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  1. KatieMI

    Written Up

    That was likely about me. As I said, there are lots of people who just cannot stand anyone who is smart and openly proud of it.
  2. KatieMI

    Written Up

    I would do whatever I can to use non-pharmacologic methods to comfort the patient and help him sleep I would explain him that what he was taking home may or may not be safe for him right now. He is in hospital because he is sick, isn't he? He takes many other meds now for that reason. Now, ALL meds are working in the same human body at once. Some of them work together, and it can be good or not. Some counteract each other, same story. I am a nurse, I cannot determine if that 1 mg of Xanax safe right now. Doctor can, would you like me to call? If I call, I will start from fresh set of vitals taken by me personally. And I will tell the whole story, not only "hi, this is KatieMI from X, about your patient ftom 1234, can he get something for sleep?". In the case I described sbove, I would sure mention loading amio, drip and quickly escalating opioids. I would not tell about "home dose Xanax for sleep" at all, unless it was verified or I can verify the dose. Most conscientious providers would not order it "for sleep" anyway. If a provider will indeed order Xanax or something equally borderline (say, Versed - I had such orders in ICU), I would politely doubt it right then and there. I would mention my discomfort re. possibility of respiratory depression and then "just suggest" Valium, low dose Restoril, eszopiclone, Remeron or Benadryl. If the provider still wants Xanax, I would call to whoever manages the amiodarone and cardizem and ask that person directly if they think it would be okay. Cardiologists are usually better verced in complicated pharmacology of their own drugs. I have strong pharmacology background, so doctors usually listened to what I said. About "1 hour apart" rule: For example, you work with IV dilaudid to be given q2h. 1) check renal and liver functions. 2) if they are more or less normal, proceed on your own; if clearly not, call pharmacy and speak with PharmD, not tech 3) go Google and search for "dilaudid half life". Or use free app like Epocrates or drugbook. You do not need a peer-reviewed article. The first link Goodle has is from something named "therecoveryvillage.com". It is good enough, as the number will be the same everywhere. Dilaudid half life is about 2 hours. So, if you gave dose at 10 AM and the next at 12, your dose #2 will be "catching tail" of the first one as 1/2 of #1 will still be there. After #3 at 2 PM, you will have 1/4 of #1, 1/2 of #2 and whole #3. After #4, you will be close to "doubling" (draw it if it is difficult to understand). Which can be fine if you treat acute postop pain or cancer pain, but not for chronic. Usually showing Higher Ups that you understand that works. But I must tell you - it sucks to be more than average intelligent person in general, and especially if you are a nurse.
  3. KatieMI

    Written Up

    Well, the same case I described before (without HIPAA details): Patient was started oral amio load while Cardizem drip was still running. Was also on IV opioid d/t NPO. Not opioid naive, but not high dose either. Liked it very much, so dose was increased. Then he was complaining on anxiety before EP lab, so was given one dose of Xanax and that pain shot plus phenergan for nausea. It was his luck that he was in ICU already because at one beautiful moment he just stopped breathing, but survived. Woke up right after Narcan + Romazicon. The two possible explanations were either synergetic actions of opioid, phenergan and benzo on respiratory center, or at large suppressed CYP3A4 by high loading doses of amio and diltiazem, adding to the benzo action.
  4. KatieMI

    Free teaching labor

    Where I am, preceptors are paid approximately the same as nurses who work PRN (i.e. $8-10/h more than full time staff) with them being responsible for all students and on top of it expected to "help" (read: do everything but the initial assessment) with admissions and discharges. Staff nurses who are assigned students are given certificates which can be converted to CE hours. They are not asked if they want or can precept that day or not.
  5. KatieMI

    Robot tells man he'll be dead in hours

    While I think that such talk is highly preferred to be done in person, we live in 2019. Technologies like essentially "moving screen" (as far as I understand, it was not a "robot" but telemed device with doctor sitting somewhere else but still talking in real time) are going to be everywhere pretty soon. I agree that we as providers and clinicians not only avoid inevitable talks, but in many cases consciously lie to patients under premice of "not robbing 'em of hope". There are tons of causes of us doing so, not the last of them being our (otherwise, very human) wish of provide comfort and what will be perceived as "caring and gentle attitude". The pressures of totally wrong in so many instances doctrine of "customer satisfaction" cannot be taken fr om the table as well. But there always comes that time where true words have to be spoken. Still, I couldn't imagine doing this through tele. I am not afraid of these talks. But I feel that, even for 15 min., I need to be there for these people, so at least they do not feel alone.
  6. KatieMI

    This MD culture

    When we're on the road, we also have the same goal: to get safely where we need to be. Sadly, some people choose unsafe ways to do that, get in trouble and put others in trouble too. Same way here: we all work on provide safe and appropriate patient care, but some of us choose to do things which unnecessary complicate the situation. And that can happen with everyone involved. The nurse who chooses to call at 3 AM to "just let know" that patient had loose BM after mag citrate is just as guilty as the doctor who yells at her. Probably even more so, because a provider carries much heavier responsibility about more patients and for him/her being overtired and upset is much more potential danger of making a wrong decision. But BOTH nurse and doc are placing absolutely unnecessary obstacles in the way of getting to the common goal - get patient out of there in better health.
  7. KatieMI

    Sitting down - New nurse looking for advice

    Option 1: find a GOOD pain specialist who knows more than just pills/shots. Such doctors are few and far between, but if you live in a large metto area, you might have easier time to find one. The ways to manage the pain are multiple, from TENS to muscle relaxers, corsages, massage, etc. Do not forget about core PT, stress management, comfortable shoes, nutrition, healthy weight, etc. Option 2: unfortunately, nursing is an area of occupation which is not very friendly to people with physical limitations. ICU in general and CVICU are not physically easy. Since you are expected to care for only 2 patients, you might be required to do total body care, including turning, bed baths, etc., etc., - alone. Option if you like machines, needles, acute management: acute HD (yes, you can found yourself pushing that 200 lbs machine around but it has wheels, moving can be done with proper body technique and after things are running you can sit back - for hours). I heard that NICU is better in the sense of less physical load but I am not sure if it is fully truthful. Case management can be another option, as well as going back to school for MSN. Unlike bedside nursing, most MSN specialties can easily accomodate physical limitations.
  8. KatieMI

    smokers and coughing

    "What my smoking can have in common with that cough?" "Nobody ever told me that salt is bad for my heart - NOBODY!!" "Do pickles REALLY have a lot of salt? Oh... but it says here "sodium", not salt... are you sure these two are somehow related?" "I eat only french fries, they have no sugar" "You tell me I cannot have coffee with caffeine, only decaf. Is it ok to drink normal coffee with some burbon - it feels relaxing!" "Do you know how much protein is in bacon? That little?? Oh, I'll have to have plenty of it then". "I cannot have STD. I washed myself right after I came home" "Daily activities of my wife are sitting in her favorite armchair and watching TV. She also has her meals and recites a prayer daily" "They told me I can have everything I can see through. I can see through a doughnut hole, so I figured that some of them would be OK with coffee" I can write a book of those...
  9. KatieMI

    This MD culture

    Well... to begin with, do you REALLY still believe to higher ups about anything in the world?
  10. KatieMI


    Can I please add to the list everyone who calls at 3 AM to just let me know that patient whom I ordered bowel regiment just had perfectly normal BM and if I want to do something about it, writes down full nursing note about this tremendously important event and then tries to justify it by stating that "it was just for me being patient advocate"?
  11. KatieMI

    Losing job due to injury

    BTW, that's what most of my buddies told after everything was said and done. They were not even aware of the world of interesting (or less interesting, but anyway good to know about) nursing opportunities available beyond their daily grind. Almost all of them changed careers after they recovered, most definitely to the better and more satisfactory ones. Sadly, in all cases it meant that bedside lost excellent nurses
  12. KatieMI

    Losing job due to injury

    Just for consideration: there are jobs in hospitals which are 90+% seated. Unit clerks are needed all the time. Yes, it is not a "nursing job" per se and it pays much less, but it is one way to keep your foot in the door, keep your networking alive and do something for some $$. Several of my nursing buddies did that (also case management, while using an one-foot scooter) while they were "limited in their mobility" under similar circumstances. Also, if you ever thought about going back to school and can afford it, online education is a God's gift for those who are "mobility challenged". I am so sorry it happened with you, wishing you all the luck and full recovery!
  13. KatieMI

    $750 CA RN License??? No way!

    They can do it, so they do it. The other choice is to get in and finish community college program here in the States, which will be significantly more expensive.
  14. KatieMI

    Thoughts on vegetarian/ vegan diet

    1). If you took Nutrition course as an RN, you should be able to offer some sensible advice. You cannot refer out 100% of everything. BTW, consulting services of RDs tend to be not covered by insurance and seriously good RDs are few and far between. 2). Vegans' (as well whoever else's) evangelical, philosophical, political and other such issues is out of our scope of practice as long as they do not do something clearly reckless with their dependants. 3). Categories of patients who must not go vegan by themselves (educate, discourage, get provider on board STAT): - coumadin users (too much vit K) - cancers of breast, ovary, uterus, prostate AND patients' BRSA-positive relatives, male and female (soy based foods have too much phytoestrogens, can potentially cause tumor growth and/or progression) - CHF and uncontrolled HTN (a lot of sodium in soy-based stuff and meat substitutions) - uncontrolled DM (carbs, especially in juices) - renal disease stage III and down, especially HD (sodium, potassium, phosphorus, aminoacids imbalance) - extracorporeal insemination/females (phytoestrogens can interfere with treatment) 4). Educate about: reading labels (protein content, vitamins enrichment); NO preference for "natural/organic" (these foods are frequently not enriched with microelements and vitamins, especially iodine), reaching beyond staples (seaweed is one excellent source of B12 and iodine, naturally pickled veggies like kimchi and homemade crout are rich in all B vitamins, and so is fresh craft beer), the fact that full and working vegan diet takes A WHOLE LOT of education, almost daily elements counting and money OR time spent in kitchen (people seem to be not aware of this simple fact). 5). Going vegan is OK. Making your baby vegan AND ignoring medical advice is not and will be reported to authorities.
  15. KatieMI

    Whiskey peg tube flush?

    And this is the deal. I work in a formally tertiary care, but in all senses regional center with tons of private practices which provide the main $$$$. There are quite a few off-label and other such things that are routinely overstepped in order to keep "customers" (both patients and private practitioners who bring them in) happy. If one of the Big Surgeons wants whiskey detox, that will be done, however much it is against current guidelines. And you probably cannot even imagine what is going on in "critical access" rural hospitals where what you and me consider as pretty ordinary treatment options are routinely not available. I saw with my own eyes a fluid bolus on patient in septic shock and liver failure with MELD 40 flowing into a varicose vein on his anterior abdominal wall. The poor fellow had only one hand, and that with AV fistula, lower extremities are out of consideration due to DM ("it's a POLICY!!!") and nobody in ER, run that day by a Family Practitioner, was able to throw in a central line of any kind. And nobody had guts even for EJ access. And the place had no kits for intraosseus access. And there was no ultrasound. And nobody except me seemed to care that flowing volumes of fluid directly to bottleneck of portal vein through cirrhotic liver was against of very basic logic of pathophysiology.