RNerd81

It makes me sad to hear of your experience in Florida. Unfortunately, I've heard the same from a colleague that worked there for a very short time (she left and came back to Minnesota for precisely the reasons you state here). I do know that there is currently a large effort underway to try to standardize the work environments. They are calling it "One Mayo". It is going to be a huge job, though. And I'm sure will take years to create some semblance of standardization. I wish you the best in your career...and if you can stand the cold weather for a few months out of the year, come on up to Minnesota!

This is a very grey area. I included the webpage from LifeSource on referral triggers. The catch is that if you are using neuromuscular blockade as part of your protocol, many of these tests for brain death will not be usable. I know there are also case reports of prolonged duration of action of sedatives, analgesics, and NMBs falsely leading to a conclusion of brain death and thus interventions and support may have been withdrawn prematurely. One of our neurology fellows was performing research on this just recently in our ICU. Additionally, I would be cautious about drawing any conclusions about brain death (or other triggers for referral) until the rewarming phase is complete. The question would then be, as just mentioned, have all the sedatives, analgesics, and NMBs been eliminated? Is the post-rewarming neurologic evaluation accurate? If you would like, I could ask the neurology fellow for some literature resources on this. Let me know. LifeSource

I'm really sorry you're going through this. I don't want that for you. Things are much better in other places. You are dealing with a very unhealthy (read: toxic) work environment. There are many things you can do to improve the interactions, but it sounds as if there is a very entrenched culture of passive-aggression there. Likely, it has been that way for a very long time...and you are the newest to join the dysfunctional crew. It can be changed, but it will be an uphill battle. I would suggest reading the book "Influencer: The Power to Change Anything" by K. Patterson, et al. And take care of yourself...rely on those that fill you so that you can battle those who drain you. Best of luck.

One other thing I might mention...a patient with CHF may breathe better without the ventilator. This is jumping way ahead (because I'm assuming that pulmonary edema is resolved), but being placed on mechanical ventilation reverses the normal mechanisms of breathing and the "intrathoracic pump" is rendered ineffective. This is particularly problematic for patients with right-sided failure who need the preload that the intrathoracic pump provides. Beyond this statement, I agree with the others who have posted that more information is needed. Being off of the sedating medications that are usually used during mechanical ventilation would also benefit the person's hemodynamic profile.

I am a nurse in the medical cardiac ICU and I did hear that the hiring pause is lifted. It sounds like you have a great background. My only advice is perseverance. I have not heard of any automated programs for weeding out applications, but I don't work in HR. Recently managers were told to fill all of their available positions...so who knows what's actually happening with hiring. I wish you the best of luck.

I've heard through the grapevine that Mayo Rochester is looking into the feasibility and benefits vs. drawbacks of a nursing "residency" program. It's my understanding that nursing residency is a newer concept that is catching on in a few places.

So, do you question the motivation of the family for wanting the monitor on? Do you think it's morbid curiosity? If the monitor is on, does that detract from a "good" death? Does having the monitor on add anything to the dying experience in the ICU?

If you're really Type-A, you may prefer a Cardiac Surgical ICU over a Cardiac Medical ICU. In Cardiac Surg, there is a lot of bean-counting...chest tube output, urine output, CRRT, titrate drip A according to protocol A, titrate drip B according to protocol B, and so on. There is certainly critical thinking, and very sick patients many times. On the other hand, if you like to fly by the seat of your pants a bit more, you may like the Medical Cardiac ICU. Oh look, my patient's in VT! Pow! Hmmm, I've maxed out furosemide at 20mg/hour and my patient's on BiPap, what next? What do you mean retroperitoneal bleed, he was fine a minute ago. That sort of thing. Really, I'm sure you'll do well no matter where you go.

Recently, I had a new nurse approach me and pose this question: How do I shut off all of my bedside alarms but keep the data on the screen? At first I wondered why in the world the nurse would want to do this, and questioned the quality of her orientation...but she has been a stellar nurse since the day she started, so I listened further...here was the scenario: A patient's family (surrogate for patient, who was comatose) had just transitioned to comfort care after making the decision to stop aggressive allopathic measures. The new nurse initially put the patient's bedside monitor in a "visit" mode in which the data can be seen from outside the room on the central monitor, but in the room, the screen says "visit". Our Comfort Care Order Set actually stipulates that all unnecessary monitoring be removed. This is the first question...what is "unnecessary monitoring"? Secondly, the family requested that the bedside monitor be turned back on, so they could see the rhythm, pulse oximeter, respiratory waveform, and blood pressure. But they, and the nurse, did not want the alarms going off as the patient deteriorated. Would you have honored this request?

I have been a nurse at St. Mary's Hospital at Mayo Clinic in Rochester for 7 years now, and I wouldn't want to be anywhere else. I grew up in Southern California, and the job at Mayo is what now keeps me in the midwest. I have had the opportunity to be a nurse recruiter (while continuing to work as a bedside nurse), a nursing instructor for a local college, and work two bedside positions: one in medical cardiac progressive care (2 years) and now medical cardiac intensive care (5+ years). I have taught internal classes, traveled to conferences throughout the US (supported by Mayo), become a Silver-level quality fellow, listened to world-renowned researchers/clinicians on my lunch break, and recently was invited by a physician colleague to speak in Korea. There's much more to list, but suffice it to say, I don't think I would have had these opportunities in too many other places. And I have not experienced the animosity and politics that one of the member's has...I'm sorry she/he had that experience. It certainly hasn't been mine.

Virchow's Triad: 1. Venous stasis (not moving) 2. Vascular trauma 3. Hypercoagulable state Your question revolves around #1...even normally healthy people get DVTs on long plane flights. There is no definitive length of time necessary to develop a DVT. The body is constantly developing and lysing clots. It is part of the normal hemostatic mechanism. Like DuluthMike said, "Use your SCDs"...and of course, pharmacologic prophylaxis (unfractionated SubQ heparin or the like).

CCRN is absolutely not mandatory. You can work your entire career without CCRN certification and not have a problem. That being said, CCRN certification (or any specialty certification for that matter) shows your commitment to high-quality patient care. There is also a growing body of research that ties certification to improved patient outcomes, staff satisfaction, nurse retention, etc. It's a good thing.

First of all, I'm sorry that you experienced this. It's really frustrating and hurtful. You are competent. Your rationale outlines that very clearly. Secondly, the situation outlines the "ethics lag" that exists in our country. We have the ability...but should we? On phenylephrine and norepinephrine...at 83 years old...with dementia...really? Don't worry. This happens at our institution too. I'm not trying to devalue life, but I do think there are worse things than death. And we accomplish them every day in the US. We wonder why healthcare is so expensive.... As for the charge nurse, he/she is over-stepping their bounds. May I suggest two books: "Boundaries" by Cloud and Townsend and "Crucial Conversations" by Patterson, Grenny, McMillan, and Switzler. Your professional life (and probably personal life, too) will benefit by both. You will never stop encountering "Charge Nurse" personalites, unfortunately.

Also, this is more like a troponin "flood" than "leak". No matter what your renal function, a trop of 6.4 isn't good. Even if it's "I" vs. "T", 6.4 is substantial. Especially given the patient's history.

Full reference for norepinephrine vs. dopamine: NEJM 362(9): 779-89, 2010 MAR 4. DeBacker, D., et al.