barbshortt

of course, you cannot use daytonite's method when you are running chemo through an IV line....you can either pull the air out into a syringe, or push the air back up into the bag with compatible fluid (NS or D5W, depending on the chemo).

Done a lot of research on the liability insurance issue, and took a poll where I work and only 5% of the RN's had medical mal insurance. i arranges for a malpractice attorney to speak at our monthly nursing meeting,and she pointed out a couple of interesting facts: (1) Lawyers do not know who has malpractice insurance and who does not. In New Mexico, they are prohibited from finding out by way of their investigation. (2) Although you may be covered by your hospital for liability issues, and they may cover you in an initial suit, when that suit is settled, they often turn around and sue the nurse, doctor, pharmacist on behalf of the hospital! They are out to recover costs from a settlement, and if they settle a case, may turn to the staff member involved in a suit. Of course this makes sense.....the hospital lawyers seek a way to recover their costs.. In my mind, the $80/year I pay for malpractice insurance is more than worht the price.

The RN's at Presbyterian do not wear all white - they wear white tops, and royal blue pants. Each department has different color requirements as to differentiate caregiver roles.

On a double mastectomy pt, we always do blood pressures on the calf of the leg. In our institution, almost all breast cancer chemo pts have a port, so we are able to do blood draws through the port. In the case of a double mastectomy, I can't imagine the pt not having a port or some other central venous line to administer chemo, since the drug regimen is likely to include a vesicant (Adriamycin). Even Taxol can be nasty (was considered a vesicant when it first came out). In the case of a single mastectomy pt, whose "good" arm has lousy veins and there is no central line.....we do see pts like this and it is not an optimal situation. Hydration does help, as does using some form of heat (heating pad, warm water, etc) to dialte the veins prior to cannulation. We do not use lidocaine routinely for IV starts - we use 24g needles for chemo, so their size is not so large that the pain is overwhelming. Certainly use a butterfly for the blood draw, but not for the chemo as again, it will probably be a vesicant drug and using a butterfly is not recommended for vesicant administration. Also, I would always try to draw the blood while starting the IV - not only to minimize sticks for the pt, but to be certain the vein you are using is fresh, without other sticks possibly superior to the one being used for chemo. FYI - I have seen a breast cancer pt get lymphedema 12 years out from mastectomy, so I never assume there is a safe time to use the affected arm. All the best - Barb

Actually, I was a pt at Disneyland once a few years ago. I had a bad case of food poisoning (not contracted at D'Land, by the way), and I had thought I would be able to make it through the day. Shortly after arriving at the park, I nearly collapsed and spent the whole day in the first aid station on a cot. It is true that the nurse was not able to provide any treatment at all. they did not even take any vitals....only sort of monitored me. I.V. fluids would have been great, but not available. The nurse there was an ER nurse at Anaheim General at her real job - this was her second job. While I was there, various other minor cases came in - bumps and bruises, and the like. And they were were not dressed like disney characters - shorts and golf shirts, as I recall. I'm glad they were there, so my family could stay and have fun while I moaned on my cot in the first aid station.....

We use elastometric infusers which sound similar to what you are describing - they do not look like baby bottles, but are continuous infsion "balls" which are gravity-fed (either 2ml/hr or 5ml/hr) continuous infusion devices which we send pts home with from out outpt chemotherapy unit. We check for blood return prior to starting the infusion, and when they return for disconnect. But because they go home with the infusion running, there is no check (nor need there be) while the infusion is running. The chemo stops running when the line is clamped, and starts up again when the clamps are open. It is fine to check for blood return during the infusion by clamping the tubing, disconnecting the "bottle", checking for blood return, reconnecting, and re-opening the clamps. On the other hand, it is obviosuly fine not to disrupt this system, since we send people home with these devices all the time and there are no checks for blood return until they return for disconnect (of course in a hospital, protocols are all together different). Lastly, your pharmacist who makes up the pumps can always help you out when no one seems to know how they work. Or, you can hook up with the outpt chemotherapy unit connected with the hospital, where these devices are really common.

I am a U.S. RN who worked in England (London) 1999-2002 (my husband's job took us there). Nine of ten nurses in London were foreign-trained (mostly Malaysian, Australian, New Zealanders, South African....I was the only American in either of the 2 places I worked, one NHS one private). The pay was so abysmal that nurses could not afford to live in London on the wages. Most lived quite a way out and commuted in on train/bus/tube. Those who had been recruited to come over to work and were promised London housing as one of the perks were surprised to find themselves living in substandard unused nursing dorms from some bygone era, so far on the outskirts of the city that they still needed to travel in by the usual modes of transport (tube, bus, train). These nurses were often goven the most god-awful shifts - 12 nights on, 3 off....but because they were on contract, and far from home, there was little or no recourse. often, they would band together to move out of the nursing dorms to find some little flat closer to town - I knew one girl who lived in a 1 bedroom flat with 6 other nurses and their significant others! But, they weren't all there at the same time due to shift work and days off, and they were so happy to be out of the squalor of the dorms, there were no complaints. Anyway, back to the topic....it seemed to me that most British nurses were not living in London, and not particularly happy with their jobs. They are treated poorly by the physicians (consultants, as they are called there), make a misearble salary, and are viewed upon by society as part of a larger service industry, and not professionals. I was happy to get back to the States - you may not think you are treated with respect here, but you have no idea....

Julie, In our setting, we mostly use a primary/secondary set-up for most chemo tx, with the secondary set-up being the chemo. However, for those infusions that often cause reactions (taxol, rituxan, erbitux, herceptin), I run it in on a second primary line, luer-locked into the distal connection(as you describle) so that in the case of a reaction, the tubing isn't full of drug. There is no policy where I work that determines this - just seems like common sense to me. I am the only one who does it this way, in fact. I don't think you will be able to find documentation for this, but if you happen, to, I'd love to have a copy. Please PM me with any info you find Thanks, Barb

I'm afraid I came across (in my above post) as not appreciating the education I got at excelsior. Sorry if that is the case - I actually think my education was better than most of the RN's I work with. Since the exams are so comprehensive, and not working towards the lowest common denominator, my studying was intense and directed not at talking points provided by the teacher - rather, I had to know and understand everything presented as it could show up on the tests. It was stressful, but valuable in that I feel I had a better understanding of the material, and a more lasting knowledge, than most of the nurses I work with. I am more than happy with the base provided my by Excelsior. And i agree that most of my current technical expertise has come from on the job mentoring by really good oncology nurses.I could not have learned any of it from a clinical experience in a traditional nursing program. I cannot explain why I think that a fuller clinical exposure would have been good for me, or how that would be accomplished in a distance learning environment. Part of it is that I just like the clinincal rotations and being exposed to areas of nursing that I normally don't see. I think that exposure would have prepared me for the CPNE mostly by helping me relax about being presented cases in unfamiliar territory. But, again, traumahawk, you are right - I was thrown into 2 scenarios where I had no background at all....and did well, through the systematic processes I had learned through excelsior. I am hoping you are right, as well, about the ability to switch areas of nursing and having the ability to assimilate new skills...I am making a change to ED nursing soon. Not really too worried about it, but rather looking forward to learning and broadening my knowledge base.

I got my ADN through Excelsior in 1998. I think it was a difficult way to get an RN, as it required alot of discipline to keep at the books, while working fulltime. I will admit that I do feel that I was shortchanged on clinical time - there are definately gaps in my education. And the CPNE weekend was very stressful - I still have PTSD! But, no institution ever questioned my qualifications. I even worked in the UK with this education, and was able to work through their stringent application process with no problems. I am certified in my field (OCN), so again, no problems/questions due to the excelsior degree. I am currently in an RN-BSN program at the Universiry of New Mexico, and they had no difficulty in transferring those credits from Excelsior (and prior credits before Excelsior), and since I am familiar with the online concept, it is not extremely difficult. Best of luck to you-

Multicollinarity- You are absolutely right - the cytokine storm is the most dangerous outcome of this avian flu (H5N1) and the 1918 pandemic (which was simialr in structure to H5N1, but not exact). Currently, this virus is not able to be transmitted easily between humans(there have been a very few family clusters in Vietnam) - but that is the big question....will it be able to continue mutating so that H-H transmission is accomplished. No one can say for sure either way, but Health and Human Sevice Secretary Leavitt has been making visits to every state int he country to make the case for preparation. he has essentially said that the time to prepare is now, and that you cannot count on the federal government to rescue you with supplies, meds, etc. Whether or not to report to work is a hard and personal decision that everyone will have to make. Thousands of infected people will flock to ER's which will be overcome quickly. Supplies, and especially respirators, will be unavailable in a very short time. Once a nurse (or any other healthcare worker) makes the decision to go in to work, they may have to remain there so as not to infect their families or others on returning home - quarantine has already been sited as the most likely was to treat and prevent spread of the flu. I can't even begin to imagine the social chaos this would ignite - parents separated from kids, the elderly in nursing homes, prisons,. Not to mention, the regular pts who would need attention - pregnant women, dialysis pts, emergencies, and on and on. My kids are grown, but are still foremost on my mind. Would my skills not be better utilized taking care of my own family (that is if I am not ill myself) and neighbors with old fashioned home care, then working in my regular unit (oncology) possibly transmitting disease myself. I still have not worked out the ethical side of these questions - just mulling it over. Right now, in the human cases, the mortality rate is a bit over 50% (not just pregnant women). There is no vaccine, and no possibility of one until the virus actually mutates to a H-H form. Tamiflu may provide some protection, but is not in nearly enough supply for everyone in the country. Healthcare workers, first responders, police, fire personnel, and "some political leaders" (really, that is what the quote os from the HHS director was!), will be protected first, but again, think of what this may mean by way of your family's care. I am glad to finally see some nurses address this issue, and would hope that we never have to face such difficult moral dilemmas. But, I think if this virus becomes pandemic, then we also have to think about preserving the medical infrastructure for the post-pandemic period.