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stevierae

stevierae

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  1. stevierae

    Circulators

    Sigh. Same ol', same ol.' This is deja vu all over again--it's just like the old "Who's better---A.A. RNs or BSN RNs." It never stops. This discussion has been had ad nauseum on this BB, if anyone cares to do a search. (Or just ask shodobe or me.) We are O.R. nurses who scrub AND circulate, and always have. We trained that way, and we expect other RNs to take the time and trouble to learn to scrub--all one needs to do is ASK to backscrub someone a few times, or take call--that's one way to get thrown into situations where you learn to be very proficient in a variety of scrub (and circulating) situations very fast. One way to stagnate is to refuse to learn to scrub--or to confine yourself to only one specialty area--refusing to do trauma, ortho, or neuro; instead sticking with eyes or plastics--you know, the easy, predictable, non-challenging stuff. Don't be so sure that OR RNs have very little training as scrubs. I learned to scrub as a Navy corpsman, in Navy O.R. tech school, during the Vietnam era. When I got out and went to nursing school, and went back to the O.R., ALL the RNs with whom I worked scrubbed--and very proficiently. By the way--what IS the difference between an ORT and an ST? I was not aware there was one. In the '70s and '80s, techs were called OR techs---even though many of them took a national certification exam. Then, in the '90s, the terms ST and CST suddenly appeared. What's the difference? I do realize that the "C" stands for "certified," and that STs who have the "C" prefix have taken a national certification exam." But, to me, the name change--from "operating room technician" to "surgical technologist" makes about as much sense as the name change from "housekeeper" to "environmental engineer--" people doing the same job, but with a fancy new title. What's the point? I don't care about calling myself an "operating room nurse" or even a "perioperative Registered Nurse." I usually introduce myself to patients, families and new staff simply as "the nurse in the room." (And when I was in Navy O.R. tech school, and graduated, I referred to myself as a "tech" or "scrub tech" or "O.R. tech--" as did the more experienced techs, even those who HAD taken the national certification exam.) I think if one is confident in his or her skills and knowledge base, one does not have to insist on being recognized by a long, alphabet soup of titles after one's name. One thing I will comment on---more and more, I am wondering what people are being taught in "CST" programs--because, more and more, I see this pattern---scrubs putting damned near their entire back tables up on their Mayo stands, rather than working from the minimum needed at any given time, and putting things in water in their soak pans once they are no longer needed. What's up with that? I swear, I've started (and finished) big bowel resections and colostomy takedowns, Whipples, liver and kidney transplants, AAAs, etc. with scrubs who put an entire stringer of vascular clamps--plus every size of loaded hemoclip applier--plus long instruments--plus long ties loaded on deep passers---up on their Mayo at the beginning of the case--- an hour or more before they will be needed! 3, 4 or 5 hours into the case--or, even when we are getting ready to close----said vascular clamps, Hemoclip appliers, long instruments, long ties, etc. are STILL up on their Mayos (but by now coated with dried blood--could have been avoided by putting them in water to soak hours before.) One last thing: For those OR techs---forgive me, STs, CSTs, whatever--who'd like more autonomy--I suggest you go back to school--either to become (first) RNs, then RNFAs or PAs--particularly if you want to first assist. Like it or not, you are working under the state licensure of your RN circulator--YOU ARE NOT LICENSED---even if you are certified. He (or she) is in charge of the room--and he (or she) is the designated patient advocate---by virtue of the ANA and the corresponding state's Nurse Practice Act.
  2. i know we've discussed this issue to death, both on this forum and on the gastroenterology forum. as an rn and operating room nurse, i have very, very trong feelings against this practice, which is now allowed in oregon, via our own nurse practice act. i wrote to the board twice expressing my feelings. i will post the most recent reply i received. note the reference of the writer to "the anesthesia community" (and her apparent disregard for their viewpoints) and the references to meetings and discussions, and requests for input, that were never, apparently, widely circulated (except on their website.) if any of you harbor feelings as strong as mine--that, i believe, would be most of you--please let them be known to the oregon board of nursing. if you reside and/or practice here, or in wa or idaho, possibly you can arrange to be at the next meeting, or to make your feelings known via mail or emails. i just think that this decision was wrong, and is a recipe for a sentinel event that could easily be avoided. without input, your own state could be next---other states; other hospitals, other free-standing endoscopy facilities, interested in using rns as cheap labor as an excuse to avoid paying or benefitting anesthesia providers, are probably well aware of this decision and anxious to jump on the bandwagon--anything to save a buck--safe patient care be damned. here's the reply i got by someone who identified herself as a "nursing practice consultant" of the oregon state board of nursing: (my own letter to which she is replying is below it: "i am a member of the board's staff and the staff member who led the task force that developed this policy. here's the history: at the november 17, 2005 board meeting, the draft policy guideline, nursing scope of practice for the use of sedating and anesthetic agents was first introduced as a non-consensus document for the board's consideration. work on this policy guideline was ongoing from the first task force meeting on march 28, 2005 until policy adoption in february 2006. the initial impetus for this work was in response to a december 13, 2004 letter from carla harris, vice president of patient care services for legacy health system, who requested clarification from the board about the role of the rn in the administration of anesthetic agents for varying levels of sedation, the task force consisted of 22 members from a variety of practice, health systems and geographical settings around the state. it included rnss, cnss, an fnp, 2 crnas and an ed physician. a literature search was done, and articles reviewed by task force members. during the november 17th meeting, stakeholders had the opportunity to speak to concerns they had regarding adoption of this policy. there was significant discussion regarding the use of anesthetic agents (particularly propofol) by the rn, np and cns for moderate procedural sedation. at that meeting, the draft policy was largely supported by those stakeholders with the exception of the anesthesia community. the board determined that additional feedback from the nursing community around the state would be useful, and directed that the policy be posted for comment on the website. the draft policy was posted shortly after the november 17th meeting, and comments were collected. e-mail comments that were received were reviewed at the board meeting on february 9, 2006. in addition to e-mail comments, dr. john walker sent a notebook filled with information for each board member including his personal statement from the november 17, 2005 board meeting, questions and answers regarding nurse administered propofol sedation (naps), a chronology of naps since november 2005, and 3 papers on naps. feedback that was editorial in nature was also received over the telephone and communicated to the board. the february 2006 meeting was videostreamed and videoconferenced into more than one location, so there was additional opportunity for public comment at that time. the information that you have pointed out in your e-mail was taken into consideration by the board in their decision-making. ultimately, based on the evidence and information in existence, the board determined that nurses may safely engage in sedation as long as the safeguards outlined in this policy are followed. as you can see, this was an extensive and thoughtful process. many safeguards were put into place. the decisions that were made, were not made lightly or without support in the literature. hopefully, this information gives you a clearer picture of the process that was followed. at this point in time, due to the fairly recent consideration of this same information, it is not my intent to forward your concerns to the actual board of nursing. if you believe that you need to pursue your concerns further, you are welcome to bring them to the board's open forum which is held during each board meeting. it is usually at 1 pm on the day of the meeting. the board next meets on february 15, 2007. you will want to check the website a couple of weeks ahead for the specific time. it would be helpful for me to know ahead of time, if you plan to be there. for your information, this is an opportunity to bring an issue forward, but any consideration of that issue must be given at a future meeting. if you want to discuss this matter in the meantime, please feel free to call." ________________________________________________ attention: oregon state board of registered nursing can you please clarify your position on rns who are not crnas giving iv push propofol to non-intubated patients? are you of the opinion and supportive of the position that this practice is acceptable as part of moderate sedation in free-standing surgical centers, ers, ors and gi labs (endoscopy suites?) i read the position statement in its entirety http://www.oregon.gov/osbn/pdfs/policies/sedation.pdf that appears to have been updated as of 2/2006. i am deeply concerned about your response to the rn (page 7) who states that she has been offered a job in an endoscopy suite, and will be giving propofol as part of conscious sedation. i do not believe that any rn, other than a crna, should be giving iv push propofol to a non-intubated patient--particularly an adult who is categorized as an asa 3, or a pediatric patient who is categorized as an asa 2. i am absolutely certain (check their position statements) that both crnas and anesthesiologists nationwide are in agreement with my position. aaaafs does not support this practice in free-standing surgery centers. you do realize that, at endoscopy labs such as the one in medford, or, nurse assisted propofol sedation that these patients are not intubated, correct? do you also realize that the package insert for propofol specifically states that it is to be administered (for anesthesia purposes) on non-intubated patients only by an anesthesia provider? do you realize that gastroenterologists petitioned the drug's manufacturer to remove this wording from the package insert--and were unsuccessful? i feel very, very strongly that the non-crna rns at this facility (and others like it) are putting their patients at unnecessary risk by administering propofol iv push. just the comments some of them make on various nursing bulletin boards shows that these people truly do not understand the pharmacology alone behind propofol, as they continually refer to giving their patients "a pain free experience." (propofol has no analgesic properties.) i do not think rns who are not crnas should be used as "cheap labor" by any facility as a way of getting around paying properly trained personnel--crnas or anesthesiologists----who deal with difficult airways and anesthetic complications everyday; multiple times a day. even healthy pediatric patients can laryngospasm and desaturate--and even arrest-- very, very rapidly. down syndrome children, for example, often have multiple co-morbidities and can become bradycardic and desaturate in the blink of an eye--yet they are the children entrusted to non-anesthesia rn providers in ambulatory surgery centers for "moderate sedation" when they need dental restorations or extractions done. they are the ones who often get assigned (and who is doing the assigning? the rn doing moderate sedation?) an asa 2 status. (why do you think that there are anesthesia providers who are specifically trained in pediatric anesthesia? these children are often medically fragile, and deserve a designated anesthesia provider--crna or anesthesiologist--managing their anesthetic regimens. they are trained in pals----most or nurses are only acls certified--not pals certified.) asa 3 adult patients--some of whom are smokers; some of whom have cardiac or vascular disease or other co-morbidities; some of whom are obese, have beards and short, thick necks, and even sleep at home with cpaps due to sleep apnea--are often difficult to "bag" (and intubate) by the most experienced anesthesia provider. endo lab nurses, and even operating room nurses and er nurses---and i am an operating room nurse with nearly 30 years of experience----simply do not have the advanced education, training or experience that crnas have. why should any of us be expected to function as "cheap labor" and endanger the lives of unsuspecting patients? these endo lab gastroenterologists and er physicians--as well as surgeons---should be able to focus their complete attention on their procedure---not on having to intubate a patient who has slipped into deep sedation--or even general anesthesia-- by a non crna rn and thus needs to be "rescued." many simply have little experience or skills even giving cpr (other than on a mannekin, at annual bls certification)--let alone intubating. please rethink your position. i know of no other state that allows non- crna rns to administer iv push propofol on non-intubated patients. it's simply not within the rn's scope of practice anywhere (other than in icus, where the patients already have protected airways.) those patients are intubated, on ventilators, have easy access to rt, intensivists, and pulmonologists, as well as anesthesia providers, and usually have arterial lines from which to draw stat blood gases (as well as other hemodynamic monitoring lines and devices.) i will be anxiously awaiting your reply. (i have actually written you in the past, as well as the orana (the oregon organization of nurse anesthetists,) about my concerns surrounding this issue.) i am passionate about my responsibility as a patient advocate, and will not rest as long as this is accepted practice in the state in which i reside--or anywhere, for that matter. this issue comes up all the time among legal nurse consultants such as myself.
  3. stevierae

    Propofol

    i was just checking out the "dr. naps" site, which appears to have recently been updated. this (below) is directly off the site. it's ("naps) just so wrong, on so many levels. i hope some anesthesia providers comment on this--i mean, the principles (at least some of them) may be correct, but they should be entrusted to anesthesia providers--not "ulenas" (the facility's oh-so-clever term for their rns.) (and what in the he** is the "western tongue scale?" or the ""bad dancing scale?" are these universally accepted terms, or just made up for their own purposes?) i particularly love the comment in # 33 regarding "satisfying the nurse's whims." and # 22--"range: 5- 350 mg to get started"--aren't those some pretty damned broad parameters for a non-anesthesia provider to be entrusted with? successful elements of nurse administered propofol sedation 1. the patient is fasting, or perhaps allowed clear liquids up to three or four hours prior to a procedure. the exceptions are that if a person is unreliable, then it is easier to tell them to be npo after midnight; patients must avoid red and purple liquids before colonoscopy, which is part of the standard prep sheet protocol; patients may need special instructions per their gastroenterologist if they have gastric outlet obstruction or achalasia in regards food the day before, and in the length of fasting. 2. the patient’s completed history and physical and parq discussion will be in the chart prior to the final words that the patient and the doctor have before proceeding. 3. on the day of the procedure the nursing assessment will be present in the chart prior to the initiation of the procedure and sedation. 4. the patient will have a reliable designated driver. 5. if the patient is supposed to be off anticoagulation, there should be documentation of this on the day of the procedure. 6. the patient had been advised about diprivan sedation and the differences, advantages, that it is relatively new, and of our local experience. anyone who requests light sedation so that he or she may watch will be granted at least an attempt at this. quite rarely people have requested other forms of sedation that they are familiar with, such as a surgery center of southern oregon patient who requested lamaze breathing and low-dose fentanyl. 7. extra time is allowed for titration if there is cardiovascular disease or pulmonary disease. 8. the initial dose is 10-50 mg, depending upon the patient profile, by which we mean the age, size, anxiety level, psychotropic drug use, alcohol use, and the presence or absence of vital organ diseases of any type. 9. the physician, sedation nurse, and endoscopic technician are all assembled prior to the initiation of sedation and any final decision making in this regard. 10. the pulse oximeter and blood pressure monitor will be working correctly and the oximeter will be audible. 11. there will be a running iv in proper working condition and ideally a proximal forearm vein is used; if not, the anticubital will be used. 12. lidocaine for the prevention of pain during injection is added to the diprivan unless there is a known allergy to lidocaine. 13. the nurse is cautious to avoid the rare circumstance in which a superficial aberrant artery is inadvertently cannulated. there have been no serious sequelae of this in the literature with either form of propofol, but this is a circumstance to be avoided with any intravenous medicine. 14. the patient will be ascertained not to be allergic to propofol, soy, eggs, or at least certain components of eggs, or metabisulfite if the generic is being used. 15. the propofol syringe is labeled with the date and time of expiration (six hours after being drawn), and the month is given in letters rather than numbers to avoid confusion with the european system of dates. usually the amounts of propofol are drawn in 50, 100, or 200mg amounts to allow flexibility and to reduce to a minimum the amount of the drug that is wasted at the end of the procedure. 16. a strict aseptic approach is taken. 17. special care is taken with people who have sleep apnea. 18. propofol for the individual patient is discarded at the end of the procedure and no syringe is carried over to another patient. 19. the patient is sedated at the proper rate until the eyes close, usually within 45 to 120 seconds, then tiny doses of sedation are given according to the physiologic challenges, the physician's gloved finger on the tongue (the so-called "western tongue scale), and subsequently the posterior oropharnyx to see if coughing is elicited or aversive body language otherwise; the digital rectal exam; and subsequently physiologic testing with the scope itself, particularly the upper esophageal sphincter for egd and ercp and certain classic zones of stretching during colonoscopy, the sigmoid and the transverse colon. 20. upon retrieval of the scope, particularly colonoscopic retrieval which is longer than endoscopic retrieval, more medication may or may not be needed, according to the patient's response. the physician and nurse are in constant dialogue about how much more time is needed. if the patient has discomfort during the phase just prior to the removal of the scope, e.g. targeting a sigmoid polyp in a spastic sigmoid, the nurse and physician will choose how much medication is needed for discomfort, well knowing that the physiologic stimulus of the scope will probably be taken away from the patient in a very short period of time. here incremental doses of 5 mg are frequently sufficient (rather than 10 mg). 21. the upper and lower endoscopy nurse assistants (ulenas) are to be trained by other pre-existing ulenas with ample experience and/or by physicians familiar with this technique. 22. the ulenas within the protocol decide the timing and amount of dosing, yet within the confines of the protocol, rather than the doctor ordering a dose. the ulena decides, again in close coordination with the physician, who is only three feet away from the nurse, according to the profile of the patient, how much it took to get started (range: 5 to 350 mg), how much time has elapsed since the last dose, how much time is left in the procedure, and in general what is going on with the patient, scope-wise. all of this is correlated with the nociciptive body language of the patient ("bad dancing scale" grades 1-4). 23. suction equipment should be close at hand. 24. oxygen is always used. usually this is provided by nasal prongs, although the prongs may be translocated to the mouth on certain occasions. 25. a working telephone is always available in the room. 26. ephedrine is readily available in the room and a triple check is made that the epinephrine is not given by mistake. 27. atropine is readily available in the room. 28. a crash cart is present in the room. 29. as little time as possible is spent with the patient in the supine position and all three team members, the physician, sedation nurse, an endoscopic technician, should be in agreement that it is safe to move the patient to this position for scope advantage. as soon as the cecum is reached with this maneuver, the patient is turned back into the safer left lateral decubitus position. [this is good practice with traditional sedation as well, and is not distinct to propofol sedation.] 30. the ulena will be acls certified and possess excellent upper airway management skills equivalent to an excellent recovery room nurse. 31. the patient is to bring his or her inhalers, if any, and use them in timing prior to the procedure so that the lungs are in tip-top pharmacologic shape. 32. patients are allowed to sip juice as soon as they can decide which juice they want, frequently within two minutes of termination of the procedure, as long as they are not experiencing pain from gas distention from colonoscopy or nausea. 33. some patients can leave within as little at ten minutes. to leave this early, they have to have a perfect aldrete score and satisfy a nurse's whims otherwise. 34. there are occasional people who have nausea or gas distention after an endoscopic procedure, more commonly after colonoscopy than upper endoscopy. if the symptoms are excessive, injection for nausea or for pain is given by a standing order by the nurse, who then subsequently reports if to the doctor. to receive such a medication, a person is usually quite awake and alert. lesser degrees of discomfort from gas distention (since propofol wears off so quickly) can be treated with tincture of time, nursing attention, and simethecone (more or less as a placebo). fortunately, significant gas distention with discomfort is seen in only about 3% of people and we may be able to reduce this to less than 1% with a more dedicated effort at suctioning air upon retrieval and at the termination of the exam. perhaps particularly susceptible are the people with a lot of diverticulosis and spasm of the left colon. 35. the ulena will complete the diprivan competency evaluation, fulfill the competency criteria, and fulfill the checklist for continued diprivan competency. 36. overall, the goal is to choose the proper and safe level of sedation for each patient in regards what is being done for the patient with the strong commitment to painless exams, 100% amnesia, and yet using the least amount of medication. we have found that even if people groan or talk, even making a complete sentence that is grammatically correct, they will not remember what they said, the endoscopic experience at all, and there will be a greater sense of the painless rendering by the team administering sedation. the range of sedation goes from anxiolysis in the preprocedural arena, to levels consistent with light traditional sedation, to deeper levels, but always with the goal in mind of being "two minutes away from sipping juice." in our experience, some of our anesthesiology colleagues have given too much medicine and too fast, although in general they have done a fair to good job and have been very supportive. thus, we will emphasize great attentiveness to the patient's needs and practice careful decision making with every small incremental dose that is given.
  4. stevierae

    Valentino's Sign/perforated gastric ulcer

    Thanks! I did google it, and found some info on Wikipedia as well. Valentino DID die, as I originally thought, from a perf'd duodenal ulcer---I think that some people assumed at the time that he died from a perf'd appendix, since he presented with R)LQ pain. But, apparently that's the syndrome---R)LQ pain resulting from a retroperitoneal perforation of the duodenum, secondary to an ulcer.
  5. Which does your institution use, and why? Do you use them under SCDs (sequential compression devices) until patients are ambulatory, or alone? I am trying to find literature to support one brand over another, but even Jobst says that they haven't done any recent efficacy studies comparing their product with TEDs. I recall, however, that in the '90s there was concern that TEDs were not true graduated compression stockings; that is, they did not deliver the pressure gradients that Jobst claimed to deliver. Since then, though, I've seen an Australian and an English study that found fault with Jobst, as well, for the same reason. I do realize that antioagulation is another factor to be considered in bedbound patients, and that proper measurement and application of whatever antiembolic stocking is chosen (and patient compliance with keeping them on, as well as keeping the SCDs turned on,) is necessary for optimal DVT prophylaxis. Just curious as to whether anyone has seen any nursing research (or medical research) that influenced their decision to choose one product over the other.
  6. stevierae

    Medication error causes 2 deaths in Indiana NICU

    no excuses. this is nursing 101, and spelled out in the ana code of ethics and most states' nurse practice acts---each person is responsible for his or her own actions. also from nursing 101--the 5 (nowadays, i think more than 5 are taught) rights of medication administration. and, lastly, from nursing 101--always, always, always check your heparin and insulin with another rn or physician before giving. heparin vials are also color-coded according to strength. they'll blame this, of course, on "systems error," rather than accepting individual accountability. here's a different article that provides a bit more detail about this tragic incident: fatal drug mix-up exposes hospital flaws by tom davies, associated press writer fri sep 22, 3:55 pm et indianapolis - early last saturday, nurses at an indianapolis hospital went to the drug cabinet in the newborn intensive care unit to get blood-thinner for several premature babies. the nurses didn't realize a pharmacy technician had mistakenly stocked the cabinet with vials containing a dose 1,000 times stronger than what the babies were supposed to receive. and they apparently didn't notice that the label said "heparin," not "hep-lock," and that it was dark blue instead of baby blue. those mistakes led to the deaths of three infants. three others also suffered overdoses but survived. now, their families, hospital officials and prosecutors are asking the same question: how could this happen? experts say last weekend's overdoses at methodist hospital illustrate that, despite national efforts to reduce drug errors, the system is still fragile and too often subject to human error. "i see what happened here as depressingly normal," said dr. albert wu of johns hopkins university, co-author of an institute of medicine report that estimated more than 1.5 million americans a year are injured from medication errors in hospitals and nursing homes and as outpatients. methodist hospital officials said they had safeguards in place before saturday's overdoses. hep-lock — a lesser dosage of heparin that is routinely used to keep intravenous lines open in premature babies — arrives at the hospital in premeasured vials and is placed in a computerized drug cabinet by pharmacy technicians. nurses must enter their employee code and the patient's code into the cabinet's computer to open it. a drawer containing a large variety of medicines then opens, and they select the prescribed drugs from compartments and enter the amount withdrawn. the system locks immediately afterward to prevent multiple withdrawals for the same patient. but there is no automated system to prevent nurses from taking the wrong medicine from the drawer in the first place. according to hospital officials' account, a pharmacy technician had loaded the cabinet with heparin, at 10,000 units per milliliter, instead of hep-lock, at 10 units per milliliter. d'myia alexander nelson and emmery miller died within hours of receiving the heparin. a little girl named thursday dawn jeffers died late tuesday. no autopsies were performed, but hospital officials said the cause of death was probably internal bleeding. even before the overdoses, the babies faced challenges. d'myia and emmery both weighed about a pound and were born more than three months early, barely past the point where survival is possible. thursday dawn was three weeks premature and, by comparison, a robust 4 pounds, 6 ounces. d'myia's grandmother lena nelson said the little girl had gained weight in her first four days, then died several hours after she was given the blood-thinner overdose. "she was doing fantastic. i could see her growing right in front of my eyes," nelson said. "then she was taken from us." hospital officials adopted new safeguards to prevent a recurrence. among them are procedures requiring a minimum of two nurses to verify any dose of blood thinner in the newborn and pediatric critical care units. another system, using bar codes to track medications, was being developed before the overdoses and is still in the works. since 2004, the food and drug administration has required that drug makers place supermarket-style bar codes on their drugs. many hospitals have installed bar-code scanners to make sure medication matches the recipient and is given at the right time. but money is an issue for many — the technology can cost millions. marion county prosecutor carl brizzi said his office will investigate the deaths, but he is not assuming a crime occurred. the county coroner also is reviewing the case. methodist president and chief executive sam odle said the hospital planned no disciplinary action against those involved. "whenever something like this happens, it is not an individual responsibility, it's an institutional responsibility," he said. the five nurses and pharmacy technician involved are on leave and receiving support and counseling, and are expected to return to work, odle said. nathaniel lee, an attorney for the jeffers and miller families, said the drugs' maker needs to change how it labels heparin and hep-lock. methodist has acknowledged two other heparin mix-ups involving babies in 2001, and said both infants recovered. "if this was an isolated incident i would say that it would be solely the responsibility of the person at the hospital," lee said. "but this is not an isolated incident." erin gardiner, a spokeswoman for deerfield, ill.-based baxter international, said the two drugs had different cap and label colors, bar codes and printing. wu, with johns hopkins, said the oversight was understandable, given that nurses were accustomed to having only the hep-lock vials stocked. "if someone suddenly were to switch in your home where something was located, rearrange where your furniture was located, it would be really easy for you to trip and fall," he said. the surviving babies face no remaining danger from the overdoses, methodist spokesman jon mills said. that is little consolation to thursday dawn's mother, heather jeffers, who blames the nurses, not drug labeling, for her daughter's death. "i don't think it was from the label," she said. "they are both blue, but one is lighter than the other. how could they mistake those?" ___
  7. stevierae

    Ephedrine for prevention/treatment of PONV?

    per yogacrna: "ekg changes with drop (read black box in package insert") yes--regarding the black box warning of ekg changes---as soon as that occurred, every place i worked at on the west coast pulled their droperidol out of circulation. i haven't seen it used anywhere since at least the year 2000--possibly earlier. but, i do have a colleague who is an anesthesia provider in manhattan, and he still has access to it, and continues to use it.
  8. stevierae

    laryngospasm and peds Succs dose.

    Seems to me it was always discussed in ACLS. I've had to give it IM a time or two for peds patients who laryngospasm'd while anesthesia was masking, (pre-intubation, and, therefore, before IV access had been established.) Always worked like a charm, and I was always glad that I remembered from ACLS how to calculate the peds dose (as well as peds dose for atropine.) Maybe we were always just lucky that we had a peds anesthesiologist available to lecture when I took ACLS. I've never taken PALS, but surely it's discussed in that course.
  9. stevierae

    Question about jewelry and ESU

    Well, as others have stated, we do so because we worry about swelling and subsequent impaired circulation. I, too, like to give the ring/rings in question to a family member to wear. Also, I don't want a ring or earrings lost on my watch, so I just tape them if they're not removed, and document it. However, I think the potential for burns or shock secondary to wearing earrings, body piercings or wedding bands is pretty much non-existent these days, and really needs to be re-evaluated via some new studies, with input by electrical engineering experts.
  10. stevierae

    Ephedrine for prevention/treatment of PONV?

    Yoga, I always read your posts attentively, and learn from them. Never apologize--you are a wealth of info and experience.
  11. stevierae

    Question about jewelry and ESU

    I've been thinking for years that this issue is really a non-issue--a sacred cow-- that should be addressed anew by an electrical engineering expert. Personally, I think we are all going on outdated information that goes back to the very early days of electrocauteries (anybody remember the giant green original Bovie machines that had reusable metal ground plates that you spread a conductive paste on--with reusable Bovie handpieces? I do!) Nowadays, electrocautery machines are far, far more sophisticated, and the chance of the current returning anywhere BUT directly to the (properly maintained and inspected by biomedical engineering) machine itself is, in my opinion, almost nil. Most cauteries simply will shut down or alarm if there is a problem with placement of the ground pad or something else obstructing the return of the current directly to the machine itself. Think about it this way: Think of all the metal retractors, particularly the self-retaining ones, such as Bookwalters, utilized in surgery. Do you ever see burns or any other tissue damage at the sites where the Bookwalter blades were attached to the skin? Do you ever see alternate site burns after such surgeries? Do you ever see burns or tissue damage at a site where a Deaver, Richardson or Harrington has been held in place for 30 minutes or more, while extensive cauterization has been going on? I've sure never seen a burn at a ring site. I've never seen nor heard of one--not in over 30 years. The single ground site burn I've seen was probably 25 years ago, with an old green bovie--circulator put ground pad on after patient was already in lithotomy; under the drapes. Pad "tented" but old machine continued to operate. (I have a feeling she kept increasing the current intraoperatively without examining the ground site or wondering why the settings needed increasing in the first place.) So why do we worry about earrings and body jewelry? I have a feeling we really do not need to do so----but I'd like to hear it from an electrical or biomedical engineer first. Incidentally, placing tape around a ring is for security reasons--to ensure that the ring does not fall off or otherwise become misplaced while the patient is under our care. It has no effect on conductivity.
  12. stevierae

    Female Foleys... I STINK AT THEM>>> HELP!!!

    Try this---it's how I've taught students who happened to be in my O.R. rooms over the years. I think it will help you, too--soon you will be teaching your OWN students this way: Get your Foley tray opened, (on a little prep stand or bedside table, or even on the the bed, between the patient's legs, which are "frog-legged"--just make sure it stays sterile) Put your gloves from the kit on Attach the syringe of H2O to the Foley--test the balloon if you include this step as part of your technique If your patient is awake, and you want to make the catheterization as atraumatic as possible, open the syringe of KY (If she has an epidural, she may not feel the catheterization, so you can skip this step) Pour your Betadine over your cotton balls, keeping one or 2 dry in case you need to wipe some Betadine off for better visualization of the urethra Make a "V" with the index and middle finger of the OPPOSITE hand (that is, NOT the one you will prep and insert the Foley with---to insert the Foley, you will use your DOMINANT hand) You will maintain this traction throughout the entire procedure. Put your "V'd" fingers at the very top of both sets (inner and outer, together) of labia and pull upwards, towards the umbilicus Prep, using your Betadine soaked cotton balls, with the opposite (dominant) hand per usual technique, while maintaining traction--the clitoris should be quite visible, and should be aligned with the umbilicus-- Look down, and while still maintaining traction upwards with the "V'd" fingers of the opposite hand, inject a tiny bit of KY--perhaps a cc or 2-- directly into the urethra, if you want to (you can skip this step if your patient will most likely not feel the insertion---just make sure you have used plenty of Betadine for lubrication) MAINTAIN YOUR TRACTION THROUGHOUT with the "V'd" fingers of your non-dominant hand!!!! If the Betadine has made things a bit slippery, "hook" the tips of your "V'd" fingers in and under the labia a bit, and adjust upward traction, still maintaining it Pick up the Foley (you can gently coil it around your fingers, if you'd like, so as to make the the excess length easier to handle, and lessen the chance of contamination) insert the Foley with your dominant hand all the way to the hub into the urethra (which should be visible a short distance down, but usually aligned with, the clitoris) When you see a drop or two of urine (if need be, you can have someone very gently Crede the bladder to push a bit of urine out and ensure you are in the right place) and then inject the entire 10 cc of H20 into the balloon port (to which it is already attached) (Alternately, if you are certain you are in the bladder, but would still like to reassure yourself by seeing urine, you can now release traction and use your non-dominant hand to Crede the bladder) Now pull the Foley gently down (with your dominant, still sterile hand) until it stops. You're done! Get rid of the trash. Put the Foley drainage tube under the patient's knee (at the "hollow" in back of the knee; that is, the popliteal space) and make sure it isn't kinked or urine flow obstructed in any way. If your policy calls for the catheter to be taped to the thigh, do so. Hang Foley bag below bed level. Chart size of Foley, amount, color and charcter of urine initially returned, and the amount of fluid you put into the balloon (this is so anyone who uses a syringe to deflate the ballon when it's time to d'c the Foley will be aware that they need to aspirate 10 cc. of water, not 5 cc. (An easier way is to simply use a scissors and cut the Foley at the hub of the balloon port to let the water drain out) If you do use KY, (on a female) don't use too much, as it can form a plug that can discourage the immediate free flow of urine--making you think you are not in the bladder, when you really are. If this happens, just disconnect the catheter from the bag and irrigate with a catheter tip syringe filled maybe 5-10 cc of H20--it will dissolve the KY and allow the urine to flow freely. Then you can reattach the bag. Be careful not to contaminate anything. (Just remember that,when catheterizing females, the technique works especially well if, instead of using your thumb and index finger to retract the labia, you make a habit of using your index finger and middle finger. It's just less awkward.) When you catheterize a male, inject the entire syringe into his urethra, rather than coating the tip of the catheter with KY---much better lubrication, and far less mess.
  13. stevierae

    OR slang doubt

    "Airplaning" just means a lateral tilt to one side or the other.
  14. stevierae

    Ephedrine for prevention/treatment of PONV?

    I asked an anesthesiologist colleague today if he's ever used it as his first-line drug of choice for PONV. Here's his response: "Nope. Never, never. Ephedrine is used like water, and I mean water for a host of hypotensive events many of which are heralded by vagal like symptomatology in awake patients such as nausea and vomiting. We treat nausea quickly in OB patients after their epidurals are topped off with ephedrine, for instance; not because it does anything for nausea directly, but, by raising the BP acutely, will restore blood flow to the part of the brain called the "area postrema" which triggers vomiting when it is deprived of oxygen."
  15. stevierae

    I am in an absolute state of panic right now... need help

    Ditto the excellent suggestions of seeking help from employee assistance. I would start keeping a paper trail--starting with a journal--of both your physical and emotional symptoms. Go to occupational health, see the doc, share EVERYTHING with him as you have told us, and ask for a mental health referral. File a work-related stress claim---this should be covered under worker's comp/disability depending on your state law. That way you will be able to take off the time you need to recoup, recover and contemplate where to go from here, without exhausting your sick time and vacation. On the job stress like you are describing is very real, and if you don't seek help soon, you will end up making a mistake that kills a patient, getting you fired and losing your license--and ending up with a serious case of PTSD, with no way to deal with it, as you will have lost your benefits, including health care. Take care of yourself first--if you don't, you will be of little use to anyone, including your own family. Also see if you can get your husband into couples' counsleing with you so that he can hear, in a professional setting, from a neutral 3rd party, how overwhelmed you are and that you can't do it all alone--and how he can help. If he won't go, go to counseling yourself--as they say, you can't change his behavior, but you can certianly change the way you deal with it. Good luck--hope things look up for you soon.
  16. stevierae

    Is it a JP or is it a Blake?

    NO. That is incorrect; sorry. In the case of a Jackson Pratt vs. a Blake, the reservoir is not what defines the drain--the drain itself (and whether it is flat or round) defines the drain. The "grenade" is simply a bulb--a reservoir. Both a JP drain (flat) AND a Blake drain (round) can be connected to that bulb; commonly referred to as a "grenade" or "JP bulb." (I guess you could call it a "Blake" bulb if you were using a Blake drain, but no one I have ever known does.) This may sound nitpicky, but it's important to chart accurately in the event, 6 years down the road, there was litigation surrounding the drain, and the manufacturers of the drain were named as defendants for, say, a defective product. It would be a real pain (and an expensive embarrassment to counsel) to backtrack and find out who supplied the hospital with Blakes at the time, serve them with subpoenas, take their depos, and then find out that the drain was, in fact, a Jackson Pratt--by a different manufacturer. As an operating room nurse, if I open a Jackson-Pratt drain, I chart Jackson Pratt, and what size --7 mm. or 10 mm.--and, if it were a Blake, I'd chart that it was a Blake, and what size. I wouldn't guess, and I wouldn't expect anyone else on med-surg or ICU to guess--what I charted is what they received in their patient. Also, I have the packaging to refer to and charge appropriately (and send to purchasing for reorder/restocking purposes.) Now, to make things even more complicated, there are Hemovacs--and then there are Reliavacs. They each come with their own drains and extension tubing, and the reservoirs look very similar. But they are a different animal than either JPs or Blakes. And, most people tend to use the terms "Hemovac" and "Reliavac" interchangeably. Indeed, both reservoirs have a spring inside--after you empty the reservoir, you squeeze it flat (like an accordion) to get the air out, then reseal it. Repeat the process when it fills with blood/fluid again. Again, for the same reasons I mentioned above, don't chart a Hemovac as a Reliavac if it's not (and vice versa)----you never know if litigation involving the product will surface 5 or 6 years down the road, and you don't want the wrong manufacturers/distributors named. I have never seen Argyle chest tubes hooked to anything but a Pleurevac, which in turn went to suction.