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RobbiRN RN

ER
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RobbiRN has 25 years experience as a RN and specializes in ER.

I'm "just a nurse," by choice and a published author as Robbi Hartford. I'm 25 years into ER nursing, on my 6th CEN renewal, 12th ACLS and PALS renewals, etc. I still enjoy the challenges of the hands-on stuff, and I'll leave the administrating to those who feel called to do it. Beyond continually improving my delivery of direct patient care, I am hoping to help our profession find a stronger voice to push back against the forces that assail common sense in our workplace.

RobbiRN's Latest Activity

  1. RobbiRN

    WHO is dissing hot baths?

    Agreed. The Japanese wash before getting in the bath, then sit fully immersed with just their heads out. The water is so hot you feel like it will burn you if you move, so you just hold really still. About ten minutes in one of those definitely raises your core temperature. It's one of many reasons they out-live us by a few years and spend a small fraction of what we do on healthcare. They think we're nasty for sitting in dirty water.
  2. RobbiRN

    WHO is dissing hot baths?

    Don't throw the baby out with the bath water! Multiple lists and quizzes claiming to debunk the myths about Coronavirus are running this quote: "According to the WHO, taking a hot bath will not prevent you from catching COVID-19. Your normal body temperature remains around 36.5°C to 37°C (97.7-98.6° F), regardless of the temperature of your bath or shower." The wording is accurate, because a hot baths do not "prevent" you from getting the virus, but hot baths have multiple well-documented benefits. The quote may be accurate about the average bath or shower, but there is a direct correlation to the temperature of the water and how long you are in it (which is why we die from extremes), so the underlying premises of the statement is flawed. Google "benefits of a hot bath" and "benefits of fever." You will find hundreds of well-documented studies from reputable sources supporting the benefits of heat in fighting infection. The media flippantly dissing hot baths may cause many to skip one of the best basic tools of health.
  3. RobbiRN

    Epinephrine Error, Part 2

    To read Part 1 of the story, go to Epinephrine Error - Broken Heart Syndrome, Part 1 How did you feel when you got the accidental IV push epinephrine? “The effects were instant. I thought I was going to die–people say that all the time, but I really did. When the doctor ran in, I actually asked him to intubate me. I felt a massive amount of pressure on my chest, trying to take a deep breath felt impossible. My hands started to get numb, and I couldn’t even move them. After about 30-40 seconds I couldn’t talk anymore. At that moment, I truly thought I was going to die. My father was visiting his dad out of state so it was just my mom and me in the emergency room. I wondered if my dad would blame himself for not being here to stop it, and I worried if my mom would be able to live with herself after watching her daughter die. I thought about a lot of things I regretted and things I wanted to do that I would never get the chance to. I don’t remember much after that until waking up about 10-15 minutes later in the trauma bay. I had mild chest pain and a terrible headache, the worst I’ve ever had.” What is it like going from the provider side to being the patient? “It was very strange having my coworkers take care of me and probably even more strange for them to be taking care of me. In a way I think it made it worse that I knew what was happening. A heart is not designed to sustain such high rates. I was hypoxic which comes with its own set of serious complications. Knowing that I was in a very critical state was scary enough, but knowing the number of things that could get worse because of it was even scarier. I wore a monitor for the entire month of February, and the first day the company called several times to warn me that my rate was 200. After a while, they quit calling because it was happening all the time. My EP cardiologist said there was nothing more to do and I’d eventually outgrow it.” How are you now, a year later? “I have been very up and down since the incident. I would improve for a few weeks then get bad again, improve then get bad. Some days are good, some are bad. I can be asymptomatic with a heart rate of 180 or symptomatic–weak, light-headed, short of breath–with a rate of 130. Overall, I’m better than I was the first couple of weeks following the incident. I’m currently taking Cardizem and Corlanor which have been the best medications I’ve been on yet. Beta-blockers made me very tired, dropped my blood pressure, and never controlled the rate well. I still have random rapid rates, even at rest, but I don’t feel nearly as run down as I did on beta-blockers. I still struggle to exercise because it doesn’t take much for my heart rate to get past 180 with minimal exertion.” What have been your greatest disappointments along the way? “Although the medication changes, doctor appointments, and heart monitors have been difficult and inconvenient, the emotional aspect has by far been the hardest. It’s extremely frustrating and depressing. Between the cardiologists and cardiac electrophysiologists that I’ve seen, no one really seems to have a clear understanding of what is exactly wrong with my heart, and some have clearly thought it’s all in my head.” “Probably the greatest disappointment was an EP study two months ago when the cardiologist said he didn’t find anything to ablate. It seems like there must be some irritable focus near the SA node that we could ablate and I’d go back to normal. Nothing else was working. When he said he didn’t find anything he could to ablate, I just cried. I’d pinned a lot of hope on an ablation being the fix. I felt like I was back to square 1 with no hope in sight. After the study, he said the same thing he’d said all along, that since I started with a young, healthy heart, and since the repeat echo had shown a resolution of the takotsubo and my ejection fraction had normalized, ‘ten months isn’t a long time to wait for the rapid rates to resolve.’ I’m seeing a new EP cardiologist now who says he can fix me, but he’ll have to crack my chest open to do it.” How is your life different now? “Prior to this incident, I was very active and healthy. I loved dancing. When I felt anything–anger, sadness or a passion about something–dancing was my outlet. Not being able to run or dance like I used to is hard, but even daily life is very different. It’s embarrassing when I have to pause halfway up the stairs at school, or need to ask for a break during a long-distance walk. I always feel like I need to explain myself which is hard for me to do, and it’s even more difficult for people to understand. I do often feel like an inconvenience to my family and friends when I can’t participate in things like I used to. Going to Disney was one of my family’s favorite things to do. Now walking around the park alone is hard for me, but I can’t go on rides anymore either because they could trigger a lethal rhythm. I’ve lost friends because of this, mostly because I cancel on plans when I didn’t feel good. Eventually, I just stopped getting invited.” What kind of support, or lack of support, have you gotten? “I’ve been shocked by the amount of both. I’ve received a good amount of negativity which is unfortunate. On the outside, I look very healthy, so I understand how people could think I’m being dramatic when I have symptoms. The low point was when a charge nurse who knew how my heart was damaged had the gall to say, “Let me explain Munchausen’s to you.” My heart rate was 180 at the time, and I was lightheaded, but she judged me to be lazy and dramatic. On the flip-side, I’ve also received so much love and positivity from others–it’s amazing, and I’m beyond thankful. I am so grateful that I have the support system I do have. Are you still hopeful that you’ll get back to normal? “I have remained hopeful from the very beginning that I will get back to normal. That’s not to say I don’t have days where it seems like I won’t ever get better. If this new round of medications doesn’t work, we will discuss surgery. If we have to crack my chest to do an ablation from the outside for me to be able to run again, it’s worth it. I know I will eventually get there.” Author’s Note: In March of 2018, a team of researchers led by Caroline Scally of The Aberdeen Cardiovascular and Diabetes Research Centre, University of Aberdeen, United Kingdom, published the results of a study representing a major paradigm shift. Their findings soundly refuted the general assumption that because there is an apparent rapid recovery of left ventricular ejection fraction, ongoing patient complaints of continued symptoms are due to anxiety or mental problems. Scally’s group studied thirty-seven patients who had experienced takotsubo cardiomyopathy, comparing them to a carefully chosen control group matching the patients’ ages and comorbidities. They concluded: “In contrast to previous perceptions, takotsubo cardiomyopathy has long-lasting clinical consequences, including demonstrable symptomatic and functional impairment associated with persistent subclinical cardiac dysfunction. Taken together our findings demonstrate that after takotsubo cardiomyopathy, patients develop a persistent, long-term heart failure phenotype.”1
  4. A good outcome is a good outcome, but I wonder how long ago this happened? The dose is 3x the current recommendations I've seen. Do you know if that protocol is still in place and what it's based on? Cheyenne's outcome is clearly a bad one, validating the strong warnings about potential cardiac damage with IV epinephrine. I'm curious if you have any knowledge of your patient's outcomes over time? Cheyenne's reaction also cleared. One might argue that had the epi been given IM as ordered, it would have been insufficient. We'll never know. It was given rapid IV push, and Cheyenne faces an uncertain future with a damaged heart. Do you know how well your patient did after you dropped her at the hospital? Even though she did well initially, are you certain there were no ill effects later?
  5. I think it's best to start with the idea that we only give Epinephrine IV push during a resuscitation, and seriously question pushing it in any other setting. The recommended IV dose for refractory anaphylactic shock is 0.1 mg over 5 minutes = ultra slow push. In Cheyenne's case 0.3 mg was pushed in less than 5 seconds.
  6. So far, the system remains firmly entrenched.
  7. It is very real and close to home. The writer did write all those things. Everyone is not okay. But, there is still hope for healing. Stay tuned for part two.
  8. The Problem Dear Mr. Thornton, I’m writing in response to the specific questions from your email this morning. A full investigation of the tragic event in our Faster Care area is in progress. You will have access to the complete report by tomorrow afternoon. I cannot deny or confirm several specifics, but I can agree this is undoubtedly the most heartbreaking incident during my tenure at Sarnia Shores. In response to your first question, I was attending our mandatory monthly performance review, so I was not in the department Thursday afternoon. Second, you asked how we could have such an incompetent nurse working in our Emergency Department. Michelle, the RN responsible for the accidental IV administration of epinephrine, is a Certified Emergency Nurse with an eighteen-year track record of excellent reviews, four awards for exceptional service, and multiple letters of appreciation from our customers in her file. She has no previous documented errors or formal patient complaints. You stated that the nurse failed the patient. Yes, she did–but first, the system failed the nurse. When you took over as the CEO of Sarnia Shores Healthcare, I was hopeful that we would find ways to increase our efficiency. Some of the initiatives have been helpful. You will likely remember that I strongly opposed the directive to move from a triage system to a direct bedding approach in which no patient waits if a room is available regardless of patient acuity. At the time of the incident, every room in our main area was occupied, and two rescue units were waiting to off-load new arrivals. Twelve of the patients occupying our main rooms had minor or chronic conditions. Ten of those twelve patients had arrived in the hour preceding the incident. Under our previous system, some of those patients would have waited in the lobby for a Faster Care room to open. The twelve patients who did not need acute care will likely increase our satisfaction scores, but their placement in those rooms removed immediate access to limited resources from those whose lives were on the line. The triage nurse identified Cheyenne as having an emergent, life-threatening anaphylactic reaction with her airway quickly closing. She notified the charge nurse but was told to send her to Faster Care because no main rooms were open. Faster Care is not designed to handle critical patients. There are no monitors. The nurse to patient ratio is 6 to 1 with a 45-minute door to door target time. It is designed for rapid discharges after minimal testing or treatment of non-emergent patients. A 56-year-old with active chest pain was also sent to Faster Care four minutes before Cheyenne, so Michelle already had a new potentially critical patient. The PA in Faster Care immediately recognized that Cheyenne needed emergent intervention and pulled the Michelle from the chest pain patient to Cheyenne’s room. The PA gave Michelle verbal orders to start an IV and give three medications, one of which was an IM injection of 0.3 mg of epinephrine. Every emergency room RN knows that we only give epinephrine IV push during a resuscitation, but, while Michelle was preparing to administer the medication, her Vocera came on, informing her that one of the rescue units was also headed to her last open room. She protested that she had two critical patients in the past few minutes and she couldn’t take another one. During the distraction of the Vocera exchange, she accidentally pushed the epinephrine IV. She immediately recognized her error, called the PA back to the bedside, and paged overhead for a rapid response. You asked why the error was not stopped by our bedside bar-code scanning process. In many life-threatening or resuscitation situations, ER staff still work based on verbal orders and chart after the fact. Even if the medication had been entered in the computer system and scanned at the bedside, the nurse would have ultimately been responsible for the route of administration. The computer can confirm the medication matches an order for a specific patient, but it cannot control how the nurse gives it. There is no question that the medication was ordered to be given IM. The rapid response was appropriate, and no other deviations from standard practice have been identified. I can confirm the results you noted as they are in the permanent record. Cheyenne’s heart rate shot to 200 beats a minute before slowing to 130 over the next nine minutes. The EKG showed she remained in a sinus rhythm. She experienced severe tightness in her chest and shortness of breath. The troponin drawn immediately after the incident was 0.01 while the repeat level three hours later was elevated to 0.36, consistent with damage to the heart muscle. The echo cardiogram clearly demonstrated a reduced ejection fraction of 40% and atypical Takotsubo cardiomyopathy, an abnormal ballooning of the left ventricle. A cardiac catheterization did not find any blocked cardiac arteries. After starting two medications, Cheyenne continues to experience random rapid rates over 150 at rest and up to 180 with minimal exertion. As I stated at the outset, the full report will be available tomorrow. I need you to know Michelle is mortified. She hasn’t slept and struggles to eat. She will carry her part of this tragedy for the rest of her life. I personally share the sadness and pain of this misfortune on several levels. Cheyenne has excelled here in her role here as a Health Unit Coordinator/Patient Care Tech in our department over the past two years, and I have become very fond of her. She is well-liked by her co-workers, and many here are devastated. We share the fear of her uncertain future. We will support Cheyenne in every way we can. She is our family too. I am deeply sorry. I didn’t know she was your niece until I received your email this morning. Sincerely, Sharon Goodwin Author's note: Takotsubo cardiomyopathy and the subsequent IST (Inappropriate Sinus Tachycardia) are often poorly understood, misdiagnosed, and marginalized. In part 2, we’ll look at Cheyenne’s ongoing quest for healing a year after the epinephrine error.
  9. RobbiRN

    What Broke our Healthcare System?

    Did the US ever really have a healthcare model? A profit model driven by greed has been running the show for decades. You are absolutely correct on lack of personal responsibility and increasing sense of entitlement. It's time to put aside our national arrogance, follow the example of the countries world who spend far less, and have healthier, happier people.
  10. RobbiRN

    On Vacation - Would You Intervene?

    I think the discussion has moved on to various other situations, but my concern in the original post was that those attempting to help were preventing the woman from moving herself from an extremely award position even though she was alert, denied pain, and asked them several times to allow her to sit up. There is a huge difference between allowing (or in this case disallowing) an alert oriented, oriented person from moving herself and actively moving the person.
  11. RobbiRN

    The Base Tan Myth on "Don't Fry Day"

    I'm going to swim upstream on this one. I don't lay out or tan, but I've lived a lot of my life outdoors. I do wear a visor and limit my mid day exposure to harsh sunlight. When I was at a dermatologist for a routine check, she started lecturing me for not wearing sunscreen. Half tongue-in-cheek, I quipped: "I think someday we're going to find out that sunscreen was more dangerous than the sun." She froze for a second. "You may be right. We started with 2 to 3 chemicals. Now we're up to 8 or 9 and we really have no idea what these do to people long-term."
  12. RobbiRN

    Why Nurses Are Leaving the Bedside In Droves

    Or, just like the doctors before us, we are surrendering the throne. . . The raging dissatisfaction voiced here can be nebulous raging or a spark to kindle a revolution. The irony of the paradigm shift to paint-by-number medicine is that doctors are rapidly becoming obsolete while more and more reassessment and treatment is managed by bedside RN's. We have the Nation's lives in our hands. Never underestimate our power to force constructive changes. If we back down, we, and everyone we care about, will suffer in the the pathetic system that is evolving while a few wealthy business people bask in their extravagance. I'm 25 years into ER staff nursing and mentored my current manager. I will fearlessly fight the lunacy at every level while I stay at the bedside, saving lives and doing the things that only we can do.
  13. RobbiRN

    Wise One Liners

    I hear the voices too; you're probably just a better listener.
  14. This is going a little off topic, but I ask where you are from?
  15. Just a reminder that the 5 days for the FREE eBook download starts today. It climbed top #31 in the Paid in bestseller area for Medical Fiction yesterday before being moved to FREE area. Notice the price has gone to $0.00. Here's link again; feel free to share it: https://www.amazon.com/dp/B07NS3K2LM To enter the contest for the FREE paperback versions, see the last paragraph of the article above.
  16. I had to think about this one for a minute. In the context of a day without nurses, it's actually quite clever. I rolled a patient toward me to assist a young doctor with a manual fecal disimpaction. He dug out a wad of hard stool, rolled it into a turdball in his gloved hands, stared at it, befuddled for a moment, then set it on the clean chux behind the patient and announced, "okay, you can roll back now."
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