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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. 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.
  2. 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.
  3. 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.
  4. RobbiRN

    On Vacation - Would You Intervene?

    I think I'd take the ICU RN over the radiologist to help with mom, but, hey, if we're ever on the same plane together, let's do this. One of my most vivid childhood memories is of my mother doing an emergent c-section with a framing saw and a butcher knife when one of our cows died during calf-birth. She directed my dad and I to help. We got the calf out too late to save him, but the courageous effort ignited my passion to heal. For better or worse, I have a strong genetic disposition to go for it and deal with a jury later if necessary.
  5. RobbiRN

    On Vacation - Would You Intervene?

    Yes. Thank you. This has been a source of grief on our end for decades. Patients who from minor fender-benders who were ambulatory at the scene were back-boarded after complaining of neck pain. Their complaints multiplied en route due to the backboard, and they arrived angry and sometimes outright hostile until we could get them off it--which used to require someone higher than RN. EMS is using them less often, and our lives are better. Pixie, you mentioned previously that log rolling is no longer indicated? Can you elaborate on that?
  6. RobbiRN

    On Vacation - Would You Intervene?

    A couple of others have noted the danger of trying to help when several people with various levels of ability are jockeying for position. That was the other reason I bowed out of the first situation. Along with the medic and the pharmacy employee, there were several others already trying to help. On the plane, I was the only one who responded, which made it prudent and easy for me to intervene.
  7. RobbiRN

    On Vacation - Would You Intervene?

    I ran the scenario of the lady who fell in the street by three different paramedics who are currently working on local EMS crews as they passed through our ER today. Each of them quickly responded they would let her sit up. In her case, the significant factors were that she was alert, oriented, denied pain, and wanted to sit up. They stated they would apply a collar after she sat up due to the head injury prior to transporting her, but they would not put her on a backboard.
  8. RobbiRN

    On Vacation - Would You Intervene?

    This is the part that really bothered me intuitively. I felt they were restraining her against her will and she was lucid and communicating. I'm not discounting guarding c-spine, but there were several clear advantages to allowing her to re-position herself, primarily improving her airway, reducing risk of aspiration, and decreasing intracranial pressure. After my suggestion, the medic did allow her to roll onto her right shoulder (from the awkward position described above) and a bystander supplied a rolled blanket which he placed under her head to improve the alignment. I appreciate your thoughts and those of all who choose to engage on the topic.
  9. RobbiRN

    On Vacation - Would You Intervene?

    You go Pixie.RN. That's the courageous spirit I'm hoping to find. You have EMT-P and TCRN, so can you clarify what "hold c-spine" means? Align and maintain, or maintain the position the patient was found in?
  10. RobbiRN

    On Vacation - Would You Intervene?

    You are right. You don't know what you are responding to and by responding at all you are putting yourself in a position of responsibility. I have no reservations about responding on the plane because clearly I was the most capable person willing to respond--no one else did. I also have no fear about defending my advice in the extremely unlikely event that it should become necessary to do so.
  11. RobbiRN

    On Vacation - Would You Intervene?

    There's a strong current of reluctance to get involved running through many of the responses here. Has our litigious society trumped all moral imperative to help when we are confident of our skill and knowledge? The irony is that if we turn away, the vacuum will be filled by those more willing but less capable. What if the person needing help is you, or someone you love, instead of some stranger? Wouldn't you want the most capable person available to step forward?
  12. RobbiRN

    On Vacation - Would You Intervene?

    The quotation marks around medic were not intended to be diminutive or pejorative. I emphasized his stated title because I'm not sure what "medic" means in the UK. I've heard "medic" used in the armed forces, but in the US we have EMTs and Paramedics in our EMS systems. My uncertainty about his level of expertise was one reason I chose not to assert myself further. It's true that my descriptions were general, but his version of maintaining c-spine was forcing the patient to remain in the awkward position I described with her head lower than her torso (please read it again) despite her denying pain, asking to sit up, and trying to sit up. She was alert and clearly moving all extremities in her attempts to sit up during which she was physically restrained. Log rolling was not option because she was not on her back. EMS maintains c-spine after aligning the head and the body. They do not maintain the tortuous and unnatural position in which the patient is discovered.
  13. RobbiRN

    On Vacation - Would You Intervene?

    I like your answer because it pretty well backs what I did. 1. I watched for a couple of minutes to get a feel for what they were doing, then identified myself as an ER RN on holiday. I suggested that since she was alert and denying pain, allowing her to sit up would reduce intracranial pressure, reduce her work of breathing and the potential for aspiration. That's when the man identified himself as a "medic" and stated he wanted to maintain her c-spine until their EMS people got there. I chose not to assert myself further. 2. On the KLM flight, I told them I was not a doctor but I would give them my opinion that there was a high probability of cellulitis based on the appearance and history with a low possibility of a blood clot, neither of which required immediate intervention. I told them to stop the cool compresses which reduce blood flow, keep the leg warm, elevated, and to re-position it frequently. The fight attendant came by my seat later and gave me a $100 voucher for a discount on my next flight for my help. I initially declined, but he insisted "this is what we do." Interesting side note. I checked later and most US based airlines do contract with an agency for in-flight direction if there are no volunteers who respond. Some airlines outside the US do not have medical backup on the ground, but licensed medical professionals on a plane in EU countries are required by law to respond to overhead pages.
  14. RobbiRN

    On Vacation - Would You Intervene?

    I thought that was the case, but I asked the attendant if they used a service or had any doctor they could contact for direction if they failed to get help on board. He said no.
  15. RobbiRN

    On Vacation - Would You Intervene?

    Thank you for your thoughts. Stay tuned. I wanted to start with an open-ended presentation to get other's ideas based on the situations before adding what I did and how it went. I will throw out the carrot that I did not simply observe in either situation.
  16. RobbiRN

    On Vacation - Would You Intervene?

    While on vacation outside of the US a few days ago, I had two chances to intervene in medical situations. I'm curious what you would have done if you had been in my situation. Case 1: In a southern coastal city in the UK, an elderly woman reportedly "just fainted and fell" while crossing a street. No one there knew her. Several bystanders were trying to help, including a man who identified himself as a "medic" and woman who worked at a pharmacy. The injured woman was obese, lying awkwardly on her right hip with her torso twisted, her upper chest on the pavement and her head twisted toward her left shoulder. Her head was lower than her body, and she was bleeding from a scalp laceration. The medic knelt beside her and held pressure on the scalp wound. She denied any pain and tried to get up several times, but they held her down even when she vomited, insisting that she should not move. Her breathing was heavy. EMS had been called, and I could hear a distant siren. Case 2: Halfway between Amsterdam and New York, they paged overhead for a doctor to come to the back of the plane. No one moved. I went back and told the flight attendant I was an ER RN, not a doctor. Apparently, I was their best option. He took me to an elderly man who was worried about moderate swelling and mild redness in his right lower leg and ankle. With his daughter translating, I learned the swelling had started during our flight, but he'd been on a plane for three hours prior to ours. He had a large scab on his lower right lower shin from a scrape three days ago but denied any pain. He was sitting on a jump seat with his leg propped up on a window well, straight and level with his hip. They were applying cool compresses. I've second guessed myself a bit on one of these two. What would you have done?
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