pinkeyICU

Propofol should never be bolused except under the direct supervision of an MD (although I know some "slips in" at times). I've seen nurses bolus for hypertension, which is inappropriate. The cause of the hypertension should be determined....is it simply agitation? Does the pt need pain medication? Does the pt need an antihypertensive agent? I, personally, love propofol, however we should not let ourselves slip into becoming lax with something due to familarity. Also, if your facility goes to "smart pumps" with wireless connection to pharmacy, someone could get in big trouble for bolusing propofol. The short-term benefits do not outweigh the possible long-term effects on my career to risk that. Also, "milk of amnesia" is a misnomer, as propofol has no amnesia properties (unlike versed). I once had pt tell me (after extubation) that he remembered everything the nurses were saying when he was sedated. Yikes! I remember that whenever I'm bathing my intubated, diprivan'ed pts....They may remember when they wake up! Also I have worked places that switch over from propofol to versed after 48 hours (much to nurses dismay in many cases because it is SOO hard to get a wild one down quickly w/versed). However versed is a slightly safer drug, and much cheaper (draw your own conclusions). I have also worked at a facility that uses propofol exclusively, no other sedating gtt for tubed pts. They also have standing weaning parameters, which necessitates the quick vacation/resedation propofol offers. And, I'm pretty sure the package insert states that propofol should only be used in surgery and ICU, not step down units. I, personally would not like to see step-down units using propofol. Too much margin for error when you've got 4 or more pts and are not constantly, visually, monitoring them.

First, thanks for using the gender nutral "spouse" :) I really wish I could come down firmly on one side or another of this issue, but have seen good & bad come out of unions. I have the same opinion of government, big business, religion, etc...I have problems! I could go on and on about UAL, but not in this forum. Nursing is a pretty competitive area where I am. There are some major hospitals that are unionized and some others that are not. The wages work out to be basically the same and a good nurse can make a decent living (I made more than an airline pilot near the bottom of the seniority list last year!) I have not specifically chosen not to work at non-union hospitals, it just worked out that way for me. I certainly do see a need for nurses to band together and address some issues like staffing (maybe not an issue in CA), overtime issues (again, CA has different rules), and redress of grievences. Is unionization the answer? I don't know. I do know that I am quite surprised that here in the Midwest where all trades are highly unionzed, nursing unions do not really have a foothold. I would work at a union hospital if that was the hospital I wanted to work at.....I will work anywhere that allows me to become a better nurse and pays me what I think I'm worth. Of course, I've also just made the decision not to be a full-time staff RN anymore because I don't want to bust my butt on the clinical ladder for a measly 50cents more. Maybe if I had more experience (positive experience, that is) I would be more pro-union. Hope this isn't too "stream of consciousness" I feel like I'm rambling.

The airlines are a mess and I can't help but notice that the least messy are the non-union ones. But, on the other hand, my mom (who is also a nurse) recently organized a union at her hospital which really, truly addressed issues facing nurses, cna's and ancillary staffmembers. So, I guess I can see the good and the bad. I guess I'm against big, old, greedy unions. I have worked on a unit where every nurse refused to work extra unless double-time was offered. They did this themselves w/o benefit of a union. However, they could not band together to say "NO" to 3 ICU pts per RN. Maybe a union could have helped.....I just get caught up in the ALPA nonsense, which may not be indicative of all unions. I just cant seem to come down passionately & strongly on one side or the other. I see too many shades of grey. & Thanks for not taking me to task for (wrongly) taking you task! :)

That's a rotten way to deal with mistakes. At our unit we get a little e-mail that is copied to our manager. I've gotten a couple and I just reply that I realise my mistake, will make an effort to prevent it from happening again and have never heard another word. I think this is a better way, because I actually will make an effort not to let it happen again. Unfortunately some people are put into management/supervisory positions without any training or talent for the position...seems like you suffered because someone was promoted to her level of incompetence. This type of public "outing" of mistakes is so unnecessary because most of us beat ourselves up about mistakes anyways. I hope you get some good sleep and have at least two good shifts in a row (is that all we can hope for?). Also may the bird of paridise fly up your manager's nose!

when I started in ICU as a new grad I was told that if I felt comfortable before 1 year, confident before 3 years I was a fool who would probably hurt someone. I still have times where I feel that I am barely keeping my head above water...then the cycle turns and I feel okay for some shifts. In the beginning I wrote everything down on slips of paper & napkins...I notice now that I use fewer napkins and have developed tricks...things I always do a certain way. Also now sometimes I can actually breathe. The thing that helps me most is getting that first assessment in as soon as possible. AND...knowing resources. We have online meds so I can quickly look up any drug I'm not familiar with as well as IV compatibility & dosage. For me it's quicker than a book. Also I never hesitate to say..."does this look right? Does this sound right? What do you think of this?" On my unit we all bounce things off each other and I have noticed very senior nurses do it too. Even now, I hesitate to say I feel comfortable, because I don't want to jinx myself. When all the planets are aligned, I've had the same 2 pts for 3 shifts in a row then I start to feel comfortable....then WHAM...heart rate is 170 sbp 65. What the HECK? What's going on? Comfort in ICU nursing (for me) is fleeting and temporary.

"And, on a personal note, I think I said "spouse" not necessarliy husband....many pilots are females, just as many nurses are male. And my spouse is no spring chicken either....gave up a cargo job for UAL for many resons that in retrospect were moot/mistakes. " Ooops! Forgot about that pesky profile that busts me as the female I am! I try so hard not to be sexist and now my feminism as turned against me and showed my inner idiot to everyone! If I had two more like me I could put on a show (is the name "Three Stooges" taken?).

You make a good point. However, from the bottom, it looks as if the Union protects the guys at the top because 1.9% of their income is a heckuva lot more than 1.9% of a guys on the bottom. I will say that the Union Members did a good thing after 9/11 and poneyed up a little more so that those guys/gals who were laid off could keep some of their benefits for a while longer. The problems with the major airlines (UAL specifically) are a combination of things and too complex to debate here. ALPA is a captain's union, and if you happen to be a capt, it's great. And yes, I know that EVERYONE at UAL bent over and took it where the son doesn't shine and gave up retirement, 40% income, quality of life, etc., etc. Makes me wish we would have gone with Southwest...but back before 9/11 when the union negotiated the highest pay in the industry and the sweetheart contract 2000, nobody knew it was helping to kill the golden goose. As to unions specifically, I have seen where they have benefited, however as they mature it seems as if they take on a life of their own. As with ANY beurocratic (spellling, I know!) organization, corruption can get out of control and those w/power want more. Sometimes the "little guy" the union was orginally formed to protect ends up feeling lost in the shuffle. And, on a personal note, I think I said "spouse" not necessarliy husband....many pilots are females, just as many nurses are male. And my spouse is no spring chicken either....gave up a cargo job for UAL for many resons that in retrospect were moot/mistakes.

Two places I've worked you have to respond to RRT calls w/no training & no minimum experience requirements. When I was a newbie nurse I was told to go on a call and said "shouldn't you send a real nurse?" Was very uncomfortable responding to calls w/a tacklebox full of meds, some forms & little else. Thank God my 1st one turned out to be low blood sugar! The nurses on the floor looked at me like an expert and they probably all had been nurses for longer than I. Now that I have a little more experience, I'm wise enough to refuse to do things alone that I haven't been trained for. I think the idea of recognizing the extra effort put in by RRT members can go a long way toward nurse job satisfaction....also to have specific members so you know those on the team WANT to do it, feel comfortable, and will be better RRT nurses. If the floor nurses look to the RRT team members as "experts" I think we'd better make sure we are!

in my experience usually 2 nurses go on RRT....One hospital that I worked at had a hospitalist (MD) who always showed up too, which was nice. But, more to the point: one hospital I worked at the first admit was automatically code/RRT nurse. That kind of worked 'cuz if I'm admitable I only have 1 pt and if I'm getting a wreck from the floor, I'd like to be the one responding up there to see whats what. At my current place of employment, the charge RN does not take pts (except as last resort) and she/he is RRT/code #1. Someone else always tags along and it usually ends up being the nurse who figures she/he is going to get the pt if it comes to ICU anyways. One place I worked did not assign at the beginning of the shift and we all just figured it out when the call came....whoever had a light load or was at a stopping point, whatever....then admin came up with the policy that at the time of code we were to say QUOTE: It is a code blue/Rapid Response. Who is Going? Are You Going? end quote. We all had a ton of fun parroting the memo but basically kept deciding the way we had in the past. BTW: Any extras out there for Rapid Response Team members? One hospital gave sweatshirts after so many times on the team....my current hospital says "a nurse is a nurse is a nurse" so no recognition for RRT skills/volunteering. Wondering what others do.

Okay, I have to reply only because of the few quotes about unionized airline pilots. My spouse is a pilot for one of the major airlines. Because of pressure from the union the age 60 rule was changed to make it so that pilots could fly to age 65. Was that a good thing? Well, not if you're young and can't move up because now there are all these older guys/gals sticking around because they either didn't have the foresight to prepare for the retirement they knew was mandatory at age 60 or are caught in the trap of rampant consumerism. I cannot speak for every union, but the major airline union (ALPA) -- My Opinion Only -- exists primarily to support the UNION and the old capts at the expense of the industry as a whole and the younger pilots. And there is NO choice of whether or not to join if that is the profession one chooses.

relying on the govt to stop people from smoking is like...well, I can't think of a proper metaphore. The govt subsidises tobacco farmers. They then tax the farmers' income. Then the govt collects taxes on each pack of cigs. If everyone stopped smoking tomorrow, tobacco farmers would go broke, cig makers would go broke, hundreds of people (cig factory workers, etc) would be out of work and collecting unemployment, and the govt would have to find some other way to raise the amount of revenue lost on cig taxes! More appropriate to this thread is my original thought that if a nurse does his/her job, why do I care what that nurse does to his/her health? Many of us make poor health choices every day (I had cookie dough & coffee for breakfast) and have our own addictions (take my coffee....I bite your arm off!). The last place I worked had a lot of smokers. Another nonsmoking nurse and I took "fresh air" breaks. None of the smokers complained or refused to watch our pts. None of the smokers would run out if it was chaotic and neither did we. Of course there were nights when nobody got breaks of any kind...then the nicotine gum would come out.

I have made a lot of mistakes....not all of them everyone knows about...but even the small ones make it so I have to swallow VERY hard to get my oral secretions past my heart which stays lodged in my throat for a long time.... The fact is, you will make mistakes. You will continue to make mistakes. The important thing is not to make the SAME mistakes! Well that, and not to kill anyone! Once another nurse tried to help me out and add more volume to my insulin dripp...she actually increased the rate! Thankfully I went in right after her and the pt only got a few cc's bolus (Dripp off! Accucheck, another accucheck, another accucheck)....But could have KILLED him! I was on my knees thanking GOD I happened to glance at my pump AND happened to catch it (I always put a tape label as to what is infusing thru what pump....Insulin 10ml/hr? What? Wait!!! Was supposed to be 2ml/hr! OMG). At the end of the day, both my pt still alive? Good. I'll go home and sleep it off. Come in next night FRESH and consider myself that much more experienced! Experienced nurses do not get that way from being perfect all the time.

Suzanne4 - thank you for your concern. Kind of a moot point since I'm not traveling, but the advice was based upon the fact that if greater than 50 miles from home I would be blocking my shifts & sleeping in a hotel/eating out for 3 nights vs taking the one bedroom apartment offered. The rule is not particularly 50 miles, it is the amount that can be safely traveled back to your home to sleep between shifts....50 miles is considered safe by most tax advisors. If itemizing deductions, a certain amount of per-diem pay (this meaning the amount an employer gives you for meals, housing while not at your "home base") is tax deductible. My husband travels (for another industry, not nursing) and we have a schedule of the amount of perdiem the government considers allowable for each city to which he travels throughout the year. If the company pays more than that, the excess cannot be deducted. IF he spends less than that, the actual amount spent is to be deducted. Of course EVERYONE should check with his/her own tax advisor prior to assuming any advice seen here or elsewhere applies to his/her particular situation.

:nuke:Thanks. Actually was my CPA who said if more than 50 miles, safe to write off 75% of housing stipend. Not that it was a "written rule" just that it is the "accepted norm" for housing stipend regardless of industry. Since this post I have actually decided to go perdiem at the same hospital, b/c I don't want to get into something I cannot easily get out of!

what's the difference between a nurse who smokes and a nurse who is obese? Both would immediately bring to mind unhealthy choices. Both have health ramifications (COPD vs DM, Lung Ca vs HTN, etc.) Both potentially drive up the cost of health care by over-utilization. Why is one less socially acceptable than the other? As long as the smoker-nurse is not reeking of smoke or blowing it in my face and the obese nurse is not reeking of chocolate and dropping crumbs on me, all I care about is this: is he/she a competent nurse, with all that that entails?