trauma Life Support Section, or ATLS. I have a fantastic ATLS crew: two medics who are eager and willing to learn just about anything, and an LPN/NCOIC (noncommissioned officer in charge) who is also a seasoned medic. It has been exciting to see us grow as a team and also to see them grow in their skills sets. We have two trauma bays and all the usual ER equipment that we check daily (oh yes, I even made a checklist!): monitors, suction, vents, Belmont rapid infusers, a Zoll defibrillator, and a host of other items. We work very closely with our general surgeons, orthopedists, CRNAs, OR staff, and ICU staff. As someone who has only ever worked in the ER, getting to go into the OR is so interesting to me! We get a lot of opportunities for hands-on procedures that we'd rarely get to do elsewhere.
Of course, it's still a war zone. We have good days and bad days, triumphs and tragedies, buckets of blood and mangled body parts. We also sometimes have to deal with incoming mortars, which is why I developed the "tactical nudity" concept. Imagine this: you're in your room getting dressed or changing clothes or whatever, and you hear a boom and feel the earth shake. It's time to sprint to the bunker! But hold on, wait a minute! You're NAKED! Tactical nudity means that you're able to get dressed or change clothes in such a manner that you're never completely naked or fully undressed. I don't know how the Army has not yet promoted this concept, but we are going to patent the idea. Of course, in the shower, all bets are off (though we do wear shower shoes, so again, never completely naked.)
Random things I am looking forward to doing when I get home: brushing my teeth with regular tap water vs. bottled water, showering in bare feet, ordering pizza, eating fresh vegetables, walking like a normal human on pavement vs. the evil gravel, and hearing silence with no generators humming in the background.
It's a strange kind of nursing we do out here. Some days we have MASCALs, some days we have onesies and twosies that trickle in, some days we have ortho clinic during which our former patients come back for external fixation removal or revision. Sometimes we take care of our own people as well, if somebody is dehydrated or hurting. We can remove an appendix or reevaluate a bum shoulder. We've had locals bring in their children who are suffering from lasting effects of this war, and it's enough to break your heart. It's often for a second opinion that's unfortunately no different from the first.
We're almost at midtour; the days are getting colder and the hours of sunlight are dwindling. We will apparently see snow! I'm half excited and half dreading it. Either way, I know that the members of the team will carry each other through the rest of the time we'll be spending together. I am so lucky to be deployed with this crew!
As someone who's been there recently:
--that feeling like you're completely clueless? That's normal. School's the beginning point, not the finish line. Your GPA, good or bad, is now irrelevant.
--When in doubt, ABCs, then Maslow.
--Get a thick skin. Yesterday.
--You can do everything right, but some patients will still die. You can do everything wrong, and some patients will still live.
--Call for help. I'd rather tell you that no, that's not a reaction to a blood transfusion, it's shingles, rather than be coding your pt because you thought they might have been having a reaction, but didn't mention it to anyone because you were afraid we'd think you were stupid.
--Stay out of the politics.
--Take it one step at a time, and speed will come. Do speed first, and mistakes will overwhelm you.
--Listen to all advice. Your CNAs will know more about how to handle pts during baths, ADLs, etc., than you do. The Respiratory tech knows more about ABGs than you do. You had xx hours of clinical, they do this for a living. You think you're too good to listen to advice from experienced CNAs/nurses/US/PT/OT/RT folks, you're going to have a miserable time.
--You'll see a LOT more psych issues that you expect. Everybody's a freak in their own way.
--Don't go into this for thanks or respect; you'll starve to death if that's what you're living for.
--Look after YOU FIRST. You can't help anyone if you blow out your back. Get really good, comfortable shoes with lots of support. And the first 3 months, my legs and feet never stopped hurting anyway.
--Know that if you're a nurse 20 minutes or 20 years, you're still going to run into things you've never seen. The only nurses that's not true for are the ones who never leave the nurses station. Beware of the "nursing from the station" nurse.
--Just because someone's a BSN/MSN/DSN doesn't mean they are a good nurse, it means they passed the boards. Don't be impressed by initials. Don't be intimidated by them, either, book smart doesn't always equate to common sense. But if the person's good, learn everything you can. Suck their brain dry.
--When you hear experienced nurses talking about the weird things they've seen, LISTEN. You may hear something that you can use to make a difference in the outcome of a future pt. If you see a nurse look at a pt who looks fine to you, and they say, "let's get a blood sugar..." ask them what they saw, after you've pushed the D50...
--If a pt says they're going to die, LISTEN. If they say they're seeing deceased relatives, they're probably going to join them.
--They may not remember what you said, but they will remember how you made them feel. And if you made them feel stupid, or worthless, or act dismissive, they won't care that you saved their loved one, they'll file a complaint because you didn't stop the code to bring them a soda.
You'll rarely be bored, you'll never be paid enough for what you risk, but the world may be a better place for families because you were there. Good or bad, you make a difference.
Ever run over a cable as you were moving a bed, CARM, Monitor tower? It's for ease of replacement. Before you had to have Biomed take the equipment or send it out to be repaired because of a cord problem.
Truth is thats another common problem the cord simply pulls out, actually I think Valley Lab has a nice bracket that keeps the power plug in place. Though honestly, I wouldn't want everyone to go this route I can't tell you how many times I've had to steal a cable from a piece of equipment we weren't using to prevent having to delay and hunt another down.
Having just finished reading a prior post about jewerly in the operating room on patients I found there was a bit of mis information and lack of understanding regarding jewelry on patients in the OR and bovies in general.
First off lets say from the beginning. Patients coming to the operating room should take off their jewelry prior to surgery for a variety of reasons which we will explore.
However, this is not because of the possibility of burns from stray current or alternate pathways from the modern bovie.
Reasons jewelry should be removed.
-the possibility of swelling
-loss of the jewelry
-can get caught on things ie, peircings or necklace getting snagged while transfering the patient
The AORN 2007 standard pg 520.
"Although there may be other reasons for removal of all patient jewelry (eg, risk of swelling, theft), the risk of an alternative site injury from stray current is negligible."
In writing the current policy regarding bovies for our department I personally contacted valley lab and spoke with their clinical expert. When asking about alternate site burns I was told. "There have not been any alternative site burns reported to us and we are not aware of any documentation of any alternative site burns in the literature when a return electrode contact quality monitored bovie is in use."
Alternate site burns have historically occurred during the use of ground reference ESUs, which is and old technology and should not be in use in a modern OR.
Pad site burns were possible prior to electrode contact quality monitoring. This technology was developed in 1981.
After a number of years of practice in the operating room and in nursing, I have found that some nurses want a definite rule to follow eg, all jewely should be removed, so all jewelry is taken off regardless of circumstance. The problem with this type of thinking from my perspective is that one really isn't taking the best care of the patient, taking into consideration the total patient.
If you have a patient with a ring or body peircing easily removable or which causes a safety hazzard by all means remove it. Tongue rings are coming out no matter what in my book, and a patient having a CABG has to have their rings off becuase of swelling likelyhood/risk.
But consider the patient I had last year. She was 75 years old and had just lost her husband last year. She had her wedding ring on of 50 years which had never come off and was extremely important to her. It wasn't tight on her finger at all but couldn't be removed because of an arthritic knuckle.
The preop nurse was saying it needed to be cut off becuase our old policy stated it was a burn risk. And this was the rational she was giving the patient. This was unfortunately completely false. As stated above, our bovies are patient monitored systems so there was no burn risk, the ring was loose on her actual finger, and to cut someones ring off for the rational of it getting stolen or lost was simply ludicrous. And yet because of the inflexible wording of our now former bovie policy, she was left with little discression as to best take care of our patient. Not to mention significantly increasing the stress level and blood pressure of an acute patient immediately prior to anesthesia induction which understandably was making the anesthesiologist very angry.
I can't stress enough the importance of using critical thinking skills to take care of the total patient. Often times we do not live in a black and white world with rules that fit every patient.
We use bovies every day in our practice in the OR, as professionals it is important to understand the tools of our trade, not simply ground the patient and turn the cut and coag up to 35 35. If you don't know what type of bovie you have or don't fully understand how it works. Valley lab has a good online resource.
i am not having surgery so this was really more of a general question. i take it from your reply that nurses and docs would be comfortable using an or tech versus a licensed nurse as well. i didn't realize this was standard procedure. it makes me a little leery that the hospital can take unlicensed people and put them in an or situation. i don't mean that to offend any or techs so i hope none take it that way.
i know someone that recently went to the doc and the doc bought the receptionist in the room to chaperone. she sent the woman out because it just didn't feel right. the doc was okay with it, but did explain that this was something he did often. yikes.
Check this out for surgery videos:
I'm a circulator (will be learning to scrub soon, hopefully) and I like to watch videos of procedures I haven't circulated yet.
Scrubbing is in my opinion a total OTJ experience. The more you do it the more you learn etc...
Let me tell you what not to do:
Don't try and tell your experienced Scrub tech how to do their job (Even if you know their wrong) Make friends with them and you'll learn loads
Don't try to invade someone else's space. Some Scrub Tech/Nurses are very territorial and will withold knowledge if they feel you'll get attention from their Surgeons.
Don't be afraid to join a service early on. I know it's frowned upon but once you become expert at a particular service picking up on others is a breeze.
Don't shy away from difficult situations. Difficult surgeons will never change, but the more you are around them the less they affect you.
Developing a thick skin is a must. The more you avoid these situations the harder they are to deal with.
What to do:
Be punctual. If you get in the room early and help open up etc... You demonstate a willingess to learn and will foster teaching from others
Be conservative with questions especially intraoperative. The less you talk the more you will be able to hear and experience. Save the chat for after the case and times when stress levels are low
Be careful!!!!! Move deliberately, know your sterile field and as was mentioned your sharps. If you get nervous and jittery it's time to breath and do your best to relax. There's nothing like dropping a custom made Implant to ruin your experience.
If your not familiar with a case, do some afterwork homework on the net and read about it or watch a video.
Get on Pubmed and read some abstracts. This alone can give you some insight you won't get from some AORN magazine or Educators handout
Safety first. Wear biogel gloves as inner gloves to help prevent getting a latex allergy. Wear ortho gloves as outer gloves to decrease the odds of needle stick. Always pay attention to where the sharps are on the field. Surgeons will often put needles back on your mayo without saying "needle back" like they should.
When you put used needles into your needle book, put it in so the sharp tip is inside the foam. I've seen people put in the needles with the sharp tips stick out just waiting to stick someone.
Label ALL medications on the field. All basins and syringes should be labeled.
If someone scrubs in during the middle of a case and wants a towel to dry his hands, don't touch the towel with your bloody gloves. Use a clean clamp to give the towel to him.
Here's a tip for gowning and gloving. Open the gloves packet so that the fingers of the gloves are pointing to you instead of pointing away from you. Then put your right hand over the right glove (which is on your left now.) Then you can lift it up and it will already be in the right position to glove.
If you use the masks with the built-in plastic visor, bend the visor down the middle before you put it on so it won't touch your face as much which leads to fogging. Tie the upper straps tight, but tie the lower straps very loose so your breath will come out the bottom instead of fogging your visor.
If you sweat a lot, wear a headband under your hairnet.
If your back table is totally set up before the patient comes in, help your circulator when the patient comes in and then scrub at the last second. Your circulator will appreciate it.
When setting up your back table, offer to count as soon as possible so your circulator will have one less thing to worry about.
When you need something from your circulator, say please. It's just common courtesy.
If your circulator wants to give you medication out of a glass ampule, ask for a filter needle. After you draw up the medication, remove the filter needle and put a regular needle on the syringe.
When a circulator gives you heparin, make sure he shows you the vial that the heparin came from. Heparin comes in many different concentrations so you want to make sure you are not giving an overdose. Patients have died this way.
Another pet peeve of mine. Do not gown off of the back table. Gown off a mayo stand or other table. Lots of scrub people gown off the back table which is incorrect because you are not supposed to reach over the back table with bare hands especially if they are wet.
I really don't feel like wasting my time taking a bunch of pre-reqs to get into a program.
*** Yes, Nova Southeastern in Florida. No prereqs. Just type the school name into Google.
If you decide to become an O.R. nurse, be prepared......
to be verbally abused by physicians, nurses, and techs.
to work your butt off.
to lift heavy objects. (Many O.R. nurses damage their back).
to be very exposed to patient body fluids, x-radiation, formalin, cleaning solutions, and other hazardous chemicals.
to memorize endless instruments, supplies, and surgical techniques.
to be required to take call.
You almost always get coffee breaks and lunch breaks.
You deal with only one patient at a time.
Difficult patients are much easier to deal with in the O.R. because they are drugged most of the time.
Surgery can be fascinating.
You wipe patient's butts only once a month or so.
As you can probably tell, I do not enjoy O.R. nursing, but I will take it over floor nursing any day.
1. Will i be orienting in all the services (General, Ortho, Neuro, Vascular, Cysto, Hearts, Women's, Ambulatory -if applicable) Will i have a different or same preceptor for each service?
2. If so how long will orientation be for each service?
3. What shifts are available?
4. How many hours of call will i have to take per week? How soon after i've completed my orientation will i be required to take call? How much more is it (wages) for calls.
5. How many cases (average) does the OR do in a day?
6. Once i'm on my own how many cases (average) will i circulate during my shift?
7. Are there any opportunities for advancement? For example at my hospital we have Clinical Nurse Leaders for each service.
8. Are textbooks required for orientation? If so, do you provide textbooks for my orientation or will i have to purchase them?
If you don't know already, you may also want to ask if you have to recover your own patients or if you drop them off and give report to a PACU nurse. I've heard in some hospitals how the OR nurses have to recover their own patients. Our hospital we just take them to PACU, then go see our next patient in Pre-op. So far this is all i can think of right now. Hope this helps.
Like most everybody, I've done the OT thing, too. Same scenerio...I got taken advantage of & had a really bad day! Once they find out you'll come in, they'll keep calling! Yeah, the money looks great in my paycheck, but the exhaustion & aggravation just isn't worth it. I agree with all the previous posts & I no longer answer my phone. Yes, I do feel guilty everytime because I know first hand what a strain it puts on the staff that's there. I'm more than reliable to be there when I'm scheduled, but not when I'm off...not even for a bonus.
I went for the longer term. It's a huge learning curve and I wanted as much time as possible with my preceptor. I did not want to be hurried out of orientation with so much responsibility on me and to risk patient safety. Plus with this program I get to learn a lot more about how other departments work and I get to do a lot more extensive education and training. I guess to me it's all about starting out on a really super firm foundation
Thanks for everyones support.. I PASSED! Goodluck Blondie00!.... bet you passed too!
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