Are we tyrants?

[Bortaz]

The other night, our RT was orienting a new guy to help cover NICU. He was taking him from bed to bed, showing him around and explaining things. I heard one of the nurses on that side of the room tell him "Don't suction my baby unless I ask you to!".

When they got to my private room (with a sick 24 weeker inside), the RT told the new guy: "Be careful with the small ones, because some of the nurses are real tyrants. Especially this guy."

Now, this particular RT is fairly new to our unit, and I have metaphorically slapped his hand several times, because of his tendency to want to suction babies as the answer to any problem. Also not keen on his habit of pouring in the NS when suctioning. So, I've told him to never suction my babies unless I request it. In fact, just don't ever do it...I'll take care of it. If you can't assure me that you got all that NS out that you put into my preemie's lungs, then just keep your hands off.

Me: My heater is beeping, can you reset it?

RT: I'll just suction.

Me: Man, is it really only 4 am?

RT: I'd better suction.

Me: The Texans won!

RT: Hang on, I'll get a gallon of NS and suction!

Most RTs have more experience in adults, where frequent suctioning and use of NS may not have any dire effects. Not so with a micro-gerbil. I know any of you with more than a year or two in the NICU have seen the pulm bleeds and worse that can come from suctioning.

So, my question is: Are we tyrants? Also, is it really a bad thing that we are?

In the interest of being the best I can be...am I out of line on this issue?

I'm also often annoyed by nurses that have no idea whether lab came by to draw blood from their neonate (so, you're telling me someone opened your bed, poked a HOLE in your baby, drew out his life's blood, and you don't even know it happened? Get out!), or who run like a scalded dog every time the portable x-ray machine approaches...so sick of distorted x-rays that you can't even see the lung field for all the crap (lines, leads, ets) in the field.

I was taught by a wise old Neo that we should only be suctioning micros rarely, when we see stuff in the tube or the baby is rattling or if they are displaying sure signs of needing it. The age of q2* suctioning is in the past.

[TiffyRN, BSN, PhD]

This jerk comes in and suctions her for literally, an uncomfortable minute. Too damn long. For God sakes! Desatted to the 80s for five minutes or more because of that dumb stunt.

Okay, I'm going to use this example of how people really don't get the level of protection we need to give our tiny patients. First let me be clear, I am not disparaging the nurse I quoted above but what she said demonstrates how different the neonatal patients are. If my neonatal client (yes, there is sarcasm here by calling them that) were to desat to the eighties for 5 minutes, I'd probably not leave the room, but that would be the extent of my actions. It would probably take them being under 87 for several minutes for me to actually intervene. One can expect a 5 minute long desats to the eighties from hands on cares no matter how careful you are with some infants.

The difference is that if an RT had suctioned my neonatal client vigorously for a full minute, we wouldn't be having a desat, there would likely be compressions and drugs involved. So that's where tyrant nurse steps in the way.

Bortaz (and the rest of us tyrants) doesn't claim to stop all ancillary staff from touching his neonatal clients, he's just tyrannically standing in the way of the ones who continue to practice unsafely even after being disciplined through traditional means. He's tried the traditional educational method and it has failed. Until this RT stops practicing unsafe procedures, they would not be allowed to touch any neonatal client in my charge. Everyone else, I'll give you a chance while I watch you closely.

If an ancillary staff member continues to practice unsafely after education and re-education, what does it say about your role as a patient advocate if you allow them to touch your clients?

[NicuGal, MSN, RN]

Trauma surfer go spend 8 hours in a NICU. You will change your tune.

[babyNP., APRN]

TrauamSurfer, Bortaz was only denying the RT unnecessary procedures that can seriously harm his patient, not other useful ancillary services.

On the other hand, you have to remember that in the NICU, the timing of ancillary services revolves around the baby, not their schedule. PT and OT call the RNs at my facility in the morning to ask, "Is it okay if I come at time X?" and aren't perturbed if they later come up and I say that now is not a good time. I love OT/PT and know that their expertise is invaluable service to my infant, but if the infant is too stressed out, it's only going to do harm and the therapist recognizes that.

Morning x-ray is an exception to this rule, but the night RNs plan for it and usually cluster care around it as they come at the same time every morning. And yes, we do get x-rays on critically ill/unstable infants without argument because we recognize that it has to be done as our kid might have a pneumo, necrotizing enterocolitis, or whatever other wildcards you can dream up...that need attention NOW and this is the only way to determine it so that we can treat them.

Oh- and if the kid accidentally extubates, in my experience at facilities, it's not on the RT, it's on the RN. So yeah, we're super protective of keeping our airway which is not easy when you don't sedate most of them and the difference between being intubated and extubated is 0.5cm. A head jerk in the wrong way can cause an extubation.

[lub dub]

I think its okay to be a tyrant ....it's not like the baby can stick up for himself

A critically ill adult cannot stick up for himself either.

Let me say this again: A nurse DOES NOT own their patients! You do not work 24 hours a day, seven days a week. After you leave, a non-tyrannical nurse, who believes in collaborative care, may follow you.

[TraumaSurfer]

[QUOT

Oh- and if the kid accidentally extubis for privacy so they can play on the internettes, in my experience at facilities, it's not on the RT, it's on the RN. So yeah, we're super protective of keeping our airway which is not easy when you don't sedate most of them and the difference between being intubated and extubated is 0.5cm. A head jerk in the wrong way can cause an extubation.

I think you did not get the first airway rule....There are NO accidents. In the more progressive NICUs both RT and RN fill out the form for inadvertent extubation for review so something can be learned to keep this number low. Those who say "accident" probably don't care to believe they could have done something differently. Usually this a trait of a tyrant who believes they are the sole provider but not when it comes to actually taking responsibiliy when things don't go as planned.

As far as scheduling, we work with IDTs to schedule the times. The RN might only have 1 baby while the other staff has the entie unit. It is not unusual for the RT to have 6 babies on ventilators along with several HFNC and even L&D call. PT and OT will also have a heavy load. Nurses who understand the roles of the TEAM and their value will work to see the baby gets the specialized care to improve quality of life.

After my previous career in EMS (retired) I was very fortunate to work for 8.5 years in a very progressive NICU. The past 18 months I have been a traveler. My previous hospital did not use travelers in the NICU. We had almost no turnover and a waiting list. But, the NICU was a team and treated each member with respect. Several experienced RN NICU travelers in the really bad units have requested adults before extending or landing in another tyrant filled unit.

Four assignments I have had in various parts of the country have been in Level 3 NICUs which should be ashamed to call themselves that. They couldn't keep staff because of a few tyrants who believed the ran the unit. They fought all staff including each other and the doctors. The whole setting including the equipment was from the 1980s.

These are a few things I learned about the tyrants.

1. They hate change.

2. They lack confidence or the ability to explain reasons why so it is easier to chase away those who ask including doctors.

3. They love seeing people fail so they can boast about their own worthiness.

4. They are lazy and will try to stretch how much just one baby needs them. They strive for only the 1:1.

5. They show both their laziness and wanting to see a fail when they sit just 3 feet away and watch radiology try to position a baby even when asked for assistance.

6. Tyrants usually have no clue what the allied health staff do in their specialty nor will they understand why the doctor ordered them. Most will not have the confidence in themselves to ask nor would they want to learn something different and upset their isolated perfect world.

7. Tyrants have a meltdown if they are asked to take a different baby.

8. Many feel they have no control in their personal lives and the NICU is the only place they can make up for their inadequacies in their personal lives.

9. Another big reason to chase others away is so they can play on the internet and their cellphones unditurbed.

Rarely is anything a tyrant does is just for the good of the baby.

The NICUs which have a large number of tyrants will have a higher turnover for RNs, will have outdated equipment, will ignor EBM for new ideas and will have a high percentage of inadverent extubations which will be accepted as "accidents" without question. These will also believe ventilator babies 28 weeks and under will need a trach.

[TraumaSurfer]

Trauma surfer go spend 8 hours in a NICU. You will change your tune.

Spend 8 years in a progressive NICU and see what a team approach can do for a baby. Time to enter the 21st century and bring your NICU along.

[RNCCMMS, RN]

It seems this conversation veered off topic. The issue that concerns me is the suctioning with NSS..that ceased to be a standard of practice years ago. There is no evidence to back it up. Do RTs not adhere to the same standards as nursing?? I think the manager/head nurse/supervisor or whatever the title should be talking directly to the head of RT to work this out. There should be a hospital policy for the unit on suctioning which everyone should be following.

[Elvish, BSN, DNP, RN, NP]

Can we please set aside the political definition of 'tyrant'? No one, not one of the posters here (and least of all Bortaz) is the second coming of Stalin. I can promise you, even having never had coffee with Bortaz in real life, that he will not have you beaten nor liquidated for daring to come near his baby (aka his patient) when you are about to genuinely help them. He is not going to throw a tantrum, either, when it comes to genuine help.

Weren't we taught the 'five rights' in nursing school? Right person/route/time/med/dose, right? If someone else is about to violate one of these five rights and the primary nurse knows it, it is the grossest of negligence to not intervene. In Bortaz' case, this RT is using an incorrect dose (of NS, when it is by all standards not indicated), and the wrong time (any time the fragile neonate will not clearly benefit from being suctioned). If something bad happens to Bortaz' baby because he failed to intervene when RT is going to go against practice standards of his own profession, it will be Bortaz' tail in the frying pan every bit as much as it will be the RT. And the baby is going to suffer.

That is not being a tyrant. That is being a damn good nurse. Perhaps a word other than 'tyrant' could be a better descriptor, but I am not going to jump on Bortaz for using it, and I don't think anyone else here should either.

[NicuGal, MSN, RN]

I work in a very well known and progressive NICU. And our teams work with us to set our kids schedules. We rank second in the nation for our care and follow up. So I guess our being bossy is working for us.

[Calabria, BSN, RN]

I'm currently laughing at this thread. Especially at the people (who don't work in NICU) that are aghast that NICU nurses take such ownership of their patients. Babies are not little adults. And it's not just instillation of NSS that's against evidence-based practice; suctioning when there's no REASON to suction (e.g., nothing in the ETT, clear breath sounds bilaterally) is harmful to micropreemies.

Just a story to share with you all: I once had one of my micropreemies die after suffering massive pulmonary hemorrhage and brain hemorrhage. It coincidentally happened after RT suctioned her. When I left her, nothing was in her ETT and her lung sounds were quite clear. She was doing wonderfully when I left, and was weaning from respiratory support. When I came back 12 hours later, she was maxed out on respiratory support, seizing, in DIC, and her sats were in the toilet. Respiratory therapy and I negotiated a game plan as soon as the shift began so that handling would be minimized. I managed to keep her alive through the night, but she passed away a few hours after my shift.

[lub dub]

Calabria-

So are you saying that RT was to blame for this?

[SoldierNurse22, BSN, RN]

NICU nurses, I bring you tidings of bad news that will be unto all tyrants! You horrible, competent nurses, you!

And now, some interpretive poetry.

I am a cog.

I think not.

I feel not.

I see not.

I hear not.

I turn, and turn against another.

Never feeling.

Never seeing.

Never desiring.

I turn because I am turned. I move because something moves me. I cannot move independent of others; I am unable to effect change without the movement of the mechanism.

When the mechanism fails, I cannot stop it.

When the mechanism endangers others, I cannot see it.

I do not think, therefore, I cannot question the mechanism. I cannot better it. I cannot stop, start or change it. I exist within, a nameless, replaceable piece in the vast machine.

I am a cog.

And that, folks, is why the term "cog" is so offensive. Those of us who do not subscribe to the "everything's perfect in the mechanism" theory are much, much more than just cogs.