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Adult and pediatric emergency and critical care
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PeakRN specializes in Adult and pediatric emergency and critical care.

PeakRN's Latest Activity

  1. PeakRN

    Paramedics in the ED

    Query: Professionalism.
  2. PeakRN

    What is your "favorite" procedure?

    One of our PICU intensivists loves giving haircuts to the long term kids.
  3. PeakRN

    Paramedics in the ED

    While I agee with some of this I would like to clarify a bit. I was a messy medic. The floor and bench of my bus were a disaster by the end of my call. That was because we thoroughly cleaned the back after every call. Also since we only us a few calls a day it want a big deal to clean after the call, had I run a 911 system that is constantly churning volume I’m sure that would have been different. Cleaning your workspace type habits were a big change for me.
  4. PeakRN

    Paramedics in the ED

    You seem to have a bit of a chip on your shoulder. Why did EDs start hiring paramedics? Simply put they are cheaper labor than registered nurses. Paramedic and nursing education is not the same, I’ve done both. Paramedics are taught the technical skills in order to manage patients outside of the hospital. They perform high risk interventions with less training than those who would typically be performing them in the hospital because the risk is outweighed by the benefit on the street. In the hospital we can lower that risk though by having specialty trained staff perform those interventions. Nurses are instead taught a general basis of care across many care environments and then specialize when they start working in a specific area. The shortest paramedic course is 3 months in the US, the shortest RN are about 16 months but requires a prior bachelors and prerequisites.
  5. In my opinion your ED has not provided adequate training. All of our new grads must have ACLS, PALS, TNCC, ENPC, NIHSS as well as complete their online ED modules and all of their staged orientation (which would include things like gastric tube placement, sedation management, invasive line management, vasoactive drug titrations, et cetera) before we allow them to come off of orientation. If my new grads can’t get the appropriate learning opportunities in the ED by the end of their orientation I will send them to one of our adult or pediatric ICUs to get that experience.
  6. PeakRN

    NGT policies about days until removal for Neonates

    If they are in the NICU: 28 days unless ordered otherwise (typically for surgery or other complex placement). In the PICU or Cardiac ICU they stay until they go bad, we don’t have a policy on rotating them.
  7. PeakRN

    Peds Nurse Furloughed During Pandemic

    We never furloughed anyone, but we did cancel every traveler and PRNs have been removed from the schedule. We did rotate a lot of nurses with adult experience back to the adult world. PICU nurses back to adult ICU, peds onc to adult onc, peds floor to med/surg, et cetera.
  8. PeakRN

    Famous person as patient?

    I’ve taken care of more famous people and their families than I can count. Professional athletes, national media reporters, politicians, several heirs to european monarchies, CEOs who’s names are nationally known, and so on. We are a bit well known amongst those circles for not caring about anyone’s celebrity status, and treating everyone equally.
  9. PeakRN

    Feeling Bored

    No offense but if you have nothing to do as a nurse on a peds unit for several hour you aren't really a peds nurse. There is always a kid that needs help with homework, another disease to be studied, an infant that would benefit from holding, and so on.
  10. PeakRN

    Finger Stick in Arm Alert AV Fistula

    For something like a glucose check I don't understand why you would really need to use the limb alert arm. In the unit we stick patients every hour when on IV insulin, often (repeatedly) on the finger of their choosing.
  11. PeakRN

    Scab nursing?

    I think that it's just part of the business for hospitals that have unions. There is probably variation based on union contracts and state laws, but if your union has the right to strike then is it egregious that the hospital has the right to hire temporary workers? That's kind of the point though, you hope that you are valuable enough that the hospital will take you seriously and the you use that as negotiation leverage. But if the ask is too great or the value compared to temps isn't worth it then it is up to the hospital to decide whether to keep or fire the union nurses.
  12. PeakRN

    Surge Pay

    It depends on the matrix but if we are down one nurse (as long as it is a float/resource) position and not a patient assignment we get your normal pay (1.5 for overtime, regular pay if under 40 hours, etc). If we are down two nurses they offer $10 an hour, down 3 or so $20, 4 or more $30. The powers at be of course have the ability to offer more or less bonus depending on if they think they can or can't get nurses. We are also offered credit for the cafeteria, movie/basketball/baseball/hockey tickets, and all other kinds of incentives if they think it will bring in staff. I wouldn't come in for $2 an hour, I could easily make more picking up a PRN shift in another facility.
  13. PeakRN

    Any 22 weekers out there?

    I don't say this as an anti religious statement, but those aren't just miracles. Those kids are the result of the hard work, perseverance, and love from their nurses, docs, therapists, pharmacists, and every other member of their care team.
  14. If an ED has ESI 2 patients waiting in the waiting room for any amount of time, but especially over 10 minutes, the leadership needs to restructure how the department flows.
  15. PeakRN

    Is the future of ER Nursing I-stats?

    Sensationalism is not professional, and has no place in evidence based practice. Since you don't seem to like my thoughts and experience on sepsis management tell me yours. What is your facilities sepsis, severe sepsis, and septic shock outcomes? What are you currently using to judge the effectiveness of volume resuscitation? What is your facility doing to improve outcomes? What do you think improves patient outcomes better than lactate on an istat, and is it a practical solution?
  16. PeakRN

    Is the future of ER Nursing I-stats?

    We are just as accountable for cost management as the next hospital. We just happen to see a lot of very sick, very high risk sepsis patients and have become well practiced in their management. The number one reason why we have good outcome though isn't resources. It's that our nurses own their care. They own rapidly assessing and identifying sepsis, they own initiating the sepsis protocol and sepsis alert (or fever in neutropenia alert) with the attending, they own getting their cultures and labs (including lactate on the istat), giving early antibiotics, starting fluids early, and completing the one hour, three hour, and six hour bundles on time and before the patient leaves the ED (our average level 3 ESI patient stays under two ours before admission, ESI 2 under three hours). Our nurses work hard to give that rapid care, and I wouldn't have it any other way. We also discuss our sepsis concerns in committee, and have ran quite a few QI/QA projects as a result. We have played with the nicom, flotrack, clearsight, and other modalities including ultrasound assessment. We ran our own data on NS vs LR vs Plasmalyte after the vandy study came out. We discuss our choices in pressors, antibiotics, and other interventions regularly when new literature comes out or we start to see a new trend. I would ask what you are using as your perfusion indicators that you feel works better and quicker than a lactate on an istat. ESR, CRP, Procal, LDH, WBCs, et cetera don't change quickly enough to judge the effectiveness of rapid fluid intervention. Sending a tube to lab to run a lactate will take most good labs 20-30 minutes, average labs much longer. Flotrack requires the placement of an A-Line, clear sight is very limited by patients that don't hold still. We found the NICOM to not be robust enough to stay in place during ED care, and the accuracy we just didn't find as good as the flotrack or clearsight. On that note a CG4 cartridge is a couple bucks, non-invasive cardiac output monitors are hundreds. Ultrasound is great, but typically only preformed by our docs and are heavily reliant on good technique. Capillary refill may indicate poor capillary perfusion but doesn't really show the level of anaerobic metabolism in the body. CVP requires central line placement. Certainly POC labs are not the only way to assess sepsis, but are a critical tool in patient management. Our nurses are not responsible for everything. They are not responsible for the medical decision making. They are not responsible for mixing non-vial dose antibiotics. Our bedside nurses are not responsible for the decisions that are made in committee. They are responsible to make sure that the bedside care is performed, but we work as a team to ensure good care. Who do you think should be running the lactate? If the lab runs it you will have delayed care. If you have an additional lab tech or ED tech in the ED you will still have a delay, albeit much shorter. However also consider that if you are up-staffing a lab or ED tech that the FTE has to come from somewhere, and will probably result in fewer nurses for the workload. Would you rather have one more lab tech and ED tech but as a result have one fewer nurse (and therefore take on another patient in your load)? Do you want that tech to be calling you while you are seeing that additional patient to let you know of the result, or do you want to delay care to only see it when you get back in the patient's chart? If your system doesn't provide adequate supplies or staffing then that is a different problem, but that doesn't make nurses performing POC tests less valid. As far as burnout. I doubt the reason many nurses leave the bedside is due to running POC tests. Most employees leave because of poor management, not because their work is hard. Back in the day docs were doing all the blood pressures, nurses were just feeding the patients, perhaps changing a dressing, and putting oil in the lamps; is that the nursing you would prefer? Or is there a different list of skills you want to keep or get rid of?