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Music in My Heart

being a Credible Source

The original ♪♫ in my ♥

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Music in My Heart has 11 years experience and specializes in being a Credible Source.

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  1. Music in My Heart

    Putting in orders without an order.

    I've never entered orders without a verbal but I have initiated therapy on occasion (a) if the doc was someone with whom I had a strong relationship, (b) the doc was tied up, (c) it was urgent/emergent, and (d) I was certain that it's appropriate and that the doc would back me up, which they always have. Some examples include starting a bolus, initiating a neb treatment, oxygen, and starting BiPAP. It's been the rare occasion, though. ♪♫ in my ♥
  2. Music in My Heart

    Help! The teacher's answers are different from mine?

    That's unfortunate. I wonder if s/he might have benefitted from getting help much earlier. I used to tutor professionally and I commonly found that by the time students sought my help, it was too late to make a meaningful improvement. ♪♫ in my ♥
  3. Music in My Heart

    I made a med error and feel so disappointed with myself

    Don't stress on it and don't repeat it. Phenergan is a terrific antiemetic and IV administration is, in my experience, more effective and more rapid in the relief of nausea... IV is the preferred route *if* you have a patent IV in a moderate-to-large vessel. Many docs would gladly change the order from IM to IV if requested by the nurse. Obviously you took an unrecognized shortcut by not verifying the route in the MAR prior to administration and that is your fundamental error, but one which is simple to never repeat. Had you more experience you would have recognized that phenergan is one of those meds which can go either way and is a high-risk vessicant when given IV. Of course, now you have a bit more experience than you did. Don't beat yourself up over it, especially since it was a harmless error. Learn from it, change your practice appropriately, and go forth to become and expert nurse. For what it's worth, I have made a similar error in the distant past as well as a totally different and much more serious med error and yet here I am as a highly experienced and much respected critical care and resource nurse. As with all errors, the appropriate response is to understand the root cause and to make appropriate changes. ♪♫ in my ♥
  4. Music in My Heart

    OB Unit for Male Student

    Personally, I wouldn't stress it. I got NO L&D experience in nursing school and it's had no impact on the trajectory of my career. The guys in my cohort who preceded me into the L&D rotation spent their hours standing at the nurse's station which seemed a complete waste to me. I asked my instructor if I might seek a better clinical experience and was permitted to exchange L&D hours for NICU hours while still being held accountable for the knowledge which I sought through alternative sources. I've been an ED nurse for 10 years as well as a rapid response nurse and a critical care float nurse. My lack of L&D exposure in nursing school has been irrelevant. As I said at the outset: Don't worry about it.
  5. Music in My Heart

    IV push meds alcohol swabs

    My practice is: swab - flush - med - flush/clamp I see no point in swabbing between the flush and med since the syringe tips are sterile.
  6. Music in My Heart

    Advice On Nursing

    Frankly, I think this is a particularly bad time to be making such a weighty decision, given the stress that you're under with your mom's illness. What might be best would be to take a leave of absence to focus on your priorities (which I can't imagine would include school at the moment). It's impossible to tell you how to manage your time without really knowing you. One thing that would apply generally, though, is to find ways to capture small bits of study time. Flash cards for use while standing in line or waiting for class to start, for example, or making audio review files that you can use while driving. And focus on making each moment count... either in passing time with your mom and caring for her or in doing school activities. Everything else should fall away. Seek to make every minute count.
  7. To be frank: The best way to handle it is to skip the holiday celebrations in favor of attending his classes.
  8. I have spent a lot of time thinking about this case from the perspective of (a) a nurse who has made a serious medical error, (b) a nurse who does occasionally pull meds on override, and (c) a nurse whose role sometimes sends me to MRI to administer medications to help patients get their scans. I have a fairly high standard when it comes to judging a nurse irreconcilably incompetent (some would probably have made such an argument about me and my own error) and an even higher standard when it comes to criminal liability. This case, however, is egregious on multiple points: 1) Pulling a medication on override isn't such a big deal to me. Confusing two medications simply because they start with the same two first letters... that's pretty bad... 2) Moving to the second point, any nurse with the least bit of experience with such medications would recognize that Versed doesn't require reconstitution but that vecuronium does. That's pretty significant to me because it suggests that there was a moment where the nurse must have had to deviate from her standard practice experience or simply didn't have the experience to do what was being asked of her and yet simply proceeded on without protest or asking for help - these being the common response from nurses that I observe... a community standard of sorts. When she realized that she was looking at a powder in the vial, I wonder what was her thought process regarding how to reconstitute it. One would think that nearly everyone would stop at that moment and pull up their Davis guide or Lexi-Comp and figure out how much of what needed to be injected... and presumably seen some cautions. 3) Beyond those issues, though, I'm particularly troubled that apparently the nurse pushed the medication and simply left the patient. Any competent, experienced nurse giving midazolam would certainly hang around for a bit to monitor the patient, both for the intended effect of the medication as well as for the dangerous adverse events such as hypoventilation, laryngospams, and hypotension. Had the nurse been monitoring her patient rather than simply pushing a med, she would presumably have quickly realized that there was an emergent problem and initiated rescue interventions... bag the patient, call for help, and get them intubated. 4) What takes this case beyond my high standards, though, is the vial of vecuronium itself. Unless Vandy is using some outdated supplier, the nurse had to remove the plastic top from the vial and ignore the words imprinted thereon: "Paralytic Agent". As if that weren't enough, when putting the needle or blunt through the vial's septum in order to reconstitute, she must have simply not looked at the words imprinted circumferentially about the septum: "Paralytic Agent." This case is egregious in the extreme and does, in my opinion, meet the criteria for negligent homicide. Simply because she was working as a nurse in a hospital, with all the itinerant problems, stresses, and obstacles, isn't exculpatory. Now, one could reasonably argue that nothing is served by criminal liability, particularly if she is never again permitted to practice nursing but that's an entirely different argument. ♪♫ in my ♥
  9. Music in My Heart

    MVA, EMS didn't use a backboard!!

    I will point out that backboards can cause harm unto themselves and aren't appropriate for general use, particularly given that there's a dearth of evidence that they prevent morbidity and mortality. Setting aside issues of skin breakdown, the very process of getting someone onto and off of a board can be problematic, especially in the field. ENA is now arguing against log-rolling trauma patients. Often times, a scoop is a better device because it can require less patient manipulation. And as others have said, I really wouldn't give much credence to the reports of nursing students - unless, that is, they were experienced pre-hospital providers. ♪♫ in my ♥
  10. Music in My Heart

    Open Fracture During CPR

    During a recent code, during the rhythm check, a small wound was noted on the patient's chest -- it appeared to be an open fracture. The MD said that the patient had had a sternotomy in the past and that the staples had probably abraded through the skin. Either way, it kind of freaked us out. Has anybody else ever encountered this? As compressions continued, the concern was for an exposure to the compressors; which risk was mitigated by placing a folded towel over the chest. Another war story added to the collection.
  11. Music in My Heart

    Frequency of Being Cursed At or Threatened

    I'm looking for some perspective since my present gig is the only large, urban ED in which I've worked. It seems that most shifts include at least one episode in which curses and or threats are directed at me or one of my nearby colleagues. It's become so common that I think I've come to consider it a normal and expected event... and one which seems to be tolerated by the organization. I'm just wondering how often others are experiencing these incidents. I don't know if it's just the reality of a large ED or if it's unique in some way to my workplace or others like it. I just find it wearing and many of my colleagues are expressing frustration at the perception that the organization does not support us or recognize the unique circumstances under which we work.
  12. Music in My Heart

    Lidocaine (UroJect) for Male Foleys

    I'm wondering what people's personal practices generally are regarding lidocaine prior to placing male Foleys.
  13. Music in My Heart

    MD-RN Relations -- There is Hope

    One of the things that I most like about working in the ED at an academic medical center is working with physicians-in-training (residents) and medical students. I find the vast majority of them to be smart, kind, friendly, and respectful. I try to remember at all times that I am helping to form the opinions of nurses that most of these nascent docs will carry forward into their "real" lives. I was just approached by one of our soon-to-graduate residents who told me that the position that they're applying highly values a cohesive team and -- get this -- is asking for references FROM the nursing staff. I hope that this becomes a growing trend which helps bridge the sometimes-wide gap which exists between the nursing and medical staffs.
  14. Music in My Heart

    Third Part Observing and Possibly Filming

    Recently, an ALOC patient needed a CT. For safety, we decided that the patient should be transported with a nurse and a tech. The patient was transferred to the CT table at which point the patient became resistant. For the patient's safety, the patient was pulled back onto the gurney and placed in soft restraints. During this occurrence, another patient was seen approaching the CT suite and craning his neck to observe. He was directed to return to his seat which he protested and refused. Moments later, he was observed holding a smartphone. He was strongly admonished that it is a violation of privacy laws to film other patients or staff. He stated that he was not filming and continued vociferously stating that he was doing nothing wrong and just "watching." At this point, security was summoned and the door to the CT suite was closed until the situation was secured. It is not known whether he actually filmed the situation or not (the cops stated that they are not permitted to demand the phone or look through it). 1) Have you ever caught or suspected a patient or family recording events in the ED? 2) Does your facility have a specific, written policy regarding same? 3) Do you have any signs posted which specifically prohibit filming? I know of a case where a patient family secretly photographed a nurse at the workstation and then posted it to Yelp with a complaint. It was seen by another nurse who contacted both the poster and Yelp stating that it was an invasion of privacy and the poster pulled the photo. 4) Does anybody think that this is going to be an ever increasing problem? 5) Do you think that your facility's risk management group is (a) aware and (b) proactive in this area?
  15. Music in My Heart

    Goodbye...

    For quite awhile, I've been feeling more and more dissatisfied with the content, tone, and bent of many, many threads on this board. I think I've just hit my limit. I'm formally withdrawing from participation here. To some of you, farewell... To others, good riddance...
  16. Music in My Heart

    Some of Us Are Trying to Help You...

    I very often read posts on this board which complain about the staff nurses. I was a nursing student, too, and I know that such criticisms can be valid but you should know that a lot of us really dig having students around and look for opportunities for you to learn. I work mid-shift (which means that my shift overlaps both days and nights) and I recently was helping out a colleague who had a student assigned to her. We had just intubated a patient and were tending to our post-tube tasks (e.g. OG tube, Foley, etc). The student was just standing at the end of the bed so I looked at him and said, "Alright, time to do an OG tube." He responded, "Um, I don't know if I'm allowed to when my instructor isn't around." I replied, "Well, I don't know either. Please close the curtain and either come in or step out." He closed the curtain and tentatively stepped inside at which point my colleague handed him the OG kit. He stepped up to the HOB and we talked a bit about NG vs OG, indications and contraindications, followed by guidance as to what to do. A couple of minutes later, he'd dropped his first OG on an intubated patient. I still don't know if he was or was not allowed by his program to drop the tube but those opportunities are relatively rare and I figured he should take advantage of it when it presented itself... So, young Padawans, know that some of us staff nurses are actually invested in your learning... not because we have to but because we like to.