Thursday, May 31, 2012
Welcome to my co-authors to this blog
During the last 3 months I have been writing a blog as an assignment for my reflective practice class. I have invited my co-authors from that blog to join me as they like to this one. Please welcome Sabina and Atefeh, who may or may not post here in the future. I hope they do, for I felt it was helpful to see their world of nursing.
Saturday, May 26, 2012
SBAR #1
Situation - basically healthy 50-ish year old in for a total
abdominal hysterectomy for a fast growing fibroid uterus. She is very
thin, the fibroids are so large you can see her uterus pushing against
her abdominal wall up above her umbilicus and to the left side.
Background - she has waited almost 5 years and suffered with heavy bleeding before coming to seek medical care.
Assessment - starts out as a relatively routine hysterectomy, turns into a life threatening event requiring 6 units of packed red cells, 2 units of fresh frozen plasma and leaving the OR intubated and directly admitted to the CCU.
Recommendation - calling for help early.
True story.
I was overwhelmed at times, but I got through with the support and help of my colleagues. Just as I was feeling the need to get help, help arrived.
BC, the nurse anesthetist (CRNA) asked me to call the blood bank to order blood. The surgeons asked what the blood loss was. There was only 300 cc in the suction canister, but I pointed out that the sponges were saturated, the surgical drapes were saturated and I could see that the linen under the patient was getting saturated. The surgeons agreed to order blood.
At one point there were 3 anesthesiologists and CRNAs, 2 anesthesia techs, 2 surgeons, 1 PA, 2 surgical techs, a helper RN and myself in the room dancing through our tasks. I couldn't keep track of all of the conversations.
Until Beth showed up, I was slowly losing ground in keeping up with all of the requests. I had been reaching for the phone to call for help when she showed up. At first I thought she coming to give me a break, I started shaking my head, meaning that this was not a good time. She then asked if I needed help. I wanted to hug her! We started working together to provide supplies, get equipment and chart all of the interventions being done. It truly was a dance.
The surgeons eventually finished their tasks. They slowed the bleeding, applied various hemostatic agents and closed the incision. BC and his attending tested the patient to see if she could be extubated, and determined that was not going to happen.
Getting the correct bed so the patient would go straight to CCU was a mix up since BC and his attending at first wanted to go to recovery then CCU.
I had Thursday off, to go to classes, and when I returned to work Friday I heard about my patient: she had returned to the OR twice to look for further bleeding. During the second time they didn't find much to concern them - the bleeding had slowed or stopped, finally.
I met up with BC at one time during the day and he thanked me for my assistance during the case and updated me further on her progress. She is doing better, may be extubated today or sometime during the weekend.
One frustration of my job is that we rarely hear about our patient's after they leave our care. HIPAA has made it so that looking at their records is not acceptable. Knowing that someone who is so critically ill is getting better is an amazing thing, especially if you took part in their care during such a critical time. I am grateful that my colleagues at work are so generous with their thanks and information. We aren't violating the patient's rights in a way that endangers their dignity or privacy. We cared for them, we care for them still, we are interested in their continued well being or outcomes.
Background - she has waited almost 5 years and suffered with heavy bleeding before coming to seek medical care.
Assessment - starts out as a relatively routine hysterectomy, turns into a life threatening event requiring 6 units of packed red cells, 2 units of fresh frozen plasma and leaving the OR intubated and directly admitted to the CCU.
Recommendation - calling for help early.
True story.
I was overwhelmed at times, but I got through with the support and help of my colleagues. Just as I was feeling the need to get help, help arrived.
BC, the nurse anesthetist (CRNA) asked me to call the blood bank to order blood. The surgeons asked what the blood loss was. There was only 300 cc in the suction canister, but I pointed out that the sponges were saturated, the surgical drapes were saturated and I could see that the linen under the patient was getting saturated. The surgeons agreed to order blood.
At one point there were 3 anesthesiologists and CRNAs, 2 anesthesia techs, 2 surgeons, 1 PA, 2 surgical techs, a helper RN and myself in the room dancing through our tasks. I couldn't keep track of all of the conversations.
Until Beth showed up, I was slowly losing ground in keeping up with all of the requests. I had been reaching for the phone to call for help when she showed up. At first I thought she coming to give me a break, I started shaking my head, meaning that this was not a good time. She then asked if I needed help. I wanted to hug her! We started working together to provide supplies, get equipment and chart all of the interventions being done. It truly was a dance.
The surgeons eventually finished their tasks. They slowed the bleeding, applied various hemostatic agents and closed the incision. BC and his attending tested the patient to see if she could be extubated, and determined that was not going to happen.
Getting the correct bed so the patient would go straight to CCU was a mix up since BC and his attending at first wanted to go to recovery then CCU.
I had Thursday off, to go to classes, and when I returned to work Friday I heard about my patient: she had returned to the OR twice to look for further bleeding. During the second time they didn't find much to concern them - the bleeding had slowed or stopped, finally.
I met up with BC at one time during the day and he thanked me for my assistance during the case and updated me further on her progress. She is doing better, may be extubated today or sometime during the weekend.
One frustration of my job is that we rarely hear about our patient's after they leave our care. HIPAA has made it so that looking at their records is not acceptable. Knowing that someone who is so critically ill is getting better is an amazing thing, especially if you took part in their care during such a critical time. I am grateful that my colleagues at work are so generous with their thanks and information. We aren't violating the patient's rights in a way that endangers their dignity or privacy. We cared for them, we care for them still, we are interested in their continued well being or outcomes.
Thursday, May 24, 2012
First day of "independent" practice
Overall, a good day. Started out kind of rocky, but things smoothed out and went well.
My boyfriend lost his name badge and spent 20 minutes looking for it when we should've been on the road to work. So I did not get to work as early as I would've liked. I was not late, but I had no extra time to look things over.
The night staff set up the rooms so the first case of the day should be ready to go, except for opening supplies and instrumentation and setting up the sterile field. The cases got switched and there is not a mechanism in place to make sure the room is checked for the appropriate equipment and supplies. The OR table was set up wrong and our case cart was missing many items. I had to call for equipment, grab the positioning devices and my scrub called CS for supplies needed. Overall, we were only 9 minutes late into the room.
My boyfriend lost his name badge and spent 20 minutes looking for it when we should've been on the road to work. So I did not get to work as early as I would've liked. I was not late, but I had no extra time to look things over.
The night staff set up the rooms so the first case of the day should be ready to go, except for opening supplies and instrumentation and setting up the sterile field. The cases got switched and there is not a mechanism in place to make sure the room is checked for the appropriate equipment and supplies. The OR table was set up wrong and our case cart was missing many items. I had to call for equipment, grab the positioning devices and my scrub called CS for supplies needed. Overall, we were only 9 minutes late into the room.
Last day of orientation
Friday was my last day of orientation. It was a whirlwind ending: my preceptor made herself available, but explained she had a project she needed to complete if I could work on my own. I had been doing the Litho room since the previous Friday and felt comfortable, so I said she was fine working on her project.
The first case went well, had to scramble to finish my charting before the case ended, but otherwise I felt really good about the flow of the case.
Then the patient went into laryngospasm after extubation. I knew it, I knew that wheezy sound. My scrub, who is really good at her job, jumps in to help the anesthesiologist, but doesn't know the drugs that are being asked for. I try to get in at the head of the table to help, but the scrub won't relinquish her spot. I also start calling in help: the anesthesia tech, and my preceptor. I pushed propofol in then I grab the succinycholine for the anesthesiologist, she asks me to push that in as well. She gets an LMA in, then tries to get an endotracheal tube in. The anesthesia tech is in the room and is helping as well now. No fogging on the ET tube, put the LMA back in. The oxygen saturations are coming back up and we are getting air movement into the lungs. Now I am asked to push some fentanyl. At this point my preceptor is back in the room and we are all just standing and breathing while the patient is breathing too. She looks at me and I explain the situation. She had been finishing her break, just about ready to come give me mine when I called. We watch to make sure the patient is stable for a few minutes, then she says she is going to go put her stuff away and come back to give me a break. Our patient is going to be intubated for at least another 15 minutes since the succinylcholine is a paralytic and needs to wear off before extubation. When I get back from my break the patient is still intubated, we are all just waiting. The anesthesiologist is being cautious now and waits until the patient is almost fully awake before she removes the tube. We get the patient to recovery just fine, the patient has a bit of a sore throat and admits now that he has been coughing a bit lately. The anesthesiologist is cautious for the rest of the day. She does acknowledge that I showed my experience in the situation - I knew the medications she wanted, knew she needed help and stayed calm.
Next time I may assert myself and ask the scrub to step away so I can handle the drugs. But really, the only thing I think I could've done better is to call for the anesthesia tech as soon as I heard the wheezing and knew we were going to have to re-intubate. As it was, the patient outcome was excellent and the entire team had a reminder of how important it is to work as a team.
Luckily the rest of the day went a little smoother than this. We had no more airway issues. On the last case we did have equipment and supply issues, which required me to call my preceptor back in to help. Overall, though, as my scrub left for the day, she said I had done a good job.
I had the pleasure of talking to one of the CRNAs as we finished up the last case. She asked me if I knew the criteria for extubation and then educated me. What a pleasure! She thinks I should think about CRNA school. I have, but I also have thought about the time: I have to work 2 years where I am now, then to get into CRNA school I have to have at least 1 year in ICU, CRNA school is 3 years, then I would have probably a year of residency - 7 years more of education and training. I am not that young! I do still consider this as a potential option, though. We'll see. Going to get the MN first.
The first case went well, had to scramble to finish my charting before the case ended, but otherwise I felt really good about the flow of the case.
Then the patient went into laryngospasm after extubation. I knew it, I knew that wheezy sound. My scrub, who is really good at her job, jumps in to help the anesthesiologist, but doesn't know the drugs that are being asked for. I try to get in at the head of the table to help, but the scrub won't relinquish her spot. I also start calling in help: the anesthesia tech, and my preceptor. I pushed propofol in then I grab the succinycholine for the anesthesiologist, she asks me to push that in as well. She gets an LMA in, then tries to get an endotracheal tube in. The anesthesia tech is in the room and is helping as well now. No fogging on the ET tube, put the LMA back in. The oxygen saturations are coming back up and we are getting air movement into the lungs. Now I am asked to push some fentanyl. At this point my preceptor is back in the room and we are all just standing and breathing while the patient is breathing too. She looks at me and I explain the situation. She had been finishing her break, just about ready to come give me mine when I called. We watch to make sure the patient is stable for a few minutes, then she says she is going to go put her stuff away and come back to give me a break. Our patient is going to be intubated for at least another 15 minutes since the succinylcholine is a paralytic and needs to wear off before extubation. When I get back from my break the patient is still intubated, we are all just waiting. The anesthesiologist is being cautious now and waits until the patient is almost fully awake before she removes the tube. We get the patient to recovery just fine, the patient has a bit of a sore throat and admits now that he has been coughing a bit lately. The anesthesiologist is cautious for the rest of the day. She does acknowledge that I showed my experience in the situation - I knew the medications she wanted, knew she needed help and stayed calm.
Next time I may assert myself and ask the scrub to step away so I can handle the drugs. But really, the only thing I think I could've done better is to call for the anesthesia tech as soon as I heard the wheezing and knew we were going to have to re-intubate. As it was, the patient outcome was excellent and the entire team had a reminder of how important it is to work as a team.
Luckily the rest of the day went a little smoother than this. We had no more airway issues. On the last case we did have equipment and supply issues, which required me to call my preceptor back in to help. Overall, though, as my scrub left for the day, she said I had done a good job.
I had the pleasure of talking to one of the CRNAs as we finished up the last case. She asked me if I knew the criteria for extubation and then educated me. What a pleasure! She thinks I should think about CRNA school. I have, but I also have thought about the time: I have to work 2 years where I am now, then to get into CRNA school I have to have at least 1 year in ICU, CRNA school is 3 years, then I would have probably a year of residency - 7 years more of education and training. I am not that young! I do still consider this as a potential option, though. We'll see. Going to get the MN first.
Doc-zilla
Originally posted 4/7/2012
I'm going to steal a term for a particular physician I have to work with occasionally. I told "R" I was, so it's okay.
There is one surgeon at work, who has been described as being very nice and funny outside the OR, but in the OR he is Doc-Zilla. The first time I worked with him I was doing my scrub rotation, he seemed a bit intimidating, but not too scary. I left without fear of returning. My scrub preceptor always works with him on Tuesdays so I would be returning. I felt bad for his residents, though, he yells at them all case long.
The next time I worked with him was a disaster, for me, the patient did fine. My preceptor did most of the work, helped me get the case set up and stood back to watch. She had asked the surgeon prior to the start of the case what the chances were of converting to an open procedure. He stated that there is always a chance that we will open. Later when he got into bleeding and had to convert to an open case we had to wait a little for instruments, he spent hours ragging on her.
During another time I was scrubbed in for him, his pager went off and our circulator, a nurse who works with him all the time made the call. It was from a nurse taking care of one his post-op patients on the floor. The nurse described what sounded to me like a possible mild allergic reaction to a medication and wanted something for the patient. He told the nurse to put some lotion on the patient's skin. He then proceeded to complain about how nurses couldn't do anything for themselves any more. I should've kept my mouth shut, but I spoke up to say that hospital policy dictates what we can do without a physician order and maybe we should work to change that. He then turned his anger on me.
I was horrified at how he humiliated me and spent the rest of the day not speaking to anyone, even outside of the OR in fear that I would start crying.
On another occasion, after a long day of working with him he said something like: you're abandoning this case like rats from a sinking ship. Someone once asked me if maybe this is his way of trying to be funny. It may be, but when I am already in fear of his anger, it doesn't sound like anything except an insult.
Worked with him again more recently. The day went better: I didn't talk to him unless I absolutely needed to, did my job quietly in the corner but it wasn't perfect. He would ask for something, then immediately yell for it again. At one point during the case I was running over cords and around equipment from one side of the room to the other to do two things right after each other. I was afraid I was going to trip and land on my face, but I made it.As the case went the pager for one of his residents went off. I really hate answering the pagers, I really hate being the "middle-man" between the surgeons and their other patients. I would really rather be focused on caring for the patient I am in the room with. I answered the pager, relayed the information and made the call back to the nurse who paged. I explained to her that the doctor was scrubbed in surgery and she immediately said: oh, I just wanted to talk to him about my patient...when will surgery be done. I'll try back then. I gave her an estimate and hung up. I then relayed the message to the resident. Then I got yelled at by Doc-Zilla because this patient had surgery yesterday and might be having a complication and why would the nurse page us while we are in surgery unless it was an emergency... I explained, again, what the nurse had said and sat down to continue charting.
Later I overheard him, amongst his yelling at the residents, say: well, even a blind squirrel gets a nut once in a while. I was appalled. He immediately said: not that I think you're a squirrel, or anything. Again, when I later relayed this to someone, they asked if maybe this was his way of being funny. I don't think it's funny. Even taking back part of it, it was the wrong part to take back! He was basically saying that his resident was lucky, rather than admitting that they had done a good job.
I am done with the Gen-surgery rotation and am hoping I am not required to work with him EVER again. I know that is not realistic, but I do hope my "opportunities" to work with him are rare from now on. He scares me. He's Doc-Zilla.
There is one surgeon at work, who has been described as being very nice and funny outside the OR, but in the OR he is Doc-Zilla. The first time I worked with him I was doing my scrub rotation, he seemed a bit intimidating, but not too scary. I left without fear of returning. My scrub preceptor always works with him on Tuesdays so I would be returning. I felt bad for his residents, though, he yells at them all case long.
The next time I worked with him was a disaster, for me, the patient did fine. My preceptor did most of the work, helped me get the case set up and stood back to watch. She had asked the surgeon prior to the start of the case what the chances were of converting to an open procedure. He stated that there is always a chance that we will open. Later when he got into bleeding and had to convert to an open case we had to wait a little for instruments, he spent hours ragging on her.
During another time I was scrubbed in for him, his pager went off and our circulator, a nurse who works with him all the time made the call. It was from a nurse taking care of one his post-op patients on the floor. The nurse described what sounded to me like a possible mild allergic reaction to a medication and wanted something for the patient. He told the nurse to put some lotion on the patient's skin. He then proceeded to complain about how nurses couldn't do anything for themselves any more. I should've kept my mouth shut, but I spoke up to say that hospital policy dictates what we can do without a physician order and maybe we should work to change that. He then turned his anger on me.
I was horrified at how he humiliated me and spent the rest of the day not speaking to anyone, even outside of the OR in fear that I would start crying.
On another occasion, after a long day of working with him he said something like: you're abandoning this case like rats from a sinking ship. Someone once asked me if maybe this is his way of trying to be funny. It may be, but when I am already in fear of his anger, it doesn't sound like anything except an insult.
Worked with him again more recently. The day went better: I didn't talk to him unless I absolutely needed to, did my job quietly in the corner but it wasn't perfect. He would ask for something, then immediately yell for it again. At one point during the case I was running over cords and around equipment from one side of the room to the other to do two things right after each other. I was afraid I was going to trip and land on my face, but I made it.As the case went the pager for one of his residents went off. I really hate answering the pagers, I really hate being the "middle-man" between the surgeons and their other patients. I would really rather be focused on caring for the patient I am in the room with. I answered the pager, relayed the information and made the call back to the nurse who paged. I explained to her that the doctor was scrubbed in surgery and she immediately said: oh, I just wanted to talk to him about my patient...when will surgery be done. I'll try back then. I gave her an estimate and hung up. I then relayed the message to the resident. Then I got yelled at by Doc-Zilla because this patient had surgery yesterday and might be having a complication and why would the nurse page us while we are in surgery unless it was an emergency... I explained, again, what the nurse had said and sat down to continue charting.
Later I overheard him, amongst his yelling at the residents, say: well, even a blind squirrel gets a nut once in a while. I was appalled. He immediately said: not that I think you're a squirrel, or anything. Again, when I later relayed this to someone, they asked if maybe this was his way of being funny. I don't think it's funny. Even taking back part of it, it was the wrong part to take back! He was basically saying that his resident was lucky, rather than admitting that they had done a good job.
I am done with the Gen-surgery rotation and am hoping I am not required to work with him EVER again. I know that is not realistic, but I do hope my "opportunities" to work with him are rare from now on. He scares me. He's Doc-Zilla.
My progress through residency, midway through
Originally posted in 4/7/2012
Every two weeks or so I am put into a different specialty. Last week I started in GYN. I had worked in GYN a few days during my residency, but that ended a couple of months ago. I was with the nurse who often works with Doc-Zilla. She is tiny, but she's a great nurse, and she knows how to deal with Doc-Zilla as well.
We were working with a surgeon who can be difficult, especially for new people. She helped me get going on the first case, then left the room to let me do the circulating. The case went well and I ended up starting the next case pretty much on my own. At 3 pm she relieved the scrub, who needed to go to a different room, and I was on my own. She backed me up from a different role.
During orientation we are supposed to have someone backing us up, available for helping us. As we are getting toward the end of our orientation we are expected to become more independent and do more on our own. But we aren't expected to be independent on the first day in a specialty. Well, I did it anyway. I keep being told by my colleagues that I am just about ready to be on my own, but I still have about a month of orientation left. This is good. That means I will be ready to practice on my own by the end of orientation. When I first took this job I knew I wanted to be in the OR, and I thought I knew a bit about being an OR nurse. I am pleased that I am mastering the skills necessary to become an OR nurse.
We were working with a surgeon who can be difficult, especially for new people. She helped me get going on the first case, then left the room to let me do the circulating. The case went well and I ended up starting the next case pretty much on my own. At 3 pm she relieved the scrub, who needed to go to a different room, and I was on my own. She backed me up from a different role.
During orientation we are supposed to have someone backing us up, available for helping us. As we are getting toward the end of our orientation we are expected to become more independent and do more on our own. But we aren't expected to be independent on the first day in a specialty. Well, I did it anyway. I keep being told by my colleagues that I am just about ready to be on my own, but I still have about a month of orientation left. This is good. That means I will be ready to practice on my own by the end of orientation. When I first took this job I knew I wanted to be in the OR, and I thought I knew a bit about being an OR nurse. I am pleased that I am mastering the skills necessary to become an OR nurse.
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