nurse2033 26,950 Views
Joined: Jun 6, '07;
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Hang in there, there are so many areas to work in you should be able to find your niche. Don't give up. Just look at all the threads in the specialy section...
As an ED Educator I am frequently tasked with training nurses who are new to the Emergency Room. It is true that every nursing unit has their own culture, practices, and sometimes jargon. But, it seems that the ER is just special in how we approach patient care (I'm admittedly biased). But a concept called "schemas" is one way to approach the sometimes demanding and rapid-fire workflow. Conditions in the ER can change minute by minute so nurses (and techs and providers) must be flexible in their thinking. They must also be quick to change direction when needed. This is where schemas come into play. I first utilized schemas as a paramedic early in my career, but didn't realize what they were until I learned the concept later in educational theory.
So what is a schema? Schemas have many definitions but a good one is, "A schema is a cognitive framework or concept that helps organize and interpret information" (Cherry, 2015). Piaget, a well-known psychologist, coined the term and popularized the concept (Cherry, 2015). Piaget recognized that we group information into mental packages, which are schemas. We all do this without thinking all the time. By describing schemas in this way, we can make it easier to develop them.
A nursing example of a schema would be starting an IV. This is one of the most common procedures in the ED. An experienced nurse will instantly be able to visualize all the steps and equipment needed. This is the schema. This includes (but not limited to):
· The indications
· Informing the patient
· Gathering the supplies
· Performing the procedure
· Adapting to irregularities
· Assessment/ reassessment
A new nurse will have to think about each step (in a process is called conscious competence). Over time and repetition, this schema will be strengthened and become unconscious. The key is to develop these schemas in a way that makes sense to you. You would start to build this schema by observing the procedure, studying the policy, and practicing.
There are obviously many, many, schemas in play in the course of a routine shift. The challenge for the new ED nurse, is to start to organize what you are learning as you gain experience. Since the schema is about organizing information, you clearly must have the information to start with. I recommend an excellent text, Sheehy's Manual of Emergency Care published by the Emergency Nurses Association (I am a member of ENA but have no other ties to the organization). The information is organized by problems and gives step-by-step advice on what you need to know for the pathologies you will see in the ER.
You also have many resources at your disposal such as policies and procedures published by your organization. You can study TNCC or other sources. What do you see your coworkers do? But ultimately you should be prepared to answer the question in your mind, "what do I do if my patient has X"? This will prepare you for when you have to do it. Think of the schema as a package you will open that contains everything you need to know.
All nurses know how the body works, and what wellness is. But the approach of the ED nurse is to drill down into what can go wrong. Injury and illness produce somewhat predicable patterns within the body. So based on a complaint, an experienced nurse will start their assessment and test, reject, and eventually arrive at the correct interventions using their schemas. This includes ruling out injury or illness based on the situation.
So as an example, a patient is coming in via EMS with a leg fracture. Just based on that information, the nurse can probably predict what assessment and interventions will be needed. The schema on fractures would include: mechanism of injury, physical assessment, x-ray, pain control, infection control, splinting, and education (among others). Obviously the nurse must be flexible because the information could be incorrect to start with. If the patient takes a blood thinner, for example, that would add another schema for that issue. Or if the injury was the result of domestic violence, that would add yet another schema.
Schemas can be described as a tool kit. Visualize a huge backpack with all your ER nursing knowledge. For each patient, you will take out smaller packages that contain each schema, customized for what they need. I made reference earlier to testing and rejecting schemas (you might call this ruling-out). If a patient is short of breath for example, you should "test" each schema within that problem. If during your assessment you find their lungs are clear, you could put your asthma schema back in your tool kit, but you would continue to test other schemas.
Cherry (2015) writes that there can be problems with schemas. You must be flexible and be able to incorporate new information into your schemas. You can't accept the schema as an "end product" that is perfect and needs no revision. If you do, you will have trouble in adapting to changes that will inevitably occur.
Hopefully, you recognize the schemas that you know and use. By understanding how they work, they can be used to help you develop and improve your practice. Take a problem, investigate all the possible actions and solutions, and this is your schema.
For the new nurse, develop your schemas as you gain experience. For each patient problem, think about the care that was given and the outcomes. As I wrote earlier, use the reference materials at your disposal to war-game all the possibilities.
Cherry, K (2015). What is a Schema? Retrieved from What Is a Schema in Psychology?
The ALTO program (alternatives to opioids) in the ED.
Last year the Colorado Hospital Association (CHA) pioneered the ALTO program. Ten hospital emergency departments across the state participated and decreased the use of narcotics from 31-46% (CHA, 2018)!
Colorado, as well as the US, is in the grips of an opioid epidemic, as I'm sure you are aware. We have the 12th highest rate of abuse of prescription opioids in the US (CHA, 2017). According to the CHA (2017), "the vast majority of those who become addicted to opioids, both prescription and illicit, received their first dose from a doctor". This effort is to reduce the unnecessary use of opioids, and thus one of the pathways to abuse and addiction.
The key to the program was creating treatment algorithms based on pain pathways. The idea that all pain can and should be treated with narcotics is not true. All pain is not created equal. So the Colorado ACEP (American College of Emergency Physicians) developed Opioid Prescribing and Treatment Guidelines. (This can be found on the CHA web site.) This method treats pain by targeting the pathway that causes it. They identified the following;
· Headache/ Migraine
· Muscoskeletal Pain
· Renal Colic
· Chronic Abdominal Pain
· Extremity Fracture/ Joint Dislocation
For each source of pain, they prescribe a set of drugs or treatments, always starting with non-narcotics, progressing to opioids as the last resort. As previously stated, a major reduction in opioid use resulted, with no reduction in patient satisfaction scores!
The medications that are used are familiar to us, but not necessarily as pain medication. Topical as well as IV lidocaine, low dose Ketamine, Toradol, Tylenol, nitrous oxide, Haldol, Benadryl, and a number of antiemetics were all used with good results. Trigger point injection is also an intervention, in which lidocaine is injected directly into a nerve bundle, or muscle fascia. It can relieve muscle tension and spasm, and works well for the release of scalp tension headaches and other muscle pain.
As a nurse who was involved in the pilot, I can tell you this works. Not only are patients looking for alternatives, but we are providing better care with less risk. Patient satisfaction scores did not go down overall. Hopefully as providers get more experienced in using these protocols, satisfaction will go up.
Preparing a hospital for the ALTO program is a huge project. Pharmacy, purchasing, IT, and physicians and nurses all have to be on the same page. New standing orders needed to be written, new order sets generated, new dosing guideline for smart pumps, and new products, such as lidocaine patches had to be ordered.
The Colorado ENA (Emergency Nurses Association) provided nursing education that included scripting in how to explain the program to patients. Nurses explained that we are looking to make patients more comfortable, or reduce their pain. Complete pain relief is not always a realistic goal, as we know. It is also realistic to discuss with patients the risks of narcotics, and the risk of abuse and dangers of having narcotics in the home.
It will be exciting to see how far we can go. There were many lessons learned that will only serve to improve this model and how it is delivered.
CHA (2018), Colorado Hospital Association, Colorado Opioid Safety Pilot Results Report, retrieved from Opioid Safety | Colorado Hospital Association
CHA (2017), Colorado Hospital Association, Colorado Opioid Safety Collaborative
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.)
Thank you for the info! I am a new grad RN in a mixed (neuro, cardiac, medical..no trauma) Critical Care Unit. I am interested in joining the AF reserves and was told that they are offering to repay my student loans if I become a flight nurse. From what I've read, it sounds like it would be hard to hold my current job because of the demands of flight nursing. It sounds like flight nurses are gone quite frequently. Is it difficult to keep your full time job while being a flight nurse?
I am also worried that I might be doing this too early. The recruiter told me that I am eligible after 6 months of experience to join, but I am just nervous that I won't have enough experience under my belt to be successful, especially because I feel that learning to be a flight nurse is like learning an entire new specialty. Would it be smarter for me to just stay with my critical care background and join as a critical care nurse? Thank you for your help!!
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.
Thank you for clarifying about deployment. I get pretty ticked at people who want military benefits without giving back. I'm not up on all the details of the GI bill. A recruiter would be a much better source of information, or the google. In my state, Wyoming, the Guard has a special relationship that allows for further money for education within the state. In my opinion, you should serve because you want to, and then avail of the benefits without actually counting on them. But, many people do join specifically for degree purposes. It will take you a lot longer though, because you have to fulfill all your current schools and job requirements, which leaves little time for school. I've only been home for a few months in the past year with schools and deployments. Most people I know who joined to use their GI bill have taken many years to complete degrees. As for your fiancee I would hope they would support you in the things you want to do. I gave up military dreams for my ex, but luckily was able able to serve once we got divorced. Good luck.
This practice reeks of the worst kind of bean counting BS. Especially in the ED, where by definition an MCI could occur at any time. At my previous job, we would be overwhelmed by a single full trauma activation because they would downsize. I believe they assume a level of liability for bad outcomes if staffing is low. Let's say a 5 patient crash came in, we simply would have to hope they wouldn't die. It made for a low level of stress I didn't like. This is one of the reasons I quit. Then they would call me to come in on my off days because they were short. I laugh at their incompetence and shortsightedness! Ha!
At my last, last job, they called me off so much I couldn't take a vacation after 14 months of never taking a day off because I had no PTO. I solved that problem and got my vacation- I quit! So all the money they "saved" by sending me home was spent on training a new person.
I believe I have a "contract" with the job for them to provide me predictable work, and me to do it. I'm a professional. I can't "downsize" my mortgage or health insurance payments. Calling people off is basically treating them like they are on call at all times, or, as an expendable component. This leads to zero loyalty. A better alternative, is to offer anyone who wants to go, to go home. Or, to offer you other work, such as administrative, so you can get your hours. It's a tempting solution for managers, but like other easy fixes, it creates a lot of problems like low retention, low loyalty, and low quality work.
However, many SANE cases are plead out without a full trial. Many times the SANE evidence is so compelling the suspect knows that a trial would be a loser.
Dear Cursed: I have to say my Air Guard experience is very different. I'm very proud to work in my unit, and at the wing level, I believe we are professional and motivated. We deploy often and have a highly utilized mission (Air Evac). We have tremendous support from our Governor (Wyoming) who recently helped save us from being axed. I guess this could just be a difference in the Air Force and Army but from what I've seen we are pretty lean and mean and keep our readiness high. I guess I'm lucky...
Hey just because you ate some bad Chinese food doesn't mean that all Chinese is bad. Take what you can from that place and move on if you can. You can't change a toxic work environment, and you don't want to become toxic yourself. Good luck.
You can always live in Virginia, but living in Japan might be a once in a lifetime opportunity. Gannbatte!
Which environment suits your personality? If your hobbies are racing, mountain biking, rock climbing, martial arts, or first person shooter games I'd go with ER. If you like knitting, cooking, sunsets, coin collecting, or long walks on the beach I'd go with the med/surg job.
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.
Yes, nurses get assaulted every day. The odds of it happening to you are higher than ever before. Yes, the nurse should call the police and press charges. Many don't because of the hassle involved though. Yes, if the patient is mentally ill charges may not be brought, but it should always be reported to law. A patient at our facility was recently charged with attempted murder for an assault on a nurse. Deescalation and situational awareness are key skills that nurses should posses. Otherwise, you may defend yourself against an attack as any other person is allowed to do. You would not lose your license for defending yourself. High acuity areas such as ED and ICU are probably the highest risk areas by far, but floor nurses get assaulted too.
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