R5RN

Also to clarify (because IDK if you want it this specific), but I pull back first to see if I have blood return before flushing. If nothing is working, we would also switch our access and return lines.

When I was in the ICU, we also used Prismaflex and we used the same method you are describing. Disconnect, flush, reconnect (cleaning the patient's access port with isopropyl alcohol in between). We did not have any built in method of flushing or create our own setup to prevent disconnecting. I do not know about other CRRT machines besides the Prismaflex, and I only worked ICU at one hospital. Hope that helps!

When I was pregnant at work, there was a couple of month time frame where smells were REALLY challenging for me. This was the only time I chose to wear masks. I certainly don't think it's insensitive to the patient. Sure, if you're matter-of-factly telling them "I'm wearing this mask because the smell of your stool is very offensive", that would be insensitive. But reassuring them that it's ok, it's no big deal, you just want to make sure they get all cleaned up, and are generally respectful and nice while not mentioning the mask at all, I don't see anything wrong with that. It's all in how the situation is handled, and if it is handled professionally while wearing a mask, there would be no reason for it to be considered insensitive.

Much easier solution - smear a bit of toothpaste between two masks.

Speaking with 15 years of EMS, backboards are no longer recommended and are very seldom used, though each state may have slightly different protocols/guidelines. In my state, the only time you might see EMS use a backboard is for extrication/moving purposes. After that, the patient should be removed from the backboard and transported on just the stretcher. There are also specific algorithms to assess whether or not a patient requires a C-collar. This is all evidence-based practice. I'm glad you asked here to gain insight about something you are unfamiliar with before reporting the crew.

I was in an almost identical situation (it's almost uncanny how similar our situations are) and posted about it here I asked the same questions you have. I actually posted this update on page 2, but here's what I ended up doing (copy and pasted from the post I linked to): I let my nurse manager know about my pregnancy very shortly after posting this thread, I was still in my first trimester. I let her know I was strongly committed to my position, I intended to work until delivery, and return full time from maternity leave. Her response was nothing short of amazing. She was kind, understanding, and made me feel at ease. From that point, I just worked like normal. I didn't hide my pregnancy but also didn't advertise it. As my coworkers learned I was pregnant, I am so relieved to say not one person seemed to bat an eye to it (other than offer me congratulations). I worked up until the week before my baby was born. I took the full amount of maternity leave my employer/state allowed and returned full time as I had intended. I couldn't be more happy about my position and returning to work went great. Not one single person made me feel guilty or bad about how everything transpired and I am so proud to be a nurse on my unit. If you do come across this thread and have questions because you find yourself in a similar spot, don't hesitate to reach out to me. I'd be more than happy to talk more about my experience.

Oh absolutely! Your role as a school nurse definitely varies from those in EMS. For example, in my state, our protocols would not warrant epinephrine in the way that you described your student (again, please know that I am NOT suggesting that you erroneously gave epinephrine, and I am a FIRM supporter of when in doubt, give it, regardless of whether you're a nurse or a paramedic). Just another interesting view that I totally see where you're coming from and the recommendations by FARE and ACAAI, but the paramedics may use a different source to determine their criteria for giving epi. Regardless, it sounds like you were very calm and made the right decision! And while this next comment is not addressing you or anything you've said, I've seen posts since mine that are still proving that "quarreling" between paramedics and nurses. As both a paramedic and a nurse, I shake my head every time I hear someone on either side of the fence try to argue who has more education, is smarter, is more trained, has more capabilities, etc. These are two very separate jobs with different focuses. It's important to consider the reality the other person has in their position, and not put each other down because of assumptions of the other persons chosen profession.

First, as a paramedic myself, I apologize on behalf of the *ahem* jerk of a paramedic you dealt with. It's so frustrating that there are still quarrels between RNs and paramedics (speaking on the paramedic's unprofessional behavior towards you). My background is EMS and ED nursing, and I have done many lectures on the proper use of epinephrine. One of the things I really harp on is giving epi early. I use the explanation that epi is for anaphylaxis and I try to explain that anaphylaxis and anaphylactic shock are two different things. You want to give epi at the anaphylaxis point so it doesn't BECOME anaphylactic shock. I have witnessed a paramedic coworker of mine opt not to give epi to my sister, who was experiencing anaphylaxis albeit not shock. In my area, we have been focused for the past few years on really trying to lower the threshold for giving epi. With that, I'd like to say, when in doubt, give epinephrine. And it sounds like you did just that. However, for educational purposes, it sounds like your patient did not necessarily meet the criteria for requiring epi. I do think it is important to understand when to give and when not to give epinephrine (again, I still stand by when in doubt, give it... and that paramedic should feel the same and not be rude to you about that), but the definition of anaphylaxis is when one or more of the following is met: 1. Acute onset of an illness (minutes to several hours), with involvement of the skin, mucosal tissue, or both (eg, generalized urticaria, itching or flushing, swollen lips/tongue/uvula), and at least 1 of the following: (1) respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, hypoxemia) or (2) reduced blood pressure or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope, incontinence); OR 2. Two or more of the following that occur suddenly after exposure to a likely allergen for that patient (minutes to several hours): (1) involvement of the skin/mucosal tissue (eg, generalized urticaria, itch/flush, swollen lips/tongue/uvula), (2) respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, hypoxemia), (3) reduced blood pressure or associated symptoms (eg, hypotonia [collapse], syncope, incontinence), or (4) persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting); OR 3. Reduced blood pressure after exposure to a known allergen for that patient (minutes to several hours): (1) for infants and children, low systolic blood pressure (age-specific) or greater than 30% decrease in systolic blood pressure, and (2) for teenagers and adults, systolic blood pressure of less than 90 mm Hg or greater than 30% decrease from that person's baseline. Source Remember, there are many reasons someone may develop hives that are not going to lead to anaphylaxis. If there are no other systems involved (e.g. hives with respiratory, cardiac, GI, etc. involvement), it may not be anaphylaxis. I'm a big proponent of self-reflection after situations like this, and it gives an opportunity to improve our practice. It helps to boost our confidence the next time we are faced with something similar. Take some time to research epinephrine administration and anaphylaxis/allergic reactions. And again, I apologize for the lack of professional courtesy from EMS.

RotorRunner had a very good post at the bottom of page 3. To answer your question directly (which I know others have), you would not start CPR. I totally hear you with your rationale, but CPR is reserved for those who are pulseless, not just bradycardic (we're talking adults here. Pediatric CPR has different parameters). And because you do not have a blood pressure in this scenario, you cannot assume this patient is hypotensive. Others have mentioned cushings triad, which this patient is likely experiencing, and that would lead to INCREASED blood pressure. EMS as a whole is a lot more "down and dirty" than nursing. Especially in the instance of a trauma patient, there aren't many interventions that can happen in the field other than getting the patient to a trauma center and surgical intervention as fast as possible with managing the patient in an A-B-C (airway-breathing-circulation) order. There are plenty of times when you may not be able to get past "A" and that's ok. EMT basics have less training than paramedics, so you don't have to think about intubating in this situation, but you should be calling for ALS. In this scenario, it's about managing the patient in that same A-B-C order and you don't have to over think it. Airway - is the airway patent? Do they require suctioning? In this case, a jaw-thrust maneuver would help to open the airway and position your patient for ventilation. You would avoid a head tilt chin lift due to C-spine precautions (a collar should be placed on this patient). You note there are oral adjuncts. An OPA is certainly indicated in this scenario. An NPA is not because of the head trauma. Keep suction nearby as head injury patients frequently vomit. Breathing - you have a cheyne-stokes pattern and poor O2 sats. Go ahead and start ventilating with the BVM and high-flow O2. Remember, you have your OPA in place. Circulation - As you've noted, there is are no drugs or pacing available, so you're more or less monitoring for a loss of pulse. If you lose the pulse on this patient, then you start CPR and attach the AED. So the summation of what they're looking for: Protect the airway, jaw thrust, OPA, ventilate with the BVM and high-flow O2, start compressions if you lose the pulse. Make sure ALS is on the way and get moving fast to the closest trauma center. (I am an ICU nurse and a paramedic with 14 years of EMS experience)

I know this post is over a year old, but as the OP, I wanted to post an update in case any other nurses find themselves in my situation and come across this thread looking for advice. First, I let my nurse manager know about my pregnancy very shortly after posting this thread, I was still in my first trimester. I let her know I was strongly committed to my position, I intended to work until delivery, and return full time from maternity leave. Her response was nothing short of amazing. She was kind, understanding, and made me feel at ease. From that point, I just worked like normal. I didn't hide my pregnancy but also didn't advertise it. As my coworkers learned I was pregnant, I am so relieved to say not one person seemed to bat an eye to it (other than offer me congratulations). I worked up until the week before my baby was born. I took the full amount of maternity leave my employer/state allowed and returned full time as I had intended. I couldn't be more happy about my position and returning to work went great. Not one single person made me feel guilty or bad about how everything transpired and I am so proud to be a nurse on my unit. If you do come across this thread and have questions because you find yourself in a similar spot, don't hesitate to reach out to me. I'd be more than happy to talk more about my experience.

Chair cushions/pads. Ikea has some for super cheap.

We have techs(/CNAs/PCAs or whatever you prefer to call that roll) in our CTICU. There are two during the week, and one during nights and weekends. They are not assigned rooms, they help throughout the entire unit and they are absolutely fantastic. They help with things such as turns, bathing, ADLs, setting up rooms, doing EKGs, assisting when patients arrive from the OR, moving patients out to the floor/step down, and doing blood sugars. They do not draw blood or do I&Os, they don't really do anything that requires any type of charting and they don't act independently (i.e. they don't just go in and turn a patient without the nurse being present to assist). This does not increase our ratios, we still only have 1-2 patients.

I came across this post because it popped up under "popular" and I was surprised that calling a gown a "johnny" is a regional thing! I am from CT, too and we always call them johnnies.

An 18-year-old in 2018 isn't a millennial. Millennials are defined as being born in 1981-1996. I'm an "older" millennial and I always carry a pen. Two, actually! One nicer ballpoint pen for me to write with and one junky pen for me to give to patients/family members when they need to sign or write something.

I attended a cadaver lab in a hotel ballroom earlier this year. The floors were covered wall to wall with plastic, there was no food anywhere near the cadavers, they had a portable hand wash station (with actual soap and water) at the entrance/exit to the room with the cadavers, and everyone wears shoe covers, gowns, gloves, etc just as I have in cadaver labs I've been to that were held at universities.

If your needle is fully immersed in the medication but the syringe is filling with air (actually filling with air and not just meeting resistance/suction that would cause the plunger to return back to its original position), it sounds like the needle isn't connected tightly enough to the syringe and air is able to enter the syringe from that loose connection. If you're meeting resistance and the plunger IS returning back to its original position, try some of the suggestions the other posters have come up with.

Whoever told you blood cannot go through an IO was misinformed. Blood can absolutely be given through an IO.

To address some questions I see popping up, I absolutely have every intention of returning to work after what I anticipate being a short maternity leave. Being a stay at home mother is not for me. I also completely understand the risk of receiving certain precautions patients and I'm sure everyone's OB is different, but my OB has stated I am able to take any patient so long as I utilize appropriate PPE (obviously). However, I do see how this is a reason to mention my pregnancy sooner rather than later. I have started orientation and was relieved to see several OBVIOUSLY pregnant nurses in orientation, which makes me feel very comfortable about telling my manager. At this time, I have decided to tell her the next time I see her, and if I do not see her this week during orientation, I will ask to meet with her specifically. I am still in my first trimester, so I have a good 6.5 months of being able to work, and I anticipate my maternity leave not being longer than 6-8 weeks. I will not make specific claims to her about how long my maternity leave will be, because of course there could be complications, but without a doubt my intention is to work my pregnant little butt off leading up until I deliver and then I'll be returning my non-pregnant butt back to work as soon as reasonably possible. As I stated in my original post, I have already accepted the position. So moving on... As I already noted, I have reviewed the maternity leave and have no concerns. While my new position is in a different hospital, it is under the same umbrella entity as the hospital I am coming from and therefore, per their policies, I am considered an employee of the same company. The same benefits will apply as this is considered a "transfer" position.

I have already reviewed their maternity and FMLA leaves and have no concerns in that regard, but thank you.

I've scoured the internet for advice on this and have asked some close friends but I am still not sure what to do. I was recruited for an ICU position at a different hospital than I am currently working in and I accepted. When they called, my husband and I had just found out the week prior that I was pregnant. We hadn't had our first ultrasound or anything. When I start orientation (orientation will be 7 weeks long before going on the floor), I will be just shy of 13 weeks pregnant. We haven't even publicly announce our pregnancy to anyone other than close family and several of our closest friends. What is the proper etiquette on this? Obviously I didn't mention it in my interview because we hadn't even confirmed viability (we had been having difficulty conceiving). But now, I feel like I am walking this line of we aren't even comfortable telling friends, coworkers, and extended family yet let alone my employer. I know they can't fire me for being pregnant, but I'm not even past the first trimester and as I mentioned, I don't like the idea of telling people I'm closer to, so I don't want to rush to tell my new employer right this instant. But I don't want to wait so long they would think I was trying to hide it from them. So I'm debating between telling them at the start of orientation (around 13 weeks), after I have my 16 week ultrasound, or at the end of orientation (around 19 weeks). I don't think it would be a good idea to wait any longer than that. What should I do? Particularly interested in hearing from nurse managers or those who have anything to do with the hiring process.

I'm a bit smaller than you, but I absolutely swear by Cherokee 4020P, I wear size XXSP. They are much smaller than all other Cherokee styles I have tried, and they are essentially the only scrub pants I can wear with sneakers instead of clogs. For reference, Grey's Anatomy XXSP are both too long and too large for me. I mention that only because a lot of petite people mention the Grey's Anatomy scrubs but I find they are just too big. I have also tried HeartSoul scrubs before, and they can be quite tiny and short, definitely a juniors cut. I prefer the 4020P because they still fit a bit baggy on me (I don't like fitted scrubs), but not they're ill proportioned and they're not too long.

Our fast track ratio is 9:1 and takes 4s, 5s, and "soft" 3s that frequently end up being not-so-"soft" (migraines, male abdominal pains, bounce back pedi abdominal pain, etc). Our main ED has 4-5:1 but we are pretty good at getting an assignment covered by charge or a float if you need to go 1:1 with a pt. Our psych area is, unfortunately, essentially unlimited. I've had 13:1 in psych.

We are required to do hourly notes and they even make a list of what we are supposed to note. -Reassessment of complaint, pain, airway, breathing, circulation, cardiac rhythm (as applicable), disability, safety, update pt on status, and general reassessment stuff. This is in addition to "interventions" such as meds, ice pack, blankets, oral fluids, snack/meal, lights dimmed, curtain closed or remains open. If I'm writing a "perfect" note, it would go something like: Resting on stretcher, watching TV with family at bedside, updated on status. Reports an improvement in shortness of breath after neb tx but still remains with weak, nonproductive cough. CAO x4/4, resp even and unlabored, skin pink/dry, remains sinus rhythm in 70s. Fluids at bedside, lights dimmed for comfort, provided with warm blankets, call bell within reach, bed in lowest position. ETA: Then we add lots of little notes like "to X-ray via stretcher", "ambulated to bathroom without assistance", "called pharmacy for meds", "family asking for update, provider aware", etc.

Some of these other posters have already mentioned some of these things, but these are all things that I mention to people starting out or looking to improve. For the cases that you mention specifically (frail, tiny, delicate veins), these tips should help a lot. Those veins require patience and POSITIONING. - Ask your patients about their veins. I've seen how easily forgotten this step can be. Is there one side that's better? Do they usually get the hand or the AC? Is it just where ever they can find one? Heed their warning if they say that their veins roll, blow, hide, etc. and be prepared for that. - Make it easier on yourself by utilizing gravity/positioning and a warm pack. I always get a kick out of people who leave the patient lying in bed and they lift up their arm to look for access. Raise the bed and have them drop their arm off of it. It can be a HUGE difference just with positioning. In regards to warm packs, I will take a large sized glove and fill it with warm water to create a makeshift warm pack. Very effective. - I'm a firm believer that if someone misses a rolling vein, it is the IV starters fault, NOT the vein itself. I hate hearing the excuse "the vein rolled away so I couldn't get it". It rolled away because it was not anchored properly. The phrase shouldn't be "the vein rolled", it should be "I didn't anchor the vein well". To combat that, if someone tells you their veins roll or if you can tell just by evaluating the veins yourself, take the extra time to position the vein exactly where it needs to be so that it doesn't roll. I will tell my patients to expect to feel me pull their skin multiple directions before I stick them because I am trying to make sure I am able to hit the vein without it rolling away. Get that vein in a steady position before you start. - This sorta goes along with my last tip, but when you're anchoring the vein, if it does move away or if you are having trouble entering it, do NOT release the traction you are holding with your opposite hand. Do that as a last resort. If you have a vein get away from you and you release the traction you were holding, you will have a much tougher time trying to line everything up again. This is especially important with the elderly who have loose skin. My tip is try to move slow and don't fish around. Pull traction tighter, find which direction the vein went, reposition your sharp, and try to enter the vein from the side if needed. Don't be afraid to get a second set of hands if the patient has very loose skin, but be careful to not pull traction so tightly that it collapses. - With IVDU, if they still have veins but you are having a difficult time (or anticipate having a difficult time) cannulating the vein, go for a larger IV. Sometimes you may miss with a 20g or 22g trying to sneak around the scar tissue when really what you need is an 18g to be able to push through the scar tissue. (This is not true for every IVDU, but something to consider). - Another trick for IVDU or people with difficult to find veins is using the basilic vein in the forearm (that wraps around the underside of the arm that is difficult to access). This vein is more difficult to IVDU to access themselves, and if the patient has veins that are used/damaged from multiple IVs and medical procedures, this vein probably hasn't been used much because of it's awkward position. To position this patient, have them rest the arm across their stomach, then stand on the opposite side of them. - Flicking is your friend. Everyone has their own methods for getting veins to appear. For me, my tried and true is flicking. I never every slap veins. By flicking, I mean the motion you make with your thumb and index finger where you flick your index finger forward so that you would hit the vein with the flat part of the nail of your index finger. It doesn't have to be super aggressive, and be careful with very thin skin or those who are prone to bruising. This works best in hands and wrists, and can work ok in forearms. I almost never flick ACs. - If you're feeling for a vein you can't see, especially deep ACs, don't look! Seriously, look away from the site. If it's an AC you're not seeing anyway, don't distract yourself by trying to look for something that isn't there. Go entirely be feel. Once you think you feel something, THEN look. - If you're feeling for a deep AC and you can't tell if it's a vein next to a tendon, if it is actually a tendon, or if it is just the skin (like a stretcher mark), have the patient bend their arm slightly while you feel where you think you feel a vein. If it's a tendon, you'll know immediately, if it's next to a tendon, you might be able to tell exactly where it is, and if it's a stretcher mark, this may help you determine that it is just that. - If you see an indentation up the medial part of the AC where the basilic vein would be, there very well may be a vein in there. It's happened to me a few times on (usually) obese patients that have difficult to feel veins where I have found this indentation even without being able to feel a vein there, and sure enough it was there. - If you're dealing with a superficial vein, always try to position yourself so that the needle doesn't have to pass over your fingers. So for example, don't pull traction straight down with your thumb and then have to come directly over your thumb so you can't be as parallel to the skin. - Veins that genuinely blow are, for me, the trickiest. Sometimes it is extremely unexpected that a very elastic and fairly decent sized vein cannot handle IV placement. I'm not talking about the ones that I accidentally manage to blow through either with the needle or aggressive cannulation, but those ones that you hit (seemingly) perfectly and smoothly and they just straight up pop. If that happens and you're going to attempt again, I suggest going with a smaller catheter size, really try to get the next vein to puff up as best you can, and go slow! The biggest takeaway from my post and my recommendations is positioning is (almost) everything!! Be aware of what you are doing to the vein and have your plan laid out. Get your vein exactly how and where you want it before you break the skin. Good luck!!

My ED is a level III trauma center and there's no real flow to how things go when we get trauma patients. Recently when I was in a trauma, both the trauma surgeon with a surgical PA and the ED physician were all trying to do assessments at the same time. I was the "circulating" nurse and another nurse was scribe. Our charge nurse came in and told me to start doing an assessment (I had been doing some other intervention at the time but I don't remember exactly what I had been doing) while the physicians and PA were actively doing assessments. I found no reason for four separate people to be assessing the same things on a patient at the same time. But the physicians are not in the habit of reporting their findings out loud, so the scribe is unable to obtain information they need for documentation until later or when someone repeats the assessment for the purpose of documentation. This is just a small example of what I perceive to be a little off. I'd like to hear an overview of how things go when you get a trauma patient. Such as who is in the room and who does what? How are your assignments set up? As in, where do the staff members come from and what staff members are involved? Are there sort of set roles prior to going into a trauma (e.g. 1 nurse is responsible for interventions and meds, an ED tech is present, a nurse or someone else scribes, what is the charge nurse's responsibility)? Who takes over the rest of the nurse's assignment if that is pertinent to how your traumas are done? Any other info you can provide would be awesome.