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murphyle BSN, RN

Emergency, Critical Care (CEN, CCRN)
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murphyle has 4 years experience as a BSN, RN and specializes in Emergency, Critical Care (CEN, CCRN).

Second-degree RN, veteran of Emergency and CVICU.

murphyle's Latest Activity

  1. murphyle

    What is your ER like.....need advice?

    370/day in a 39-bed shop?! That's not just efficiency, that's magic. You must have amazingly fast inpatient admissions, or be seeing a lot of fast-track traffic, to make that work. How do you keep up that kind of throughput?
  2. murphyle

    What is your ER like.....need advice?

    45-bed adult acute care/10-bed adult minor care/10-bed pediatric acute care, seeing 280-330 patients/day: An acute care team, of which we run four, consists of one physician (plus or minus a resident or a PA/NP), three RNs, one tech, one secretary and one "tech aide" (these folks handle vitals, transport, patient comfort, and stocking). Up to 15 "active" patients can be slated to a team. We occasionally alter the ratio upward if a team is full of low-acuity hold traffic, and frequently cut the ratio down if it's all Priority II and post-resus. We also typically staff at least two float nurses and a float tech at all hours, and try to staff a fourth nurse and occasionally a second tech per team during peak hours to cover Resus and manage the heavy players. Minor Care gets two PAs, two nurses and a tech; Peds runs two pediatric NPs, three nurses and two techs, with the whole thing supervised by one physician. Those two units are side-by-side, so staff typically float between the two if traffic in one zone is low. Tech aides typically handle psych sits if we can't get house sitters (and with our volumes, the house is usually pretty good about finding us sit coverage). On top of all that you have anywhere from 2-4 nurses and a like number of techs and tech aides at Triage, another nurse and a tech in the Ambulance Bay, and two nurse clinicians running the show (one out at Triage and one in the back). We also get ancillary support from Respiratory (one RT staffed for the department 24/7, two during peak hours) and Pharmacy (EC pharmacist on duty 0700-1600 Mon-Sat). I agree with the OP that his/her staffing mix seems very lean for the volume and acuity described, and would likewise suggest that the issue of perceived poor performance stems more from departmental short staffing than his/her speed of work. However, I'm a little surprised to hear that other shops are running with 1:3 ratios and staff feel that that's struggling. When we've up-staffed to that degree in the past, we typically see a lot of slack staff and no real improvement in patient care metrics.
  3. murphyle

    Warmed lidocaine

    Anecdotal evidence suggests that warming lidocaine decreases burning and stinging associated with local infiltration. I have not seen any papers proving this one way or another. We typically do not warm our lido beforehand, except in the context of rolling the vial in your hand for a few moments prior to drawing the dose. The drug is stored at controlled room temperature in our automated dispensing cabinets. I would be curious to know if there is any degradation of the drug associated with medium- to long-term storage in a fluid warmer.
  4. murphyle

    ED techs to start IVs?

    IV starts are a "delegatable task" in our shop, and many of our EC techs are frankly brilliant at it. Indeed, we typically assign our orienting nurses to work with an experienced tech for half a shift or so to develop their IV competencies. We do reserve EJ starts to nurses who've completed a competency training program and been "checked off" by one of our physicians.
  5. murphyle

    Ebola... What'cha Gonna Do When It Comes to You

    We do have a quite robust plan for viral hemorrhagic fevers in place in my department, covering identification at Triage, a chain of notification, rooming requirements and visitor policies. If anything, it might err on the side of overkill (it calls for airborne isolation to be instituted and staff to wear Level C suits with PAPRs when treating known or suspected Ebola patients). Then again, given the eternal battle we all face to get people to wash their hands, they might just be using the Level C requirement as a forcing function... I'm far more worried about enterovirus D68, frankly. The respiratory season here is already ramping up big time, and these kids are sick. In years past, pediatric respiratory complaints usually followed an 80/20 rule (80% well kids with worried parents vs. 20% legitimately sick kids). This year, it's more like 60% sick kids, and far more of them than one would typically expect for mid-September, even accounting for the usual back-to-school spate of URI and gastro. Nobody's confirmed any actual cases of D68 in this state yet, but I don't think we have all that long to wait - and that's one bug for which we don't yet have a plan in place. Implications... unpleasant.
  6. murphyle

    OB ultrasound...foley or no?

    We've been waging this battle in my shop for the last 4.5 years that I've been in practice, and likely for a lot longer before that. Our physicians have repeatedly stated that they no longer agree with routine Foleys for pelvic ultrasound, we certainly don't like placing them because we incur trouble for violating the CAUTI protocol, and our radiologists have stated they don't care one way or the other as long as the image quality is decent. However, all our hands are tied by a certain non-trivial number of sonographers who will not perform any pelvic or abdominal ultrasound for any reason without a Foley. I've even had my ECP write a physician-to-nurse order "Do NOT place Foley for ultrasound, please send patient for exam when bladder full" and had the sonographer refuse to do the exam. (They also adhere to the rather quaint practice ADeks mentioned of refusing to do exams without a quantitative HCG result in hand, but that's another story.) This issue has gone to the respective chiefs and directors of all parties involved (physicians, nurses and radiology technologists) at least three times that I know of, has come out with the same resolution every time (no Foley for pelvic U/S unless truly emergent), and yet we still have problems. At this point, I'm not sure if it's a lack-of-education issue or just plain stubbornness. For those of you who have working no-Foley practices, how did you get all your stakeholders on-board?
  7. murphyle

    ER Workflow

    45-bed department, midsize community hospital: An acute care team consists of one MD, three RNs, one tech and one secretary for up to 15 patients. ECGs are done by dedicated staff from Heart & Vascular Services (one always stationed at Triage, the other floats). One RT floats the department for nebs, ABG sticks and vent management. Techs can draw labs, start lines and insert Foleys. RNs do everything else. (Typically you and your tech will agree at the start of the shift what you want him/her to do for you - e.g. "I'll start my own lines if you can get my vitals" or some other such arrangement).
  8. murphyle

    how to deal with management?

    So let me make sure I understand this: you got into it with a charge nurse, then made an error and didn't document it, for which you've already had a verbal counseling and are being threatened with Warning A, and now you're slacking at work, complaining about the "unfairness" of your assignments, and developing an absenteeism problem? And all this in an eight-month period? In my shop you'd never have gotten off orientation. I've seen nothing in your post that demonstrates that you have the maturity or the skills to work trauma/resus of any description, let alone Level I. You need to be able to demonstrate that you can come to work on time every time, do the work as you're ordered, and work effectively with fellow nurses as well as management. Based on what you've stated, I wouldn't train you for trauma either. Why would I spend the money and the resources, when you're already a net liability (forcing the department to use pull staff or work short every time you call in is a huge patient safety risk as well as a cost issue) and not likely to be here in six months or a year? You need to sit down and have a good hard look at whether this is the right specialty or even the right profession for you. If you're insistent upon staying, then I'd request a meeting with the charge, your nurse manager and HR (plus or minus a union rep, if your shop is unionized). Make it very clear that you know you've screwed up royally and work with your managers to develop a performance improvement plan. Be prepared to keep your head down and eat low-rank assignments for however long as that plan entails. You will need to accept that you're going to be on the short end of the stick for a very long time while you repair all the damage you've done yourself. If that isn't something you can do, then get out before you're fired. In this day and age, a termination for cause (in any career) means you'll never work again. Good luck. I hope it works out for you.
  9. murphyle

    Documentation in the ICU

    Head-to-toe assessment, LDA (Line/Drain/Airway) documentation, SIRS screen, Braden and safety assessment are all done q shift, plus any changes. Strips (at a minimum two ECG leads and your alarm limits, as well as anything else with a waveform - art line, PA line, et al) have to be printed, mounted, analyzed and signed q shift. Diagnosis-related notes also have to be written q shift. Neuro and neurovascular are done q4h unless ordered otherwise. VS, I&O, vent settings, positioning and glucose check q1h unless ordered otherwise. (By policy you can go to q2h on your glucoses if your patient has had target-range glucoses and no titration required on their insulin for four hours or more.) If your patient is in soft wrist cuffs for a vent, that has to be checked q1h; leathers are vanishingly rare here, but if your patient does have them it's q15min. On fresh post-ops, we do initial head-to-toe within 15 minutes of arrival, and VS and I&O q15min x4 sets, then q30min x4 sets, then q1h thereafter. Hemodynamic profiling off the Swan is done on arrival, then q2h and PRN.
  10. murphyle

    Are swans going "out of style?"

    You do? Interesting. Policy here is that any Swanned patient has to stay on SBR, due to concerns about accidental migration of the catheter (either RV whip or PA occlusion).
  11. murphyle

    Are swans going "out of style?"

    I'm in a cardiovascular surgical ICU, so every post-op heart comes back with a Swan. We have rather a love/hate relationship with them; they're great for accurate hemodynamics, but as long as the Swan stays in, the patient has to stay in bed, which makes us look bad on early mobility goal measures. Hence, we're seeing a few of our docs and midlevels start pushing for Vigileo FloTrac on patients whom they want mobilized but still want hemodynamic monitoring. Therein lies the rub. My issue with FloTrac, and by extension most of the minimally invasive devices (whether they run off a radial A-line or a bioimpedance method) has to do with the accuracy of the system under one of the reps' biggest selling points - namely that such systems claim to provide hemodynamic profiling that doesn't require the patient to be vented and bedbound. For an intubated, vented, bedbound patient on a pile of drips (i.e. your average MICU player), Swan and FloTrac are probably going to come up with pretty similar numbers, and FloTrac might well be the better choice. However, once your patent is extubated and starting to get mobile, the FloTrac becomes less and less reliable, to the point where it eventually starts giving you voodoo numbers. If you have a patient who still needs hemodynamic profiling at that point (worried about low CO/CI r/t hx systolic failure or hx cardiogenic shock, need to titrate inotropes, whatever), the machine starts turning from a friend into a frenemy. FloTrac's accuracy also suffers if your patient is arrhythmic for whatever reason (A-fib, higher order AV blocks, other sinus and supraventricular arrhythmias, etc). As a result, I've seen nurses, midlevels and physicians all trying to manage patients - and erring badly - as a result of inaccurate FloTrac data. In a case of serendipity, I had an extensive discussion with our local Edwards Lifesciences rep yesterday about just this issue. According to her, there's a next generation system coming out Real Soon Now that aims to address all those issues and more. Personally, I won't be holding my breath.
  12. murphyle

    ER transitioning to ICU

    Feline, your resume looks an awful lot like mine! I am also a 3-year emergency veteran, who just transferred to CV-SICU a few weeks ago. The only differences were that I came from a Level II center, and already had my CEN and CCRN when I applied. :-) Like you, I preferentially worked Resus and ICU holds, and had a fairly extensive body of work as an emergency critical care specialist to back up my application. I was not asked about drips in my interview at all; rather, it was expected that one wouldn't be applying if one didn't at least know the basics there. Instead, they wanted to know about my familiarity with invasive hemodynamics (Swan-Ganz, Vigileo FloTrac, IABP, etc) and vents. I also heavily emphasized my interest in critical care and preference of Resus and Priority I/II assignments during the interview, which I think may have been the deciding factor. Juan's comment quite closely reflects the experience I had interviewing, and I think he offers some excellent advice. Good luck to you!
  13. murphyle

    What's in your pocket - ER Style

    Reply to Airwayguru: Neither. I wear Aviator Scrubs - Classic shirt, ER pants. They're comfy, last forever, and are the source of one of my two department nicknames, "Pockets."
  14. murphyle

    What's in your pocket - ER Style

    For me, this question should read "What's in your pockets", plural, as I'm quite well known for the plethora of them on my scrubs. That said, on to the tally... Left sleeve #1 and 2: Pen and penlight. Left chest: Surgical site marker, misc personals (chap stick, artificial tears, etc). Belt clip: Stethoscope, mobile phone w/ apps. Left hip: Leatherman multi-tool. (Amazingly handy for fixing gronked-on clamps, busted electronic gear, etc...) Right hip: Wallet, loose change. Left thigh #1: Carpuject adaptor. Left thigh #2: Department SpectraLink. Left thigh #3: Rolls of tape (1 silk, 1 paper - nothing quite so annoying as "I'm allergic to tape!!" just as you're securing that impossible-to-obtain IV...) Right thigh #1: Pocket vision card and tape measure. Right thigh #2: Trauma shears. Right thigh #3: Alcohol and Betadine swabs. Left lower leg: Misc papers.
  15. murphyle

    Best one sentence handoff report

    "303's EtOH is only 378 this time, which for them is practically stone cold sober." "Your Resus coverage is the med student, the resident and (slow-moving attending). I'll light a candle for you." "He's had three liters bolus, six units of PRBCs, four of FFP, a six-pack of platelets, Levo just went up, and MedFlight was supposed to be here half an hour ago. And yes, that really is his pressure." "Patient speaks not a lick of English, is older than God and apparently too demented to use Language Line, and the family stayed just long enough to sign the consent and split."
  16. murphyle

    How do you decompress/debrief?

    Love it! We call our department's "breakfast club" the Atheists' Bible Study. :cheers:
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