pappyRN

Hello JayJay, They had her on half a 25mcg patch? Did they cover 1/2 the patch or did they cut it? I can't believe that there was a nurse who actually followeed that order. Of course, you'd think for what they charge for each patch(approx $37.00/patch for 75mcg) that Janssen would develop a 12.5mcg patch for opioid wimps or little old people who can't tolerate the 25mcg patches. Fentanyl can and does cause some really powerful nausea, and it's really hard to forget it when you have experienced it due to the intensity of it. I'd say that this PMP has an attitude for sure. Did his head fit through the doorway with it being so large? How sad and awful for his clientelle that he is so egocentric and insecure. Maybe you could give Janssen an anonymous call and very diplomatically encourage them to send their detail rep for his region to this doctor's office to review the correct application and indications of the patch. He could say they were having some safety issues and that they are just making sure that everyone understands exactly how they are meant to be used. Opioids can cause somepowerful itching and also some very powerful nausea. Most of the time it is dose related and when the dose is adjusted correctly, pts start to realize that their symptoms are getting better. Doctors can really be uh, a bigger problem for pts than their diseases can be. Do you think they were sent to earth just to aggravate us or punish us??? Maybe THEY are our hell on earth or at least I believe some of them are!!! Can you imagine if we told a doctor that IF he wanted the pt to have just one half of a patch applied, that HE would have to apply it himself? Wouldn't you just love to say that to him sometime? The thought of it is tempting but unreasonable and sure to get you fired! Doctors. You gotta love 'em! Warm personal regards, PappyRN Thank you for your reply. Warm personal regards, PappyRN

Hi RN-PA, I am unable to take any of the AD's in the SSRI category due to the fact that I experience a phenomenon known as serotonin syndrome. My sister is currently struggling with weaning off Effexor- a really hideous medication when you are late with your dose or when you try to wean off without some type of medical support for the severe, repugnant symptoms one experiences with weaning fgrom this drug. I can't believe my eyes as I watch the poor thing go through absolute hell in an attempt to get off this poison. It infuriates me and her that NO one, not the doctor nor the pharmacist warned her about the potentially gruesome physical dependence that develops with it's use. In addition to feeling like her blod is boiling, she feels as if she is suffocating and losing her mind. She is being treated for clinical depression. Her previous shrink had her on 300+ mgs of Effexor, Prozac, Nortriptylin, and Wellbutrin in addition to the Duragesic patch that is prescribed by her pain management doctor for severe fibromylagia. When she first started the Effexor she had violent headaches and her shrink told her to just sit tight and they will go away on their own. They did but what happened insterad is that she became more easy to anger and lash out, she had very frequent panic and anxiety attacks, and felt like she wasn't really in her world for lack of a better way to describe it. I found some accounts from pts on Effexor and how horrible their side effects and withdrawal was for them. I spoke to her about these unpleasant behaviors that she displayed and then went with her to he new shrink, of course with her permission to be in there with her. I gave him some copies of the stories I had found. He was at first skeptical defending the Effexor by saying it is a very useful drug for some and has it's place in psychiatry. My sister insisted that he give her a wean schedule at her next visit but didn't remember to ask for something to assist her with the symptoms she was bound to feel as she withdrew from Effexor. We ended calling him on the phone for an RX for Valium because she was beside herself with the horror. She is so very angry and offended that NO one told her about these deep dark little secrets about Effexor. He is withdrwaing her from it at 37.5mg at a time every three weeks and she is still feeling these exasperating symptoms of withdrawal. You might ask your doctor for Remeron or Nortriptylin(Pamelor), Desipramine(Desyrel), Trazadone, or Amitriptylline(Elavil). My personal preference is Norti[ptylin. I am not hung over and I haven't felt this well as far as the clinical and situational depression goes, in a long time. Elavil made my mouth and mucous membranes way to dry and I would cough half the night and guzzle water to quench that very dry throat. One thing about the tricyclic antidepressants is that they make some patients crave sweets or have a way bigger appetite. It is something to be aware of so you can keep track of. Good luck and I hope things settle down for you soon. You are so smart to recognize there is a problem, admit it and seek help BEFORE it becomes a huge problem. Warm personal regards, PappyRN

Call the state Elder Abuse hotline and also call the Ombudsman. Pts can NOT be threatened with being moved. Thank God you are a person with integrity and are willing to risk possible consequences if need be. However, that said...it is also against the law to retaliate in ANY way against anyone making a hotline call in good faith. IF they are ANY repercussions to you for making this call...call whatever licensing board is in control of Nursing Home Administrator's licenses. Then, call the state Elder Abuse hotline AGAIN and report these repercussions and retaliations should they occur. Both steps are needed to complete the full circle of handling an admin who not only is foolish enough to even THINK of retaliating but to actually carry it out. That's IF he does. The retaliation may be subtle but you will know. Start documenting any and all behavior exhibited with this admin. I have been through this process with the admin of the LTC where my Mom is a resident. My sister and I made a hotline call recently for failure to provide dental work for her when they knew she had at least two abscessed teeth. The repercusions were more obvious at first but now they are somewhat subtle such as we need a note from the social worker stating that Mom is on Medicaid and is indigent and a resident of a nursing home. That requires "to whom it may concern" and about two sentences to accomplish what we need. The social worker assigned this task to the office secretary- TWO weeks ago for two sentences. Each time if we ask if it has been done, she launches into a tirade about how busy she is and says a little too cheerfully for me " Sorry I have not had the time yet and I don't know when I will." My next conversation with her is to ask her how she's going to like it when we call the Ombudsman and the state again to report her for retaliation. Please keep on advocating for these poor residents. I remain in a state of shock at the fiascos I've seen at this home. Believe it or not...it is the best of the best and THAT imakes me unbelievably sad. If I ever get well enough to return to nursing, you'd better believe that I will be applying for a state surveyor job. The nrsg staff left my Mom's AFO brace off for over EIGHT MONTHS. It was irritating her foot and instead of having it fixed or padded, they set in in the corner of her room where it never even got worn much less fixed. The head PT left the facility about 3+ months agao. There's a new head PT and gues what...somewhere around the time of the state's visit, they called me and asked if they could get her another one. I told them to ask her because she still signs consents for herself. Well, about 3-4 weeks ago AFTER state had visited...my Mom is now walking SEVENTY FIVE FEET with a hemi cane and asistance. The last therapist hated my sister and I and so he didn't pursue getting the AFO brace fixed for her. SEVENTY FIVE FEET more than TWO AND ONE HALF YEARS since having two strokes!!! Three months ago she was barely able to transfer and walk ten feet without at least two people holding her up. That was without her AFPO brace! I hope I die before I end up in a nursing home after seeing what happens to my Mom. Warm personal regards, PappyRN

Hello, I can only speak from my experience as a chronic pain patient but the instructions for using a Duragesic patch specifically say that the patch must be pressed firmly against the pts skin with the palm of the hand for 30 seconds, making sure that the contact is complete especially around the edges. They also states that the system should NOT be altered in ANY WAY prior to application. What's the point of trying to make a half of a patch by covering half with opsite??? That's ridiculous, highly inaccurate and completely goes against what are the recommended instructions for the application of the Duragesic patch. What will he do the next time...ask you to CUT it in half? I happen to save all the package inserts from any of my medicines and not just those monographs that you get with the prescription from the pharmacist. I guess it's a carry over from my nursing school days and my early days as an RN. I don't know if new nurses do this now, but we were taught to bring our drug box cards to work with us, even after graduation. We had to make an index card lisint drug information for every med prescribed to every pt we took care of while as student nurses. I'm almost embarrassed to say that I still have my file box full of drug information index cards! I add these package inserts to it whenever I remember to tell the pharmacist to give me the pkg insert from the manufacturer, not those monographs. I will share with you what the insert says about Duragesic Transdermal System. Just skip my post if you aren't interested. I can't get to sleep so I thought it might be helpful if I share what the insert says. Duragesic is a rectangular transparent unit comprising a protective layer and FOUR functional layers. Proceeding from the outer surface toward the surface adhering to the skin, these layers are: 1) a backing layer of polyester film; 2) a drug reservoir of fentanyl and alcohol USP gelled with hydroxyethyl cellulose; 3)an ethylene- vinyl acetate copolymer membrane that controls the rate of fentanyl delivery to the skin surface; and 4) a fentanyl containing silicone adhesive. Before use, a protective liner convering the adhesive layer is removed and discarded. If Duragesic is cut or damaged controlled drug delivery will NOT be possible. Duragesic releases fentanyl from the reservoir at a nearly constant amount per unit time. The concentration gradient existing between the saturated solution of drug in the reservoir and the lower concentration in the skin drives drug release. Fentanyl moves in the direction of the lower concentration at a rate determined by the copolymer release membrane and the diffusion of fentanyl through the skin layers. While the actual rate of fentanyl delivery to the skin varies over the 72 hr application period, each system is labeled with a nominal flux which represents the average amount of drug delivered to the systemic circulation per hour across average skin. While there is variation in dose delivered among patients, the nominal flux of the systems(25, 50, 75, 100 ug of fentanyl per hour) are sufficiently accurate as to allow individual titration of dosage for a given pt. The small amt of alcohol which has been incorporated into the system, enhances the rate of drug flux through the rate limiting copolymer membrane and increases the permeability of the skin to fentanyl. Following Duragesic application, the skin under the system absorbs fentanyl, and a depot of fentanyl concentrates in the upper skin layers. Fentanyl then becomes available to the systemic circulation. Serum fentanyl concentrations increase gradually following initial Duragesic application, generally leveling off between 12 and 24 hrs and remaining relatively constant, with some fluctuation, for the remainder of the 72 hr application period.Peak serum concentrations of fentanyl generally occured between 24 and 72 hrs after the initial application period.Serum fentanyl concentrations continue to rise for the first few system applications. After several sequential 72 hr applications, pts reach and maintain steady state serum concentration that is determined by individual variation in skin permeability and body clearance of fentanyl. After system removal, serum fentanyl concentrations decline gradually,and 17 hours or more are required for a 50% decrease in serum fentanyl concentrations, (range 13-22) hours. Continued absorption of fentanyl from the skin accounts for a slower disappearance of the drug from the serum than is seen after an IV infusion, where the apparent half life is approx. 7 (range 3-12) hours. Since elderly, cachectic, or debilitated pts may have altered pharmacokinetics due to poor fat stores, muscle wasting, or altered clearance, they should NOT be started on Duragesic doeses higher than 25ug/h unless they are already taking more than 135mg of morphine a day or an equivalent dose of another opioid. Information from a pilot study of the pharmacokinetics of IV fentanyl in geriatric pts indicates that the clearance of fentanyl may be greatly decreased in the population above the age of 60. The relevance of these findings to transdermal fentanyl is unknown at this time. * The recommended starting dose when converting from other opioids to fentanyl is likely too low for 50% of pts. However, this starting dose is recommended to minimize the potential for overdosing pts with the first dose. The whole mechanism of Duragesic patches is predicated on the correct application of the FOUR LAYERED transdermal medication delivery SYSTEM inherent to the patch's construction. Each layer works in conjunction with the others. Even the adhesive contains fentanyl so it's important for you to handle the adhesive border as little as possible. ALL layers of the patch contain medication, not just in between the layers that are obvious. Disrupting the intended mechanism of delivery negates the whole purpose of using this steady delivery system. Each layer of the patch, including the adhesive border, is dependent on the correct application for the dose to be delivered in an even manner so hold the patch in place for 30 seconds and be sure the edges of the patch adhere to the skin. Trying to construct a 25mcg patch by rigging it with opsite is questionable at best, most likely very inaccurate and possibly ineffective. As was said by Karen, if the pt was opioid naive, 50mcg would be a very hefty dose. Janssen instructs physicians to always start with a 25mcg patch regardless if the pt is opioid naive or opioid tolerant. Doses higher than 25mcg are contraindicated for an initial dose. Dosing can be titered upwards if need be after determining the pts response to it, but should really only be done after at least two applications of the patch. Steady state is reached after 17 hours with the patch applied and because fentanyl's serum level drops gradually, for any reason if ordered to reduce opiate therapy or switch to a different analgesic, give only half of the equianalgesic dose of the new med 12 to 18 hours after removal. With that amount of time needed to reach steady state and it's slow serum level drop, it seems strange to be ordered to interrupt the medication delivery by removing the patch and then reapplying it later especially if under 12 to 18 hours. Maybe I misunderstood, but is the patch being used as a prn med? I hope the family of this pt didn't want the pt to be snowed with drugs after seeing the pt was up and interacting earlier in the day. What was the doctor's major malfunction? Was he just trying to hasten things and keep the pt quiet so he would be called less and wouldn't have to deal with the pt? What in the heck was he thinking? Did he even know if this pt was actively dying? Sounds to me like he was robbing the pt's family of valuable time together with the pt interacting and the family conversing with the pt. Was the doctor a pain and palliative care specialist? IF it was my parent, I'd be livid that he was either trying to speed things up OR dosing too heavily when obviously the time wasn't quite right yet and the pt not imminently terminal or expectant. It's one thing to be made comfortable but quite another to be rendered out of it and unable to communicate. I'd guess that he screwed up by applying a 50mcg patch instead of a 25mcg patch but also by giving her the Haldol. It also sounds like he was embarrassed because you caught his mistake and he got busted by you in front of the family and so he tried to make himself look important and in control by raking you over the coals and then having such a long conversation with the pt's family to reassure them that HE was right and YOU were wrong.Sound a little like he was trying to talk his way out of his mistake when he was speaking to the family? Hopefully, the pt's family was smart enough to see what was really going on. He got caught messing up! Based on a pharmacokinetic model, serum fentanyl concentrations could theoretically increase by approx. one third for pts with a body temperature of 104 due to temperature- dependent increases in fentanyl release from the system and increased skin permeability. Therefore, pts wearing Duragesic who develop fever should be monitored for opioid side effects and the dose should be adjusted if necessary. All pts. should be advised to avoid exposing the Duragesic application site to direct external heat sources such as heating pads or electric blankets, heat lamps, saunas, hot tubs, and heated water beds etc. while wearing the system. There is a potential for temperature-dependent increases in fentanyl release from the system. Duragesic should be applied to non-irritated and non-irradiated skin on a flat surface such as chest, back, flank, or upper arm. Hair at the application site should be clipped NOT SHAVED prior to system application. If the site of application must be cleansed prior to application of the system, do so with clear water. Do NOT use soaps, oils, lotions, alcohol, or any other agents that might irritate the skin or alter it's characteristics. Allow the skin to dry completely prior to system application. If the pt experiences any breakdown from the patch or from it's adhesive border, spray the skin with either Azmacort, Flonase or Beconase nasal spray to help to prepare the skin and prevent the rash that occurs frequently with Duragesic. Of course, let it dry before attempting to apply the patch! The drug company, Janssen, will NOT continue to supply the pt with free bio-occlusive dressings if you or the pt reports that there is ANY skin breakdown no matter how minor. They are instructed to discontinue ordering these dressings for a pt if they know about a rash or blisters and those bio-occlusive dressings are very expensive. Care should be taken not to reapply a patch to that area until it is well healed. The concomitant use of other central nervous sytem depressants may produce additive depressant effects. When such combined therapy is contemplated, one or both agents should be reduced by at least 50%. Duragesic is supplied in sealed transdermal systems which pose little risk of exposure to health care workers. If the gel from the drug reservoir accidentally contacts the skin, the area should be washed with copious amounts of water. Do NOT use soap, alcohol, or other solvents to remove the gel because they may enhance the drug's ability to penetrate the skin. To dispose of Duragesic, the system should be folded so that the adhesive side of the system adheres to itself, then the system should be flushed down the toilet immediately upon removal. Like I said, my perspective is from that of a very ill chronic pain patient as I haven't been able to practice nursing for the last seven years. I just found out a few weeks ago that it is very likely that I am also now diabetic on top of having RSD, TOS, fibromyalgia/CFIDS etc. I am just sooo sick of being sick! Hope I wasn't out of line for expressing my opinion. Please excuse me if I have repeated certain information. I have not been to bed since Wednesday night due to insomnia and really bad pain levels. It is extremely cold here with a lot of wind. The cold is very hard for me and the Reflex Sympathetic Dystrophy/Fibromyalgia/TOS. My rt arm and rt leg is rather cyanotic and cold even though the heat is on and I am wearing long sleeved and long pants pajamas with slippers. It is just the vasomotor effects from the disease. I don't know how to describe my pain except that it is deep, hard searing bone pain with very severe bouts of hard lightning like jolts that occur anywhere it wants to. I think if you think about experiencing "brain freeze" when you eat very cold food such as ice cream and the roof of your mouth screams out in pain. That is almost a dead ringer for what I feel on the entire rt side of my body with the characteristic of 'burning' added to it.I am hoping beyond hope that this doesn't represent diabetic neuropathy on top of everything else that is wrong with me. If you have any spare prayers will you please keep me in mind and send them my way? I also just found out lsat night that my nephew is dying from Kaposi's sarcomas in both lungs. Yes, he is HIV positive. He also has malignant melanoma. He's 35 years old and a wonderful nephew. I am saddened beyond my ability to think. Sorry if I have babbled too much. Thaks for allowing me to get so much typing practice.lol Warm personal regards, PappyRN

And a Good Morning to you, also. Allrightey then. Get some ice chips for me to munch.Thank you for your uh, tongue lashing Nursie30. That sure was nice of you. There's NO need for you to direct your hostility towards me and others who don't share your opinion. I clearly stated that my intention was NOT to flame. It is out of my control when I state my intentions and they are then interpreted in a way I didn't intend them to be. Should I jump through the monitor and yell "No, that's NOT the way I meant it"? I say what I mean and I mean what I say. I said it was NOT meant to be a flame. It can't be much more clear than that. When posts and replies are found to be inappropriate, the moderators enforce their predetermined remedy. "Nursie30" perhaps you should take a cold shower and cool off. Lighten up, please! There's no need to be so intense. I believe I have adequately stated what my intentions were. I have always felt that nursing was one of those fields where you felt either a strong desire to be one or a strong aversion against being a nurse. If a person already knew for sure that he/she would HATE wiping hineys and other equally distasteful tasks, WHY would someone choose to go into a profession that necessitates that experience both while training and when practicing as a registered nurse? Why would we encourage someone who states objections to performing those tasks, to enter the field when we know those tasks to be a part of this profession? Manyquestion's talents would probably then be put to better use if the position doesn't require tasks that involve excrement or mundane but completely necessary tasks such as feeding a patient. Manyquestions if you truly feel like your intelligence exceeds the range that you assign as probably adequate for nursing and you enjoy intellectual challenges, you would most likely be disappointed. I suspect your post and questions were really not as much about ADL's as about getting into a field that is exciting, stimulating and challenging. In my own case, my desire to become a nurse far outweighed the thought of having to do unpleasant tasks. It had been my childhood dream to pursue a career in nursing. I had never experienced any doubt about choosing to be a nurse.Pediatrics and neonatology were my areas of specialty. Neonatology was truly one of the most rewarding experiences of my life. Don't get me wrong, it wasn't always a picnic. It was a very busy unit where the census and acuity levels remained very high. There were many young (11-15) teenaged Moms who were every bit as much a part of my assignment as the babes were and who required extensive discharge teaching.I found it preferable to work in the NICU step down- the Special Care Nursery as the acuity levels were lower and I was able to spend more time with the families and be able to also hold the babies etc. BUT...that all ended for me eight years ago with an on the job injury to my neck and rt dominant shoulder/arm/hand and I now battle the excruciating pain of both reflex sympathetic dystrophy and severe fibromyalgia/CFIDS. I never even gave being a PA a thought. I think that would be a great job to have. I believe in most cases it requires about 2 years of school to become a PA. If you like intellectual challenges, why not try to get into law school? IF, you still decide to attend nursing school, there is the legal nurse consultant area of specialty. There is also nursing infomatics if you prefer working with computers.I am unsure of all that it entails but I imagine you would review cases and possibly function as an expert witness for some. I could be wrong but possibly you should check into that. I do disagree with you to an extent, Manyquestions, about not needing to be of more than average intelligence to be a nurse. Of course, it's not a necessity to possess extraordinary intelligence but there are many specialities in nursing that really do require the nurse to have above average intelligence to function.There are many situations that do require the ability to apply critical thinking skills and analysis along with problem solving. There is a lot of memorization which just about anyone can do but there is also the necessity of being able to apply all that you have memorized. I may be old fashioned(a VERY likely probability) but I also feel that nursing is one of those professions that you either love or hate. If you are a person who fully embraces nursing, you will have a passion for it and wont be hesitant to enter this profession. You are very correct when you said there's room for many kinds of people in medicine. I wasn't trying to flame you Manyquestions, just like I said, but I believe when someone asks a question they want an answer. I am sorry if my directness offended you but I also do not consider my attitude to be of the holier than thou type. I just say it like it is. But again, sorry if you found my reply offensive. I have to agree with you about all these requirements for degrees or certificates only to find yourself doing work that could have been done without those things and getting paid an insulting amount for the time, effort and money you expended in school. I imagine some employers just like to know that the 'paper proof' is on record. Sorry to hear about your being poor. I'm in that same boat as was my husband until approx one month ago. He has a business degree but was unable to find steady work except for temp agency positions and one 1 1/2 year stint at a company that went bankrupt. In the last EIGHT years, he has only worked sporadically for several weeks at a time. Of course, there were NO benefits so that was really tough as I am disabled and on disability. Problem was, my meds cost over $750.00/month so that left us $50.00/month to stretch for groceries. Fortunately, depending on how one looks at it, we had retirement money saved that we had to dig into because without it, we would have lost just about everything. I hope you are not in a similar situation. Good luck in whatever you decide is the best career for you. I think there's definitely a certain amount of excitement in being a paramedic with a very busy fire department. I'm sure you will be successful at whatever you decide to pursue. Warm personal regards, PappyRN

Manyquestions, I truly do not think you should choose nursing. It requires so much empathy for the human condition. If you feel that you don't want to spend time a$$wiping, I don't hold out much hope for you when say you have to empty a disgusting suction cannister etc. Remember, thank God that there are nurses because some day the a$$ that needs wiping might be your own or one of your family members. Would you honestly want to be under the care of a nurse who believes a$$ wiping insults her intelligence? What if it was you who had to lie in a pile of excrement until someone who wasn't put out with having to engage in such a demeaning activity, was found so you could get cleaned up? Have you considered art, floral designing, law schoolor possibly hospital administration? This wasn't meant to flame you but realistically how in the world would you be able to do the jobs required of you in nursing? Rather than putting yourself in that postion, why don't you avoid it in the first place? Sometimes, poop is the LEAST of a nurse's problems. You can't imagine some of the disgusting things we have to see or do! Warm personal regards, PappyRN

The LTC where my Mom is unfirtunately a resident has an RN just like Rustyhammer's exhippie nurse description. The only exception being his hair isn't long but looks like it was inflated with air and sprayed to stay in that big poof. He flat out DOESN'T take care of the patients unless it can be done from his chair in the nurse's station. All the new nurses get notes from him that this or that wasn't done and if it isn't there will be people getting written up. He never helps the day nurse with anything. He sits in his chair and jopkes with the pts who are with it but moves or has moved by the cna's the pts who are disruptive or making any type of noise regardless if it is involuntary and can't be helped by the pt. He has the cna's take the other annoying pts all the way to the lobby and point them towards another division. This way it takes forever for them to wheel themselves back to the division. Personally, I think that is just plain cruel and proves what an a$$hole he is. He makes fun of me and says I think I am a doctor. What an insult! I told him I wasn't going to play stupid just for him. I know what I know and am proud of it. He is so threatened by anyone with more knowledge than him. Mom's PCP can't stand him because of his laziness and his failures to notify him of changes before they become extremely serious or life threatening situations. He went crazy when my Mom's PCP told him he should listen to me because I was a great nurse and really knew my stuff. He even suggested that he have me work with him for a few days so he could learn from me!Talk about rubbing the crap under his nose!lol This doctor is no longer on his list of favorites to say the least. This nurse got a part time in the ICU at a local teaching hospital but left after two weeks because it was too demanding. That's what he told the nurse who works with him on the day shift! "I ran my legs off!" There's so much more I could say but I will spare you and stop here. All of these descriptions about Types 1-4 and the ex hippie nurses are cause for some deep introspection..They are cause for any nurse to stop and think if these descriptions even partially describe themselves. If they do, time for some R&R or a change of location. Warm personal regards, PappyRN

Hello Roland, I can't answer your question because I don't know. Plesae accept my condolences on the death of your Mom. I would just say to trust your gut feeling as a nurse. If it feels really wrong it most probably is. It seems as if the doctor was treating your Mom and her nausea as he would treat someone at such an endstage point that death was expected to be almost imminent. If Haldol can not be recommended for use with opioid pain medicine that is an additional issue. You must be feeling very cheated about the loss of more time with your Mom and time with her grandson. I'd just say to go for it in trying to find out the truth of what happened. I will also caution you that it is VERY difficult to prove anything but also to get expert witnesses to give testimony against fellow nurses or doctors. I am ver surprised that the nurses weren't more forthcoming with you about the Haldol, especially in hospice where all I have ever experienced or heard has been brutally honest. I am so sorry for your sadness and I completely understand what you are feeling. I experienced a very similar event when my Dad passed. You just feel cheated and angry and it doesn't feel that anything will make it go away because nothing you do will bring your Mom back. The frustration is enormous. Warm personal regards, PappyRN

The pediatric hospital where I worked neonatal services before an on the job injury took me out had a policy of three sticks and then another person tried. After 6 sticks, the baby was to be given rest if possible and either a transport RN or an NNP would attempt to get IV access. We were encouraged to report and/or write up anyone who abused the three sticks rule by attempting the IV more than three times. Prior to this, I witnessed numerous times when nurses just kept repeatedly sticking and sticking because their pride wouldn't allow them to admit they couldn't access the vein. The babes would get wiped out and stressed from all these attempts. I always looked to see if the big vein right behind the ear looked like it was suitable for the type of IV catheter and the type of therapy being delivered. Other than that, I just made sure that whatever I was sticking could be visualized or felt so that I was sticking just for the sake of sticking. The only hints that I can give to you Kristi is to just make sure you are not trying to stick and advance the catheters too quickly since these vessels are so superficial and fragile. It used to make me flinch when I'd see a nurse stick and try to advance the catheter quickly. IV access can be and is a slow delicate process for neonates. However, don't take so very long that the catheter has a chance to clot off. Remember, only stick what you are confident you can access. Their veins are very superficial. Select the appropriate size of catheter. It's unlikely that you will be able to place a large bore catheter in a thread of a vein. Take the time to restrain the babe adequately so that movement doesn't interfere with your attempts.Have all your equipment ready and the tape torn so that valuable time isn't wasted while someone tears the tape and the catheter doesn't clot off while you are waiting.I don't specifically know of any books to recommend. It has now been almost seven years since I practiced but it seems like yesterday to me. I was fortunate to be a technically competent IV starter but I also had a lot of experiences since I worked in a tertiary referral center and our patient census was consistently high. I worked neonatal services for 13 years before my injury put a stop to it. I miss it terribly. Shortly before I left there was a lot of discussion regarding using heparin flush solution in the catheters before inserting them. It was done infrequently in our unit but not as a general practice. Be patient. I wish you the very best in your pursuit of technical proficiency at starting IV's. Many nurses try without success and instead of trying to take action to improve their skills like you have they just keep sticking in their ususal manner. Warm personal regards, PappyRN

The symptoms you describe from coming off the Paxil are the symptoms of withdrawal. Many physicians are unaware of the need to taper off Paxil and/or even that Paxil can cause the symptoms of withdrawal when DC'd abruptly. Some people are so sensitive to it that they experience withdrawal if they are even a few hours late taking their Paxil. They can experience agitation, nausea, abdominal cramping, diarrhea, sweating, generalized aching, and myalgias like they have a virus or 'bug'. I am unsure if other SSRI's can cause wd symptoms when not tapered to discontinue. I have heard that it can happen with Prozac but I have no scientific proff to back it up, just heard it as secondhand rumor. Serotonin syndrome is experienced as a result of taking SSRI's, not discontinuing them. When experiencing serotonin syndrome it is necessary to discontinue the med and change to a different AD. However, this should be closely monitored by the physician as supportive drugs may need to be prescribed. Serotonin syndrome is also referred to as "serotonin storm". Patients who are experiencing serotonin syndrome are frequently feeling extremely "wired" and abnormally hyper. Having experienced it myself as a reaction to both Paxil and Zoloft, I can tell you it is not a good feeling. I found the experience to be quite scary. I felt like I was coming unglued or like I was going to burst, from what I don't know! Some of the symptoms mimic withdrawal such as the sweating and agitation. I also experienced dangerously high, prolonged tachycardia which led to the precipitation of my developing Postural Orthostatic Tachycardia Syndrome or POTS. It has never resolved and I now take Inderal and Clonidine to control the tachycardia. I also do not tolerate caffeine even in small doses. My pain management physician told me that the drug company that makes Pxil is in a whole lot of trouble for not warning patients and the medical community of the withdrawal problem, hence the need to be tapered when Paxil is DC'd. Many patients suffer needlessly and over several days as this information is not well known and the drug company has virtually shirked their responsibility in providing awareness to not only patients but to prescribing physicians. It is also a frightening experience because the symptoms make one feel absolutely horrible and if you don't know what is happening, it can be very upsetting to you. It is completely preventable by weaning the dose to discontinue and in some cases ordering supportive medication until you are over the hump of being symptomatic- which is usually a week or more. Hope this has been helpful. Warm personal regards, PappyRN

FYI- Reflex Sympathetic Dystrophy can be greatly influenced by an increase of stress. Perhaps the child in the chronic pain program had more stress at home than in the hospital so he/she experienced symptom migration to a different limb, which by the way is not at all uncommon for those who are familiar with the pathophysiology of RSD/CRPS. In fact, it happens quite frequently and can be and is quite frightening for the patient. I hope for this child's sake that his physician was informed of this migration. This wasn't a "miraculous experience" but a manifestation of a brutal, hideously painful neuropathic disorder that can lead a person to commit suicide without adequate pain management. Pray that you never become a victim of RSD/CRPS. There are an unbelievable number of nurses who are injured on the job and develop RSD/CRPS. You never know when you may be it's next victim and your life plans taken away from you as you struggle each hour just trying to deal with the burning pain that makes you feel like you have been boiled in oil. I can't even hold my grandson. You are in a profession that gets hit disproportionately with this disorder. That may make you advocate more for the patient instead of disbelieving him. Educate yourself about this disorder. I lost my nursing career from this and yes, along with that all income and future earning potential. I live on SS disability. My meds cost me $700.00/month out of pocket. At the time of my injury I was sailing to the top of the career ladder. I never expected anything like this to happen nor dol you. But it can and does. And when it does, you will be begging for someone to believe you. Warm personal regards, Pappy

R.L. Silva, You might try contacting the Massachusetts Division or Department of Aging. There is usually an Ombudsman program that deals with nursing and residential treatment facilities. Since nursing homes frequently use CMT's to pass their meds either of the above suggestions may be able to provide an answer. You could also try your State Board of Nurse Examiners. Warm personal regards, PappyRN

Floating is what put me in the situation of getting injured. I CHOSE to work NICU because the patients are so small and I had some cervical spine degeneration that I preferred not to aggravate. I was hurt in a lifting injury and am permanently disabled and am now in chronic persistent pain. (You can read my story and my opinion of my situation by looking at many of the previous posts I have made). Floating put me in a situation which ended my income, my health, my career, and most pleasurable activities. I believe that any unit should self staff and strive to be as completely autonomous as possible. Take responsibility for the staffing in your own unit. Be loyal to it and take some ownership of it's problems whether it be staffing or other concerns. Let the staff be involved in it's problems so that they may become part of the solutions. They will feel as if they have more control over their situation(s) and it is a great way to develop camaraderie. Administration should serve as leaders by serving as advisers and guide the staff into coming up with solutions instead of making rules without their input and shoving it down their throats. Let the staff do their own problem solving and have inservices on conflict resolution. There will be less resentment of those in charge if you show your staff that you are just as committed as them by never asking them to do anything that you wouldn't also do yourself. I believe that fosters a lot of respect with the staff and in turn it show them that you respect what they are doing. Nurses shouldn't have to be the "jack of all trades" by being floated to floors where they are not familiar with the diagnoses, etc. Chronically understaffed units/floors should take this same approach and figure out why they can't get anyone to work on their division instead of expecting every other division to solve their problems. Deal with people who chronically call off on your unit but in a mature way that may help these persons to see how detrimental to the unit their actions are. Give them a fair chance to improve and if they don't then follow HR's policies for termination due to chronic absenteeism. Pay attention to staff who may have extenuating circumstances and try to help them with their situations in a compassionate, constructive way and as a team instead of being demeaning and suspicious. " A little sugar goes a long way". If the situation can't be resolved- again, use the HR policies already in place to deal with the situation. This method can and DOES work. The atmosphere should be one of absolute RESPECT for patients and coworkers, cohesiveness and cooperation as a team. There is way too much fighting, jealousy, and suspicion. Petty bickering is disruptive to the normal business of the unit. Cruelty, verbal assaults, fighting, character assasination, unfounded or second hand accusations and gossip etc. have no business being present and should not be tolerated without serious consequences. Mind only the business that you have been given permission to be a part of. Matters of workmen's comp., injury, light duty, and duties assigned to injured workers returning to duty should only be handled by the administrative staff due to the legalities involved. Staff who gossip about whether the employee is really injured to the degree of restrictions, interfere with what restrictions have been placed on the employee, or refuse to perform additional duties should be dealt with accordingly. Those who refuse to pick up any extra work assigned because they do not feel that the employee is as limited as her restrictions should be reminded of their job descriptions and counseled as to the disruptive nature of their actions. There should be consequences in place for their insubordination as this behavior is extremely disruptive to the normal business of the unit. Administrators should not discuss the employee's limitations or situation with employees over whom they have supervision if it in any way violates the returning worker's right to confidentiality. They should however, be available to listen to the employee's concerns. It should be known and stated clearly up front that there are some matters that are not in the control of the employees. That should be handled early on as the staff begins the work to set up their model for the unit's business and policies. Even though I worked in a pediatric hospital I never felt competent to work on Hematology/Oncology or with Adolescent/Teens. The only real experience in that age group was with my own kids. Teen patients used to play jokes on the "pulled" nurses like switching ID bands etc. Actions that could have resulted in horrible consequences but in their youth and immaturity they never thought about that part! If the staff can not come up with an acceptable policy which avoids pulling one thing is for sure- "double pulling" (ICU to Tele, Tele to MS) should not be allowed. Pulled nurses should not have to take pt assignment but should serve only as extra help- vs, meds, etc. Good luck with a universally difficult situation. Regards, PappyRN

There is a movie called "The Doctor" with William Hurt. He is a very arrogant ENT who becomes a patient himself. It's about his experiences and the steps he takes to make things better for patients. Also, what about the movie "MASH 4077" that led to the series MASH?