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Ok - I just read this excellent article which explains why diuretics a in ESRD patients. Here is the link: http://www.advancesinpd.com/adv14/115-119_Kumra.pdf

Since Lasix is a loop diuretic - pulling K+ out of the bloodstream via the kidneys it appears to me that it would not work in an Anuric patient who is on dialysis. However I have found many anuric HD patients still on Lasix and still not sure of the rationale for this. If a hospice patient opts to stop HD - I can't imagine that Lasix would prevent pulmonary edema since that fluid has to go somewhere. If someone isn't urinating - then the K+ would go up - unless they were losing it through their bowels.

Can you please direct me to the site where it is mentioned that in order to do phlebotomy in a Physicians office there needs to be a certification. I just see phlebotomy certification. I am doing complicated lab draws and glucose tolerance tests - I am perfectly capable of drawing the specimen - but the processing is another story. Most specimens need to be centrifuged and then have serum separated into transport containers, then different specimens kept at different temperatures and some protected from light. I do not even have a space or a table to do this, other than my office desk. Where there are other people around. There is no splash station either in case there is accidental splashing . Wow. I was initially told I would be going to people’s houses to draw blood - which is acceptable as I can drop it off at a nearby lab - but this is horrendous.

Thank you everyone. I did go for the smaller vein after the second try and didn’t tie the tourniquet tight at all. Very deceiving. Thank you.

Thank you for that. Yes, I do know what I need to do. I just need to hear it from someone else. After years of working with wonderful fellow nurses, I find I am by myself trying to apply all the principles that I know to be appropriate and feel somewhat in a vacuum. For example the other day- the physician put his burrito in with the lab specimens and the vaccines. When I mentioned this was not allowed he said he wasn’t going to listen to me. He now wants me to do a fitness test on a gentleman in his 60’s. This man has not had an EKG, in at least a year. MD takes offense when I say that these things need to be done, as if I am undermining him. Thanks for the feedback.

Has anyone had trouble drawing blood from patients with very large veins? As a former ICU RN - placing IV's in large veins was occasionally misleading as you would think you could get in without any problem but the tunica appears to be thicker and sometimes they roll. Today I had to do phlebotomy on a young man with absolutely massive veins. I got in, but there was minimal flow and when I applied the test tube to the vacutainer there was no suction. I stopped and went in the other arm and chose a smaller vein, but as soon as I got in, the vein bulged up. I got my specimen, and I don't think I caused a hematoma, but I have never seen veins respond like this. I gave him some ice and applied pressure. The blood also clotted immediately - does anon think this has to do with anything. These veins were so large, they almost looked like shunts. Any advice?

Hello, I left my 16 year nursing position in a critical care environment in the hospital, after a couple of surgeries made the physical work of standing, lifting etc not a good fit for me anymore. I was hired by an 'integrative physician' I was very excited, the position was in a gorgeous resort, with his office in the Spa and healing arts center. I was his first nurse. This is a 24 hour position. I have been there 3 months. From the beginning this has been fraught with problems. I was hired to case manage patients - by coordinating care between therapists, trainers, doctors, and various services. I was supposed to meet with the doctor twice a week to discuss patients. The doctor is never on time for his appointments with me sometimes showing up 5 hours late - when it is time for me to leave - then I end up leaving late. He said he would pay my mileage - but so far I have not seen a check. We have yet to sit down and discuss a pt in depth. 1. Our offices despite being in a great location, are miserable - with dirty carpets and floors, no space for supplies. He doesn't have a sink in his office - and I do not even have a table to centrifuge and pipette specimens into containers. I do this at my desk. 2. Stress testing - he wanted stress testing - but has a resting EKG machine that is a dinosaur - and a BP cuff that doesn't do ambulatory BP's. I refused to do stress testing until we had state of the art equipment. 3. He wants me to do all of his documentation and spend hours re-typing information that is already in the EMR into another section of the EMR - because this saves him time. 4.I do inventory, order supplies, call in prescriptions, create logs, make appointments and communicate with patients about their appointments and V02 testing. 5.I do complicated blood draws and Glucose tolerance tests - these require centrifuging and pipetting serum into containers, then separating by temperature - I do not have an appropriate lab area to do this; no table - and specimens have been rejected if they are not centrifuged and pipetted in a timely manner. 6. I have created spreadsheet, vaccine information sheets for patients, consent forms for V02 testing and vaccinations - which he never had before- 7. Since this is a concierge practice - the patients are wealthy. I have dealt with all types of people in the past and treat everyone with respect. I am chastised for saying things like: "please let me know when would be a good time for you to have an appointment so I can fit you in" Fit you in is deemed inappropriate - 8. Last week I was asked to order 'mole removal equipment' I did not see such a thing, but knowing how this is generally done, I ordered sterile supplies - the doctor doesn't have a sink in his office to even wash his hands prior to doing a sterile procedure, or in between patients. 8. Most of the appointments on the Dr's schedule are book deals, talks on nutrition and lifestyle, book writing workshops, guitar lessons, etc with him seeing about 8 patients a week and supposedly checking in with 10 by phone. 9. He now wants to stock narcotics. Since he is so bad at documenting - I am afraid this will have repercussions... I am putting everything in a locked box, and have created inventory sheets with 2 person counts and I have ordered rx in unit doses when possible. I do not feel like a nurse - I feel like a glorified secretary who is not given respect. I am an RN with lots of experience and I am not using my critical thinking nursing skills I would love to have a job doing hospice care and wish I hadn't left the umbrella of the larger organization where one has protection of the protocols and the union. I feel like I thought I could make a difference - but am getting a huge wake up call. Has anyone else experienced working for a doctor like this who beats to his own drum? What are the liability issues? What are the laws of accountability ? He isn't accredited by any organization like JCAHO. Does not comply with meaningful use criteria.

I became an RN 16 years ago, while raising a family and other animals.... I was a front line RN. I worked hard, and enjoyed my work immensely. I loved taking care of my patients, and feeling validated that I made a difference, moment by moment. I remained per diem for most of that time so I could be available to my growing children, and I am glad I did that, but then my world changed. I currently find myself with a plethora of nursing experience, but having worked for the same company for so many years, I was tailored to fit into their round hole. When some life changing events happened in my personal life, I found that what I thought was my home away from home at the hospital, was less than compassionate and caring towards me despite the good care we offered our patients. After close to 16 years employment I made the decision to leave the organization, but now what? I am not sure if all the events leading up to my decision to leave this company will be of interest to anyone, but suffice to say, that on several different occasions, when I either had a family crisis, such as my 21 year old son lying in a hospital in Europe with a broken back, or personal medical problems requiring two surgeries 8 weeks apart. I learned that the organization which I had served for 15 years didn't really care about me at all. I returned both times to resentment, lack of compassion and hostility. This appeared to be a new phenomenon, and I wonder if it had anything to do with the economic changes, causing people to look out for themselves more than others. The environment I was working in felt, hostile, and toxic. Nurses swearing constantly, bickering, and putting other nurses down. Resentment had built up because apparently my absence/medical leave had caused increased workload amongst my co-workers, since they had not been staffed appropriately while I was gone. Very soon after my return, I was forced to take an unpaid sick day, due to infection, fever, and rapid heart rate. When I returned I was greeted with increasing hostility, finally culminating in my coworker flat out accusing me, in front of management of 'faking a sick day' Not only was I shocked, (and still not 100% physically), I was floored that as nurses, we do not take care of each other. I have always been a smart, kind and caring nurse. My skills were excellent, and I cared well for my patients. I tried hard to help my coworkers, and felt quite destroyed by this set of circumstances. Being still somewhat fragile physically and hence emotionally, I should have called in my union at the time, but I didn't. After much debate with my husband, who encouraged me to hand in my notice, I resigned in good standing, with a wonderful letter of recommendation. But I feel like that is all I have now. I thought I would do travel nursing, go to rescue / relief efforts, but those fell through. I have been scouring the internet, and job sites looking for work, but my training and experience are a little out of the ordinary, and really tailored for the organization that I just left. I have been looking for other training programs in the San Francisco Bay Area, but cannot seem to find anything. I haven't worked on the floor for 5 years, nor do I really want to go back to that. I have excellent IV skills, and people skills. I have 16 years experience in everything from med surg, telemetry, stroke, procedural sedation, PICC line insertion, chemotherapy, orthopedics, etc. But feel like I am a square peg in a round hole. I am updating my skills, my ACLS, BLS, NIHSS, and will be doing PALS soon. But I wonder what opportunities are out there now for someone like me. I was very well paid at the organization I was working for. Any jobs I see pay only 40% to 50% of what I was paid before. I am willing to take a pay cut for increased job satisfaction, but what? Advice and help would be appreciated. I am not a spring chicken, but I am not ready for pasture. Despite a few medical issues, I am reasonably fit, and can only get stronger. I am smart, kind compassionate. I just want a job where I can use my great skills to make a difference, but also feel supported, validated and respected. A new area of nursing might even be what the doctor ordered, such as Labor and Delivery, or a comprehensive Critical care training program. (I was always on the fringe,- filling in, helping out, learning on my own, with management refusing to pay for a fully fledged training program) I just finished my Bachelors degree three years ago, graduating with honors, and I also have my PUblic Health License. These must be worth something at this point. I have tried to convince myself, I can sustain my voracious spirit with the art that I do, but I really do love nursing, and I truly wish I could be working as a nurse again. Advice - anyone - (If you got through reading all of this) Thanks

Thank you so much for the lovely comments. I try to encourage new nurses because we have to keep our eyes open for those moments that can stealthily sneak by unnoticed at times. The honor of nursing comes from the very fact that we humbly learn so much from those we take care of. We learn about courage, life, challenges, weakness and a lot about ourselves. I appreciate your beautiful words immensely. In peace……

OH no, I just saw this, can you look at my captions? i was on a caption roll this morning!!! maybe I will just have to ‘green' and bear it that the competition is over!!

Nurse to patient:”Vill you stop greening, zis is serious!!”

Nurse to Doctor: “Herr Doktor, ve fibbing,labs show ze patient had too much iron in blood, call =Code Green”

Nurse to student: “Well now you know all about the nuts and bolts of nursing”

After 1000 X-rays, I would say he is radiated and x-rated.

Spinach OD ! ENdoscopy STAT to the ER.