Jump to content
February 2019 Caption Contest: Win $100! Read more... ×


Registered User

Activity Wall

  • RobbiRN last visited:
  • 149


  • 3


  • 9,513


  • 0


  • 0


  • 0


  1. RobbiRN

    Charge Nurse in 6 months?

    Several trends contribute to the toxic situation you described. 1.) Experience is valued less; a nurse is a nurse and one straight out of college costs less. 2.) Profits are more important that quality care. 3.) Policies protect the institution while insuring the nurse can be blamed when things go wrong. 4.) Charge nurses are no longer the most capable person on a team, just someone who will do it. 5.) Charge nurses spend a huge amount of time distracted fro the flow of the department because they are doing clerical tasks, compiling QA reports, doing call backs, etc. I've worked in the same ER for 20 years. On some shifts I can add the years of experience in the department and the grand total of the other 6 RN's will still not equal 20. We do put young, new grads in as charge and some do well, as long as the rest of the team does what we are supposed to do. The toxic environment you describe goes way beyond a charge nurse assignment. If you stay, you could be the miracle worker to take a pathetic place and make it work like it is supposed to. The challenge appears to be massive. Anything is possible. (By the way, I do take charge for limited periods on rare occasions because I work 11am-11pm. I prefer patient care, and a strong core of nurses each holding down their assigned area leaves a CCN little to do.)
  2. RobbiRN

    Holding Hands with AI (Artificial Intelligence)

    Ouch. Our Pyxis clocks often run a few minutes out of sync with our charting system. The sad part of your story is that someone was getting paid to come along later and make an issue out of your situation. The morphine was pulled, it was given, and it was charted accurately according to the equipment supplied by your facility. AI is the new spy. It's cheaper, remote, supposedly accurate, and much easier than each level of management knowing their employees and actually paying attention in real time.
  3. Last night, my MSN homepage bannered a slide-show article by Peter Giffen entitled, "20 ways artificial intelligence is changing our lives." The slide-show opens with an adorable little robot looking submissive and inquisitive. He, she, or it, looks safe, friendly, clever, and, well, almost lovable. I want one. Giffen asserts: "From chess-playing computers to self-driving cars, artificial intelligence involves machines learning from experience and performing tasks like people, only better." (Geffin, 2018, para 1). In the arena of healthcare, he intones, "AI has the potential to make medicine more precise and personalized." (Geffin, 2018, para 4). Or, more robotic. I wonder which it will be? AI's presence has blossomed in my world over the past few years, but it's learning curve has introduced new forms of danger. I research a trip to Australia. Within minutes, a bunch of adds for travel to Australia pop up in my FB newsfeed. Targeted advertising is cool, and a little creepy. Do I want to be spied on? Apple really wants my fingerprint to keep my phone safe. But, if I give it to Apple, my fingerprint becomes a new member of the AI community, making it available to anyone, or anything, clever enough to find and use it. Apple also suggested using facial recognition for security. Hey, why not? God knows, my face is already out there- except a photograph can pass the recognition hurdle. A few numbers in my head might be safer. My opinion, for what it's worth, is that privacy and autonomy are the commodities at stake in our courtship, or struggle, with AI. Whatever we give to AI comes out of our own pockets. When AI gets more, we have less. There are subtle levels of vulnerability in our surrender to AI, and our work environment is not immune. About a year ago, we adopted mandatory bedside scanning of patient armbands and medications prior to administration. In theory, scanning a patient's ID bracelet and every medication prior to administration removes risks of errors. We may have gained some safety, but we slowed the process. Giving AI a big voice has introduced several arguments I'd rather do without. For example, I need to give a child 240 mgs or 7.5 mls of children's Tylenol. When I scan the first 5-ml container, my KBMA warns me that I've only got a partial dose. When I scan the scan the next container, the KBMA hits me with a stop which I must justify. After scrolling through a drop-down menu, I choose the "physician's order" option to inform the KBMA that I won't be giving the full 320-ml dose which has been scanned. AI has the doctor's order too, and, hopefully the next upgrade will simply ask, "Since the Dr. ordered 240 mls and you scanned 320 mls, you're going to waste 80 mls, right?" That would allow me to confirm that we are all in agreement. Now, our AI simply knows I've got more than the doctor ordered. After our conversation, the KBMA signs off without knowing how much I'm planning to waste. And, it still has no idea how much volume is going in the syringe or in the child's mouth. AI may confirm the patient, the dose, and the route to its satisfaction. But, after making the computer happy, nurses still have full control over how much is pulled up, where it goes, and how fast it gets there. The same vial of Decadron can be given IM, IV, or PO (despite the "for IM or IV only" warning on the label), and the patient will probably have a similar outcome despite a route error. But, giving Bentyl IV (trust the warning) instead of IM will cause multiple adverse reactions including pain, edema, thrombosis, thrombophlebitis, or reflux sympathetic dystrophy syndrome. A 0.3 mg dose of Epi IM will stop an allergic reaction but giving the same dose IV will destroy even a young, healthy heart. Sometimes, I choose to override my KBMA for practical reasons. Our PO potassium order defaults to two 20 MEQ tabs. Most patients can't swallow them, but I have to override AI to substitute four 10 MEQs. In life-threatening situations in the ER, we still routinely work off verbal orders and create a record later. Despite the appearance of AI control, the autonomy in medication administration is still largely ours. The responsibility is definitely ours. Our wireless communication Vocera units are a mix of AI. They're getting better at voice recognition and taking more initiative in conversation: "Jason is not logged in. Would you like to leave a message?" But, they're still learning. If you have any doubt, crank up two of them and set them next to each other on the counter. The artificial conversation is entertaining. Their lack of intelligence shows up by the second or third sentence. They're very polite though, and they apologize to each other a lot. "I'm sorry, I didn't understand. Could you repeat that message?" "I'm sorry. I didn't hear you. Did you say to call to call Martha Johnson?" When two consecutive sentences start with "I'm sorry," the AI meltdown is well underway. One evolving pitfall of AI is the notion that simple clicks equal completed tasks. Recently, I had one patient waiting for transfer to another hospital when my shift ended at 11:30 p.m. I told my coworker assuming care that I'd called report to the receiving faciality. My coworker asked me to put in a disposition note. I said that I couldn't do it yet because the patient was still in our department. "It would be falsifying the record for me to chart that she's gone when she may still be here two hours from now." The oddity of the encounter was that my coworker was clearly not impressed with my explanation. I can understand her confusion though. New management instituted a plan where a receiving unit "pulls" the patient to the floor in their computer as soon as a room is assigned, creating a digital record that the patient has been moved. While this makes their times look great, the report has not been called or charted, transport may not come for fifteen to twenty minutes, and the patient is physically in my room. In a glaring AI failure, our ER charting system and floor systems are separate. After a patient is "pulled," I can no longer see him in our ER system. I can only chart by adding an append note, and vitals and other pertinent data are displaced. As reverence for virtual reality evolves, there's a growing acceptance that clicking creates reality. If it's clicked, it's done, end of story. The real world can catch up later. The greatest danger of AI in our environment is the ease of wrong orders entering the system. Doctors can order multiple order sets and sweeping protocols with single clicks. The configuration of our dashboard gives them a margin for error about the size of a cursor between patients. AI is not yet equipped to ask if it's sensible to order a psych consult on a two-week-old or question the fluid bolus ordered on the CHF patient. Instead of making medicine more precise and personal, AI is making it more cookie cutter. Extremely diverse complaints are evaluated with the same "might be septic" battery of tests. The evolution of AI protocols has made doctors more obsolete while passing more of the ongoing assessment, treatment, risk, and responsibility to bedside nurses. Ironically, even when AI seems innocuous and safe, it may be the most dangerous. We recently got bedside scanners to print lab labels. They've been great. Within seconds of an order going into the computer, I can scan an armband, print a label for a specimen I've already drawn, and have it in the tube system in about one minute. After more than two decades without a labeling error, last week I had an "ah ha" moment. I realized that I'd come to trust the seemingly infallible new system and let my career practice of carefully checking the name and birth date slide. Scanning an armband is only infallible if the person who put the armband on got it right. Geffin makes an interesting observation. In autonomous car crashes, there was a human on board. "The human 'safety driver' in the car, who was supposed to provide emergency backup in cases like this, was apparently looking down at the fateful moment." (Geffin, 2018, para 9). Our fragile love-hate relationship with AI will evolve, and we will surrender more autonomy. Until AI becomes like us, "only better," nurses will remain the safety drivers, the patient's last line of defense. Someone still has to pay attention. For now, we're it. Peter Giffen. "20 ways artificial intelligence is changing our lives." 2018. Web. November 3 2018.
  4. RobbiRN

    Mandatory Hurricane Evacuation - Can I be Forced to Work?

    On the coast of Florida, I've worked before, during, and after several hurricanes. We are required to sign an annual agreement that we will work as assigned during storms. One of the hospitals in our network is routinely evacuated due to its location. Mine stays open. If I have a choice, I take "during." EMS doesn't run through the heart of the storm; no one is coming in and the hospital has a generator. Before and after are crazy. Best of luck to all in the path.
  5. RobbiRN

    "You're the Best Doctor."

    Thank you your for finding the joy Libby. (Did you ever live in Walla Walla?)
  6. RobbiRN

    "You're the Best Doctor."

    Your suggested introduction is textbook perfect, safe, appropriate, and defensible. Mine is, well, clearly risky. Sometimes, I start your way (except it's 25 years), but sometimes I start just like I did in the story. I would have been disappointed if no one called me out on the "higher on the food chain" designation. "Just a nurse" was no accident. My purpose for using both in this somewhat artsy article was to highlight the ability of patients to see past traditional hierarchy, choosing to honor and respect caregivers who treat them well instead of arbitrarily ascribing honor to titles alone. As the use of artificial intelligence escalates and the practice of medicine becomes increasingly remote and robotic, nursing remains the warm point of human contact patients crave. Some doctors are great with patients. I wish they all were, all the time, so we wouldn't need to clean up after them. Some are terrible at taking time to explain and answer questions. When a doc fails to take time communicate well (so he can get back to the internet), I will not waste one word trying to build him up in the patient's eyes. When I do what the doctor should have done, the patient knows which one of us met his/her need for a "doctor."
  7. RobbiRN

    "You're the Best Doctor."

    "Just a nurse." Thank you for noticing. I'm old now too. When I was young, I sometimes felt defensive when people called me "just a nurse" derisively. When I became secure and assertive, I started taking the term out from under them before they got a chance to use it, redefining it as a term of endearment instead of an insult. Patients quickly learn who is caring, competent, and responsible, and they choose to put their trust and confidence in those caregivers, regardless of titles. So, if your are often confused with the doc for those reasons, beyond or in addition to being old and male, then you are seen as honorable.
  8. RobbiRN

    "You're the Best Doctor."

    Doreen came from church. Before anyone says anything, I already know. It's 11:18 on a Sunday morning. Her dress is a striking blend of rich primary colors. Deep blue, bright yellow, candy apple red and dark leaf green jump off the stark black background of the thin chiffon knee-length dress. It will be hard to get this one off her without tearing it as she reclines with the head of the ER stretcher raised about thirty degrees. Her friend helps me get her into a gown before I hook her up to the monitor. Doreen seems accurate, but she speaks slowly and searches for words as the story evolves. She had coffee but no breakfast. While standing at the door to the church as a greeter, she started feeling lightheaded and walked toward her friend at a nearby table. The friend takes over, telling the story from her point of view. "She wasn't walking right and seemed confused. We helped her sit down, and I gave her some orange juice. She didn't pass out or fall, but something wasn't right. She's better now, but she's still not normal. Are you the doctor?" "No. I'm just a nurse. Someone higher on the food chain will be here soon, but I'll get things started." Most people laugh at my "higher on the food chain" notion. The truth is, it's getting complicated trying to list all the possibilities. She may see a doctor or a PA or a NP. I won't know which until one of them walks in the room. Doreen is in a sinus rhythm, has normal vital signs, and moves all extremities without guarding. I page for an EKG and do a complete NIH stroke evaluation. Aside from the friend's observation that "she's still not one-hundred percent," she has no obvious neuro deficits. An IV catheter slides smoothly into a large vein in her upper forearm, and I'm drawing labs to cover a possible stroke alert when Jason walks in. I introduce him as the Physician's Assistant and give him a short synopsis of Doreen's history. He asks the same questions we've already covered, and Doreen is sharp enough to tell him so. He shrugs, "Well, sometimes we double check to make sure you stick to your story. I'll go get your workup started. Again, my name's Jason. I'll be the provider taking care of you today. Let me know if you need anything." Doreen looks at the blood tubes in my gloved hand: "Did you just take that from me? I didn't even notice you were drawing blood. You're a really good doctor." I correct her one more time. "Honey, I'm just a nurse. Jason, the young man who just left, is a Physician's Assistant. He's essentially the doctor taking care of you. He reviews your case with the ER doctor who may or may not see you while you're here." Doreen's observation is matter-of fact. "I don't know why he says he'll be taking care of me when you're the one doing everything." Her brain seems to be working just fine. Despite the normal NIH scale and resolving symptoms, Jason and the attending designate the patient a stroke alert. A few minutes later we're back from CT. Even the friend who has been with her since the onset agrees that her recovery is complete. Doreen laughs and waves when a large posse of beautifully dressed women from church show up. If you want a massive group of visitors, make sure you're at church, preferably Jamaican, a Hispanic party, or a kid's sporting event when you go down. I coax the visitors back to the lobby for a few more minutes and drag in the neuro-tele unit with a monitor and video camera facing the patient and a monitor and keyboard on the opposite side for the nurse. It looks like it could get us to the international space station if we could figure out how to fly it. Our neuro-tele-doc halfway across the country "examines" Doreen, walking her through the same questions we asked previously. Once or twice she looks at me shaking her head when he has her do a few of the function tests from the NIH scale. Doreen finally tells the neuro-tele doc that she'd already passed this test before she went to CT scan. Mercifully, he cuts her test short, declaring that he doesn't see any evidence of an acute stroke and doesn't believe she's a candidate for TPA. The beautiful ladies from church pour into the room, fawning over the patient and laughing together for about half an hour before Jason comes back to discuss her results. He tells Doreen that everything has come back okay, and it's up to her whether she'd like to stay in the hospital for observation or go home and follow up with her doctor sometime in the next few days. She chooses to be discharged, have lunch with the church group, and head home from there. The friends help her back into her colorful dress. She walks well and feels like she's completely back to normal. She asks me if she's making a mistake by going home and wonders what I think might have caused her symptoms. "I think you're good for another lap. I would choose to go home if I were in your situation. There are a lot of sick people here; you might catch something. My best guess is that you should have eaten some breakfast this morning. Your blood sugar may have been a little low, and you were probably a little dehydrated since the orange juice seemed to turn things around. Standing in the heat for too long might have made everything worse. It's not impossible that there's more to it though, so listen to your body and come back right away if anything else happens." She gives me a hug and a beautiful smile. Her closing words are no surprise. In spite of several corrections, some people just don't get it. But there's no point in correcting Doreen's designation again as she says goodbye. "Thank so much. You were the best doctor I've ever had." I don't know what causes so many patients to fall back to the doctor title when expressing their appreciation at the end. Maybe it's because they are forgetful. Maybe it's because they are subconsciously elevating us to what they perceive to be the highest level of care and expertise. It really doesn't matter. After correcting them two or three times, I just let it go. The title doesn't matter. Their sincere gratitude is everything. Sometimes, I gaze into the not too distant future, imagining myself on the stretcher as the frail and possibly forgetful patient. I'm hopeful that we won't completely deteriorate into cold dark environment of apps and bots by then. I'm hoping that there will be someone there who is competent and dedicated to help me when my time comes. I'm hoping that nurse will not scorn my weakness, that he or she will take enough time to hear my real complaints and make sure legitimate symptoms are addressed and unnecessary testing is avoided. Mostly, I hope that nurse will value me and treat me with dignity and respect. When that day comes, and it's my turn to say goodbye, I sometimes imagine myself saying, "Thank you so much, you were the best doctor ever."
  9. RobbiRN

    Oh, my aching feet!!!!

    I regularly do three 12's in a row in an ER which allows me very little sitting time, some days - none. My formula is to start with three different pairs of shoes that I love and rotate through them. I leave one pair in my locker and change my socks and shoes at my mid-shift break so I don't wear the same pair more than six hours straight. The pair I remove at break stays in the locker and goes back on 24 hours later at the next mid-shift break. I trade to a different pair at home every day.The fresh socks and change in angles and pressure points is a refreshing start on the second half of a shift. Throw in a little caffeine hit and you're good to go. I would massage your feet, but it would be a felony in Florida if you paid me. I'd just have to do it for free if that would work for you.
  10. RobbiRN

    It Never Occurred To Me.

    Excellent. That's that best ending to a touching nurse-patient story I've heard for a long time. Maybe write a book?
  11. It's 11:34 a.m. The triage complaint is listed as possible stroke, with dizziness and facial droop listed as secondary complaints. A fifty-six-year-old female still in her street clothes is partially curled up on her right side scrolling through her phone. Patti arrived six minutes ago via private vehicle, walked in from the parking lot, and was brought to the room in a wheelchair. She doesn't appear to be in any acute distress, moving freely while repositioning herself on the gurney, breathing easily, with good skin color, and strong fine motor skills going into the phone-work. Her husband is leaning back in his chair at the bedside with his left ankle crossed over his right knee, reading a magazine. Nothing in this room conveys a sense of urgency. "The triage note says, 'possible stroke.' Can you tell me what happened today that brought you to the hospital?" I slide on a blood pressure cuff and a pulse oximetry clip as we talk. "I've been having headaches for a couple of months. But they've been worse for maybe two weeks now. And I've had some dizziness too." Her facial movements are symmetrical. She speaks clearly, without difficulty. Her vital signs are all within normal limits. "The note also says, 'facial droop'. Can you tell me about that?" The husband takes over. "She was just sitting at the table after breakfast this morning about nine o'clock. The left side of her face kind of pulled to the left, and she was having a hard time talking. It happened twice, about ten minutes apart, and it only lasted for a minute or two both times. She's had seizures so we didn't know if it was a seizure or what? Her face just pulled to the left." His description of pulling to the left doesn't sound like the "facial droop" described in the triage note. "Can you demonstrate how it looked to you?" The husband uses the muscles in his left cheek to pull the left side of his mouth laterally toward his ear." The patient adds, "I was having a hard time swallowing and I couldn't talk." "Any new or different medications recently?" "No," they say in unison, shaking their heads. About an hour later, we have normal findings on her EKG, chest x-ray, CBC, CMP and coagulation labs. Her repeated vital signs are also normal, and she's in a sinus rhythm with no ectopy on the monitor. She breezed through her NIH stroke scale with no neuro deficits. I'm headed to the room to let them know her CT has been read as "no acute intracranial findings." Intuitively, the husband's recreation of her face pulling to the side is still dogging me when he suddenly bursts through the privacy curtain, running toward me. "She's doing it again." Patti's sitting up at a ninety-degree angle, gripping both side rails. She's clearly anxious now; her eyes are wide, and she rocks rapidly back and forth. She's still in a sinus rhythm, but her heartrate is up to 110, and she's breathing fast. Her lower jaw is pulled laterally as far to the left as it can go, confirming the husband's choice of words in his description that "her face just pulled to the left." Somewhat relieved, I feel her tight muscles displacing her lower jaw radically to the left. "Can you move your jaw?" She shakes her head and tries to talk, but her voice is throaty, and her articulation is predictably muddled. "Is there anything else that feels wrong to you right now, other than your jaw being locked off to the side like this, making it hard for you to talk?" She looks at me and shakes her head, mumbling a garbled "no." "Patti, I can see you're really anxious. This doesn't look like a stroke or a seizure. I think it's a much lesser evil. Try to relax while I get the doctor in here to look at you." Dr. Spicer agrees that her presentation is consistent with a dystonic reaction causing a spasm of her jaw, lips, and tongue muscles. She's allergic to Benadryl, and, after considering Cogentin, he gives me a verbal order for 0.5 mg of IV Ativan. Her symptoms resolve rapidly, and, instead of being sleepy, she's just loopy enough to be happy and fun as we process her admission and move her to the observation unit. Patti's case is interesting for a couple of reasons. In looking for a potential cause, the most likely culprit appears to be her carbamazepine. They said 'no' when I asked about any new medications, but it turns out that her husband had changed jobs two months ago, forcing a change in insurance and doctors. The new doctor took her off Dilantin, which she had taken for years without incident, and put her on carbamazepine. The headaches had started a few days later, but they hadn't made the connection between the medication change and the headaches until we explored the timing together. Usually, a dystonic reaction happens after the first dose of a new medication or after an increase in dosage, neither of which applied in Patti's case, unless she had accidentally taken extra medication. We add a carbamazepine level to her labs, and the result comes back a little over the high end of the therapeutic range. Acute dystonic reactions are relatively rare in our flow of ER patients. Acute dystonic reactions to carbamazepine are also rare. Carbamazepine is sometimes prescribed to treat dystonia from other causes. The real key to the story was the husband's description that "her face pulled to the left." More specifically, just her jaw pulled to the left, but he was accurate in describing something that didn't sound like facial droop. (Try looking in the mirror and alternate between using your facial muscles to pull only your cheek or your jaw laterally. It's easy to see how he got his description.) It's unfortunate for Patti that she became one more causality of a system which forces changes in medical care because of a change in employment. The good news: there's no facial droop, no stroke, and no seizure. The simple longer-term fix for drug induced acute dystonic reactions is to discontinue the offending agent.
  12. I like the article. Our work environment is cluttered with noise. But, just because no obvious action is taken every time an alarm sounds does not mean the alarm was not evaluated. Often a quick glance at the screen, especially when I'm with the patient, shows that artificial intelligence has outdone itself once again.
  13. RobbiRN

    Damaged Goods

    Your dark, impressionistic picture of the pain in ER life and death is beautifully done. Many will feel your emotion; only those who work there will understand it. I won't judge you or anyone who serves and survives in the ER environment. If you can stay focused and get the job done, you deserve your coping mechanisms, dark humor, or whatever works for you. Dancing, traveling, and time at the beach dissolve my toxic residual, replacing it with enough energy for another round of chaos in a place where the pain and rewards are equally intense.
  14. RobbiRN

    Which nurse do you want for your Little Johnny?

    Excellent article. Unfortunately, profiteering and exploitative greed aren't keeping the guilty up at night while three million nurses go home wishing we could have done better. One crumb of poetic justice: their money won't matter when they become patients in the system they created and their lives are in our hands.
  15. RobbiRN

    Which nurse do you want for your Little Johnny?

    I'm reluctant to detract from the focus of a well-written article with this little detour, but I'm curious if the doc shared his rationale for wanting to use a NS base instead of D5w? God forbid we should ever stray from a protocol even if there're a myriad of great reasons for doing so.