Ceteris Paribus

Well here were my thoughts: I came from a hospital (about two months ago) where giving dig in this circumstances would have been unthinkable (against hospital policy). The hospital (small town) where I now work simply doesn't have a policy on this. I honestly felt that giving the dig. could have pushed the patient "over the edge". That's why I posted here because I wasn't really satisfied with my response (or the input from my co-workers) and want to respond better the next time. I've only been a nurse for about 18 months and this is the first time where I've been ordered to do something that I felt clearly put the client in jeopardy.

I had a client a few nights back who had been transferred to our PCU after going into tachycardia in the 150's. (not sure what type of tach, but I'm pretty sure it was a narrow complex). The person was elderly, anemic and had lung Ca with mets to the kidneys, history of PE and many other things. Any way by the time I came on evening shift the client was in sinus brady at around 50 with a pressure of around 92/50, AOL 2-3, GCS 14-15 and with Amiodarone going at 0.5 mg per minute per protocol. Anyway, I'm supposed to give 0.25 mg of dig (the second of four doses) the first brought her out of the tach on the other unit. I called the cardiologist because I didn't want to give the dig with the Amio drip and borderline HR/BP. He responded "the dig won't affect the heart rate and you need to give it". He did have me run down the medications to make sure she wasn't also on a Beta or Ca++ blocker. I consulted with my charge nurse and was told that if this Doctor says to give the drug then that is what I need to do. So 0200 rolls around and it's time for another dose of dig and the HR is now 47-48 with the pressure 91/45. I'm told that this doctor hates to be called late and besides the protocol only specifies calling doc for HR under 40 (the Amiodarone protocol that is). I consult with several other nurses and end up not giving the dose and charting that the patient refused (she actually did, but with my explanation of the circumstances). If I ever encounter this situation again what are some better options for me. Also were my concerns about the low HR/BP without basis (with regard to giving the dig).

Going back to the AA example from school what impressed/amazed me was that there seemed to ALWAYS be a meeting somewhere! The way I envisioned this working you would join the organization and then you could attend ANY of the get togethers so long as you brought a dish. Also, like AA any money given beyond bringing the dish (to help pay expenses) would be strictly voluntary.

Thanks for the input. I had pretty much resigned myself to Oahu for several reasons. First, I felt it was the only island which offered a reasonable chance at a job. Second, although like the rest of Hawaii although it is expensive they at LEAST do have places like Wallmart/Sam's club (they may also have food pantries in Honolulu if things get real tight). As for family we basically have none other than our son ditto for friends and working nights/weekends we VERY seldom see those few friends that we have. If we can find travel assignements we will definitely try that route for sure!

My significant other does her most expensive shopping at Wallmart and usually the clothes that we purchase come from the DAV thrift store (about half the price of Good Will). I do believe that the visit idea is a must, but again I'm looking at a five year event horizon.

If I earn an income which facilitates doing so I will repay the loans. However, I'm going to remain in school however long it takes to earn a BSN and then NP degree of some sort. I do not feel that obeying current rules to minimize my payments is defrauding the system (indeed by definition fraud implies intentional deceit and a violation of the law neither of which apply to staying in school part time). Thankfully, we live in a free nation where we don't need the endorsement of others to live where we choose. You may not welcome me in Hawaii, but I welcome, you to Indiana or wherever you may choose to live. Furthermore, I am eternally grateful that we live in a nation where those with diverse opnions can peacefully coexist.

Well take this advice for what it is worth from someone who takes pride in being viewed as an over the top "psycho": Here's what I would do: 1. Monitor www.indeed.com daily. Use the advanced search feature to list only jobs posted in the last several weeks. They list virtually EVERY job from all websites. Try to be the FIRST to apply. Also I would apply even to the ones that I was SLIGHTLY underqualified for (those say asking for a year of experience). 2. I would actually start VISITING the nurse managers on a regular basis at the hospitals/units where I was interested in working. Ask them to consider you in the future even if they do not have anything currently available. Tell them (if you are) that you are willing to work any shift and EVERY holiday. If you can become more than a NAME then you will have something of an edge. I've heard of people who wanted to work in certain difficult areas (to get jobs) like labor and delivery who utilized this approach. Also it might be useful to get business cards to leave in lieu of or in addition to a resume. During nursing school I was successful in getting an L&D interview for a classmate just by walking in and asking the manager during clinical downtime. Often people will respond positively by polite "in your face" audacity. Unfortunately, some of the time the response will be negative so you have to be ready to roll with rejection and take it in stride. 3. Take the waitress job or whatever, but as hard as it will be MAKE yourself use every available free hour looking for nursing work. If you could find a second or third shift job all the better since it would leave more time during the days (when managers are in) to look for employment. If you cannot find an RN job right now consider taking an aide/Tech job. At least this will give you SOME relevent experience and more importantly people (other nurses and managers) will get to KNOW you!

Thanks for the input. Keep in mind that my goal is a FIVE year one. Not even I am so foolish as to think that I have a good chance of finding employment without having five plus years of experience a more advanced degree, a better job market and every certification available for what I hope is ICU nursing by that point (CCRN ect). As to stopping the pontification not a chance! It's who I am dude! My SO will tell you that I will often launch into a five minute "Braveheart" speech on the mortal coil of mankind before even taking out the trash! This is not a new obsession for me. Literally, half my nursing class literally expected me to abandon my family and move to Hawaii as a Bushman on the day I graduated!

My significant other has had her license for about a month while I've only had mine for a few weeks. I'm getting calls back on most of the applications that file, but my followup working nights has been less than ideal. We had hoped to MOVE on a travel assignment (at least for her) to avoid coming down for interviews. Thus, far the only travel opportunities have been in Gainsville and Penescola and she's still not willing to consider these over Orlando/Tampa. Based upon my "weekly job tracking" on www.indeed.com (searching only jobs posted within 7 days, by city keep in mind that this pulls virtually every job from all job sites posted online), Orlando/Tampa is creating virtually twice as many jobs as here in Indianapolis.

As a free market liberatrarian I believe that money/perks are great motivators! When I used to wait tables no doubt money was my primary goal however I gave 110% to each and every one of my customers (I used to sometimes annoy my co-workers, parents, and friends by saying things with a fanatical zeal like the customer is my God and I will have no Gods before them), this is not to say that I always did a good job because frankly I just wasn't that GOOD of a server. In the same way although I entered nursing in large part for the money, flexibility and benefits I still give 110% each and every shift. I seldom take breaks (only to use the restroom), allmost never take lunches (only when they occassionally have ribtips and then only for 10 minutes to run to the cafteria), and usually stay late to chart "off clock". I serve each of my clients like they were the President himself and it doesn't matter if it's a prostitute with late stage HIV (a typical type of client at my inner city facility) or my own mother (and speaking of nepotism if I were in position to hire someone it wouldn't matter where they were from or if they were my best friend or worst enemy if anything I would hire my enemy first just to prove my fanatical dedication to my ideals of equality). This is not to say that I always do a good job, because I'm frankly not that good of nurse yet, but darnit I'm trying very hard to be the best one I can be. Yes, I'm motivated by the HOPE for a worthwhile future/career with good pay and flexibility, but I wouldn't try even one percent harder were I motivated by the promise of eternal life and salvation and the revocation of my sins (as were the Crusaders who approached their goals with fanatical zeal). As I look back upon my youth saying "the customer is my God" was foolish, but serving each and everyone of my clients to the absolute best of my ability matters to me greatly.

The power of Allnurses to organize and inspire such a vast compendium of nursing thought, practice, news, and opinion along with the awesome existing example of the YMCA is actually what inspired this vision. What if there were place(s) where this thought could actually be translated into physical reality?

I would argue that I would simply prefer to stay in school and take classes and continue to improve my educational base if I can do so at price that is less expensive than paying the loans directly. I would argue that it's no more a matter of taking advantage of a loophole than those who trade their cars in for $4000.00 subsidies paid for by other tax payers or banks that take billions based upon governmental programs that authorize them to do so. At least half my debt (the Perkins loans) could actually be forgiven OUTRIGHT, if I only applied based upon the type of facility that I work in as a nurse (but I haven't applied for this and have no intention of doing so). Also, if I took a job at the VA (as several of my classmates did) ALL of my loans would have been repaid outright by the government (plus I would make more, have more vacation time, and better insurance/retirement pay). If it's not "stealing" to accept a job which pays the loans off with government money, then how is it such to defer my loans indefinitely while I'm in school?

She is a pretty "matter of fact" person and doesn't care to participate in online activities especially discussion boards. She loves to socialize, but vastly prefers face to face interaction. Our son is homeschooled so changing schools isn't an issue. No doubt she has higher standards for life than me. I could literally be happy living in a tent (as long as it's near the beach and I can afford at least one decent meal once a week or so, indeed during nursing school when I dropped from 270 to 180 over the course of a year I often water/multivitamin fasted two sometimes three days per week (and ate low carb the rest of the time when it was necessary to meet my self imposed weight loss goals). She is on board with Florida perhaps to an even greater degree than myself (it may not be paradise, but at least they have Disney, the beach, and no snow) and providing that we can find jobs which approximate what we currently earn (about $28.00, and $30.00 with night shift diff included) will be movnig within the next three to six months. She would consider herself (self described) a Jimmy Buffet, Hedonist, but with conservative, Glenn Beck like liberatarian social/political views. She considers me something of a left wing nut job, but never the less sometimes finds me at least remotely attractive if only in passing. Before being nurses we were once essentially "debt free" and gambled it all on a business which did well for several years. We basically decided to go back to school, take on massive debt and earn about 1/2 the money to enter a field that we felt would offer better long term prospects and offer the potential for life time growth (not to mention things like health insurance and work weeks which were not seven days per week and 16 hours long!). Plus, as I said originally we literally sat down and said what job(s) could do where we could dependably find work even in places like Hawaii (at one time nursing pretty much fit the bill!).

I pay about $60.00 per month to the YMCA and really love the place. I can go there and swim, lift weights, take various free (and not free) classes ranging from karate and yoga to aerobics and fencing lessons. One can participate in various/numerous self help/interest groups ranging from weight loss to hiking. High quality childcare is available up to two hours per day for free so that even when my significant other is working I can still go. If I want I can even get a massage, personalized fitness training, tennis or swimming lessons. I can mingle, talk, chat and just hang out with other often like minded (as well as radically diverse) individuals. I would like to see something similar for HEALTH PROFESSIONALS (thinks nurses, RT's, tech's, doctors, X-ray/lab techs et al). This would be a place where you could brush up on your ACLS with supervised "mega codes", improve your IV skills, grab a cup of java, catch a workout, network, or just vent about the difficulties of nursing and ways things might be improved. It would be open 24/7 (although obviously not all services would be available all the time). I pay $60.00 per month to the Y, and I would pay even MORE to be able to go somewhere like this! My vision is a network of such places in literally every major (and eventually minor) citiy in the country funded by both members AND local organizations with an interest in promoting health care excellence. Could such a place as this become reality and if so what would it take?

Understanding of course that like most of the rest of the country that jobs are hard to come by in Florida WHERE in the state has the most opportunities? We hope to move to Florida by mid to late Oct. My significant other has about 5 years as a cardiac ICU nurse and I have only a year as a PCU nurse. She prefers Orlando (I prefer Tampa), but I am willing to commute anywhere within about a 90 minute radius. We live in Indiana currently and expect to take a SLIGHT pay cut (I currently earn 21.75/hr plus shift diff for working nights) she earns about 25.00 plus differentials for nights. Would Miami offer superior prospects? Fort Myers? Jacksonville?

Thanks for the input. I would make one point of divergence however. Just because the average stay is two years that doesn't necessarily mean that the trip wasn't worthwhile! I believe that Thor Hyerdahl "only" stayed on Fatu Hiva with his wife for a year (it nearly cost both of them their lives), but it was one of the defining experiences of his life! Those who walked on the moon were able to experience it for a matter of HOURS and yet for many it was THE defining experience of their existence. IF we moved to Oahu (or one of the other islands) for a year or two and ended up coming back to the mainland would we really be any worse off than in our current situation? Would we regret the decision to move out there in the first place? My significant other and I agree on at least one thing we don't plan to EVER retire! Whether or not I live in Antarctica or Hawaii, my plan is to stay in school until I DIE (penniless so that I won't even leave an estate for the government to confiscate). Indeed, one of my "dreams" is to start a "cheaper, online, but accredidated" college where those like myself (in boatloads of student loan debt) could take 6 hours to defer their loans (basically forever), but instead of charging $150.00 per credit hour, get the rate down to closer to $50.00! I know MANY people who started, but did not finish med school or law school who owe as MUCH or even MORE than me, but instead of making 55K per year earn less than 30. Here's the thing one way or another I'm going to get to the islands the only questions is whether or not it will be living in a nice apartment/condo or in a tent somewhere up in the Ko'olau mountains. An even more basic question is which scenario would ultimately make me happier!

My wife and I are resolved to move to Florida from Indiana. Currently, I have one year as a PCU/medsurge telemetry RN and she has allmost 5 years in a cardiac ICU. Because the job market is so tough right now I have resolved myself to taking essentially WHATEVER job I can get even if it means taking a step in a direnction that is opposite my goals (which is to work in critical care and then possibly become an NP or CRNA). However, the ONE thing that I'm having a hard time getting my mind around is 8 hour shifts! If I could "open up" applying to long term care facilities then my prospects of finding a job would be much greater, BUT 8 hour shifts mean five days per week and ONE of the major reasons that I went back to school for nursing was to work three day work weeks (or at least get overtime if I worked more). Do any/many of these facilities offer 12 hour shifts? IF not would they likely consider letting me work two 16 hour shifts plus an 8 hour shift? If not why not? I've also noticed that 8 hour shifts also seem to be THE NORM in psyche nursing (which is one reason although I loved it in nursing skill and was offered a position as a new grad on a psyche nurse, I did not accept it). It would seem easier to staff two 12 hour shifts instead of three eight hour shifts. I no that at my hospital they basically stopped hiring people who only wanted to work 8 hour shifts because it is just easier to staff 12's. Can someone give me a short history lesson on the whole 8 verses 12 hour shift thing and why certain specialties prefer one over the other? Is it "job protection" (more shifts means more needed workers), long standing industry practice (that's the way its always been done and no one has thought to change things) or are things so much harder in these areas that people can only bare to work eight hours at a time?

Well my reason for suggesting Southern California was that I had spoken with a travel agency (Access Nurses) who told me that they couldn't help me with Florida because I only had one year's experience (nor could they help my wife in Florida who has allmost five years ICU experience), BUT they said that they could probably place us within a week at $35.00/hr (a little more for her) and over $1200 EACH for housing expenses in Southern California. She doesn't consider California an option for us but for our friend these numbers could work. Would Northern California be a better option? What about Texas?

A friend of ours has three kids and is recently divorced from her husband who is on disability (he is planning on moving to Europe to live with his mom). To complicate matters further a change in management on her unit means that she can no longer work overtime (she was working 60 hours per week) and has in fact resigned over this and other disagreements with the new manager her weekend option position (she has two weeks left and still no local job). She wants to work travel nursing somewhere that is warm, and where they will have good pay at least as good as here. She has approxmately six years cardiac ICU experience/BSN/charge nurse experience. We are planning on moving to Florida and she had hoped to move with us (her kids are close to ours and we do many family activities together), but travel nursing prospects there seem dismal right now (unlike her we can afford to look for lower paying permanent jobs and don't have an economic ax hanging over our heads and would rather endure a week of flogging than work even an extra minute of overtime). Where in the United States can she find the best combination of (in this order) demand for ICU nurses, pay, reasonable cost of living, and warmth? Thus far my advice has been Houston and Southern California can anyone add to this list (or correct or improve my input?) . Depending upon the input we may even change our plan from moving to Florida to someplace else (however for us the order of priority would be beach, warmth, nursing demand, pay, cost of living). My wife and I have pledged to jump off the highest building in Indy before enduring another Indiana winter!

It's not that I was rejecting the advice. However, moving to Oahu was essentially my raison d'etre for going to nursing school! Call it a substitution for drugs, sex, prozac or food (although not really food I guess since it was only during nursing school that I magaged to drop from 270 to about 180 before going back up to 200)! No doubt my general attitude about life often bordered on severe clinical depression, but I would always comfort my dispondency with the mantra "if I can just hold on I can make it back to the island at least I will have the beach and no one can take THAT from me". That dream kept me going even when I quit nursing school halfway through a BSN program (my mother was terminally ill and the two hour commute each way with no sleep on my cinical days was killing me) only to start again from scratch to claw my way through an ASN program.. It continued to sustain me when I lost my first "dream" critical care nursing job because they said I "didn't have the stuff" to be a critical care nurse and it motivates me today on my PCU unit to give 110% each and every shift. Even when my relationship was on the rocks, my 300K+ car faultering (and no heat here in Indiana winters with a 30 minute commute is no laughing matter), my central heat in my home not working, bathtub cracking into the crawlspace (the list sadly goes on and on) it sustained me... Now, despite my best efforts that dream seems as far away (perhaps further) than ever and the only thing advancing is my age. I'm 40 and I truly do hope to take a crack at learning to surf on the North Shore before 50 (or die trying!). If push comes to shove at some point I very well may follow Thor Hyerdalh's example and take a stab at living off the land in the backwoods of Oahu, Molokai or Kaui until the local authorities lock me away for vagrancy. Perhaps my greatest fear is that I might indeed one day obtain my dream, but do so at an age that renders the endeavor moot. Even more I fear that you are all correct and that THIS is as close as I will ever get to my dream http://www.youtube.com/watch?v=0ltAGuuru7Q&feature=related . Sometimes however the pursuit of a dream can be as or even more important than its realization. I guess you could say that I'm a bit sensitive when it comes to this particular area, but I mean no one ill and wish you all the happiness that still seems to elude me. God bless.

One way to fight the high cost of eating out and groceries on Oahu might be the creation of "clubs" where people get together and each bring a dish. Nothing revolutionary here except these "pitch in" clubs would be more of an organized endeavor making use of cheap/free space in churches, schools and even member's homes and would be available to attend virtually if not every day (think of AA meetings, one of the things that amazed me in nursing school during my psyche. class was the fact that on ANY given night one could find anywhere from 10 to 20 AA meetings located in various parts of the city). Everyone would bring a dish and together a feast could be enjoyed that would rival the best dinner out at a fraction of the cost!

Well one BIG expense that we currently pay is anywhere from $500.-800.00 per month for childcare! Opp's that kind of blows my Oahu budget off the map (we both work nights and when we have schedule conflicts where we both work it costs about $100.00 per night for a third shift babysitter). On the other hand my goal is to live there by 45 or five years from now and my then my son will be allmost 14, maybe I might even be able to find a job with a set schedule for a change so my wife and I wouldn't have conflicts! As for a van no doubt we will have to buy two different vehicles when we get there since the one's that we have would be to expensive to transport so I am estimating the "car payments' for two vehicles similar to the ones that we currently own.

Well keep in mind my goal "move date" is five years out! Two or three years ago the nursing job situation in Hawaii was signficantly, if not radically different and I dare hope that it may again change for the better. In fact one of the things that made Hawaii have better than average job prospects was the fact that it is significantly shielded from large amounts of illegal immigration from South of the border (on the other hand that illegal immigration also helps nurses in places like Texas and Arizona by putting pressure on the demand for healthcare). With all of that said I would submit that my "sample budget" (listed in a different post) IS at least somewhat reasonable. Indeed, if given the power to make the decisions I believe that I could feed my family of three for about $50.00 per week (and we would be healthier for it). How? First we would eat ALOT of soups. Vegetable, cabbage fish, ect. We would also eat things like eggs, vegetables, and oatmeal (indeed there was a period in my life where I ate allmost nothing besides Ramen noodles, brown rice, and cheap apples, and cheap multi vitamins spending about $2.00 per day on food, plus I would water FAST and eat nothing every other day saving even more money). Anyone who has read Thor Hyerdahl's Fatu Hiva Return to Nature will learn that it is POSSIBLE (although not easy) to subsist allmost entirely off the land (albeit such an attempt would involve a certain amount of tresspass in most parts of Hawaii). Heck if one were truely willing to give up everything (including their family/careers) to live in the islands as nomad/bushmen in remote parts of the island(s) it could probably be accomplished to one degree or another it's just a matter of HOW FAR are you willing to go to achieve your goals. Did anyone see the movie about that guy who gave up everything (including an Ivy League education) to go live in the wilds of Alaska (perhaps not the best example since he died a miserable, lonely death, still he largely achieved his goals at least in part however misguided that most people might judge those goals to be). Another man who wrote the book Worldwalk literally WALKED AROUND THE WORLD living allmost entirely on the generosity of others (he was nearly killed on several occassions).

I have been told by at least two travel agencies that California is a "walkthrough" state and that if you go to Sacramento (some agencies said they will pay for the trip) that you can get at least a temporary license on the same day. Not sure about the verification system, but many states use the Nursesys company for license verification.

Thanks for the info. You will note my "sample" budget below. Clearly, any "successful" move is predicated upon certain "key" elements: 1. A significantly improved economy/job market. 2. Improved experience (time and effort will take care of that). However, what I was looking for was more subtle (and hence harder) to ascertain. For example I've noticed that Renal/dialysis nurses tend in many markets to be in demand when allmost no other nursing positions are to be found. Were I to learn that this was my "ticket" I would work on becoming a renal dialysis nurse and getting every credential in that area that I could. Other's areas that seem to be in consistent demand include pediatric/neonatal ICU, but are these the "hottest" areas on the islands as well? As for pay at least until recently most salary comparison sites listed HA to pay SIGNIFICANTLY more than areas such as Indiana (where we live) or Florida (where we hope to move in the SHORT term). Do you mean that salaries are lower than California, NV, and Arizona which have the reputation (again at least until recently) for having really good nursing pay or the mainland in general. Currently, we earn $22.00/hr and $24.50/hr respectively before night and weekend shift differentials (and we work nights).