The work-around, what is it and why can it be dangerous?

Picture that you are an operating room nurse going about your day, doing cases, preparing for the next case, taking patients through the entire process of the case, induction of anesthesia, case, emergence from anesthesia, and taking patients to the recovery room. The entire gamut.

Suddenly management appears with what seems to you to be a new nonsensical rule.

Let’s use the example of not having bottles of saline in the warmer above 104 degrees Fahrenheit.

They leave you to your own devices.

You continue on with your shift, cases, lunch, more cases. The usual, you know.

When suddenly a surgeon says out of the blue that they wish the saline that was being used to wash out this patient’s abdomen were a little warmer. They don’t think that 104 degrees Fahrenheit is warm enough. After all, the saline doesn’t feel warm to their gloved fingers. Everyone knows it cools off during pouring and as it sits in the pitcher on the back table. Can’t they just have a little warmer saline? For the patient.

The work-around is used to circumvent the rules. Because the rules don’t make sense to you or to your coworkers. You think to yourself, why should the saline only be at 104, the blankets are heated to 130. I can just stick the bottle of saline in the blanket warmer. The patient will be warmer, the surgeon will get off my case, and everyone wins.

You continue to put the saline bottles in the blanket warmer. The surgeon is happier. Because what is the harm?

That’s the lure of the work-around. Standing up against the nonsensical new rule. Or finding a way to do a task a little faster than the last time. It can feel good to find a useable work-around, kind of like a dopamine hit.

But…

You have to consider why the rules exist. In the litigious realm of healthcare, it usually is because someone fucked up. Somewhere else. And the powers that be overreacted and made a new rule. But the rule is impacting you now. However, consider the possibility that there is danger behind the rule and that management and leadership are trying to protect you and the patient.

Going back to the saline bottle that has been warmed, routinely, 26 degrees more than the rule says. Ever consider that the rule change wasn’t arbitrary? That warming the bottles to 130 degrees had the potential to cause real and considerable negative impacts on the patient. Maybe it was discovered that the plastic of the bottle leached into the saline and therefore into the patient at temperatures above 120 degrees. Maybe there had been a reformulation of the bottle’s chemical formula that let this happen and the company found out about it and was just trying to protect the patient.

Is this scenario unlikely? No, more than likely.

Are the kudos and the dopamine you get from the surgeon enough to risk the patient?

That is why work-arounds, although sometimes useful and needed, are dangerous. Rarely do they give up all the facts when making a change, they may not even think about it because they, as leadership and management, know the reason behind the change. I’ve only met a few management-type people who offer up the reasons behind the change, instead of taking the hard line of “because I said so.”

Even before I went back to school I was always the one who needed the data behind the decision. Nothing has changed.

After all, the patient on the OR table is the reason for our job.

Tuesday top of mind 2/20/24- Cassandra calling

We warned you.

We warned you about the threat to Roe, despite assurances that there was nothing to be concerned about with settled law. Look what happened to Roe v Wade with the Dobbs decision. You know, the decision that knocked down fundamental, important rights of being a woman: the right to bodily autonomy, the right to privacy with discussions with their own doctor about their own body. That decision.

We warned you that medication abortion was next.

Along came Kacsmaryk and his ruling that called into question the FDA safety processes around mifepristone. The same ruling that was based on shoddy research that has since been recalled by the publisher? Yeah, and the case is now in front of the Supreme Court which has already shown willful disregard of laws and precedents in order to advance their religion on the United States. That one.

We warned you.

We warned you that in vitro fertilization was next.

After all the logical path says that if all abortion is murder, then in vitro embryos must be treated as people. The Alabama Supreme Court yesterday ruled that the embryos that were destroyed by accident by someone who wasn’t even allowed to be in the room but “wandered in” opened the freezer, took out embryos, and dropped them because the very cold temperatures required to gave them freezer burn to their hand. This broke the frozen clumps of cells. Yeah, and that temperature is -320 degrees Fahrenheit. The Alabama Supreme Court ruled that the embryos were to be considered children.

This was a terrible thing to happen to those cells. Terrible for the clinic that housed these cells, terrible for the family whose potential children were destroyed by someone “wandering around”. There should be charges.

However.

Respectfully an embryo is not a child. Embryos are potential children.

This ruling will send shockwaves through reproductive health. Again.

On a side note, the Mayo Clinic 10-20% of known pregnancies end in a miscarriage for a variety of reasons. That is not even counting the ones that are not yet realized and the woman may think nothing of a 1-2 day delay in her period or not even have a delay in her period.

Shall we take bets on what the courts will say about that? Are women going to be punished for having a miscarriage, a phenomenon that often has no answer and no causative agent? For being a woman. Bet me and you’ll be proven wrong when this slippery slope gets steeper and faster and men can act out their revenge fantasies on women. Because control.

I am sick of being Cassandra for reproductive health. Reminder, Cassandra was the daughter of the last king of Troy. Apollo bestowed the gift of prophecy on her in exchange for her doing his bidding. When she refused him, he said that no one would ever believe her prophecies. Sound familiar? Are you icked out yet?

Control has been the cudgel of powerful men for millennia. Even in fiction.

For now, in Alabama, frozen cells are to be conferred personhood.

We should all be frightened.

School Me Saturday 2/17/24-the more we learn, the less we know

The more we learn, the less we know.

This is a stark statement and it can also feel a bit disheartening.

What do you mean I have more to learn? When can I be done?

We can break down the phrase. The more we learn. Yes, there is always something to learn. It is impossible to know everything about everything. Learning is a privilege, some people do not have that luxury. We’re not going to unpack that; that’s a Tuesday top-of-mind topic.

If you have the opportunity to learn, absolutely do it! No matter how you learn, what you learn. It is always important to stretch those brain muscles.

The second part of the saying is no less important than the first part. The less we know, to me this means there is an opportunity to examine what we know and what there is still to learn in whatever realm you want to learn.

If you are a current adult learner you are already engaging with learning more. The key is always to be learning more and expanding your knowledge. You have to be content with the learning because it is not about learning all the things. Because that is impossible because no one has the time to learn all the things, not in a human’s life span. Even AI doesn’t know everything. Because there is always knowledge being generated in every minute, in every day.

Albert Einstein said that the brain is a muscle. In growing older the idiom if you don’t use it, you lose it really becomes clear. Your brain, your muscles, the foreign language you took in high school. All of it has to be augmented; there is always something to learn.

That fact that there is always something to learn is the takeaway from today. As is the idea of additional education in whatever realm that you want to learn.

Learning will never be done.

There is always something new. Being willing to learn is half the battle.

Cookie Thursday 2/15/24-cracker toffee with chocolate on top

To recap the theme of the month is Tracie’s Favorites. This is sadly the last Thursday that Tracie will be at the hospital and the fourth cookie on her favorite list is cracker toffee with chocolate on top. This is also called Christmas Crack, or Cracker Crack but I like Cracker Toffee with Chocolate on Top as a name.

Let me tell you a little about Tracie. She’s whip-smart and has seen some shit in her life and is one of the most caring nurses I know. And she’s leaving us. Insert sad face here.

She let me poach her from the pre-op staff. There was a patient with an injury and a surgeon who wanted to fix the patient but the patient had had pizza about 2 hours before. It is the same old story, surgeon didn’t want to wait, patient needed surgery but it wasn’t urgent enough to compel anesthesia, or the surgeon didn’t declare it an emergency. It’s been a long time, details are a bit fuzzy. It was decided that the patient could have surgery IF it was local anesthesia only.

Well, on call there is only the OR nurse as the only nurse in the department. A local only needs 2 nurses, a monitor nurse to monitor the patient’s vital signs and talk to them and keep them calm and a circulator to do all the OR things. I took a chance and called one of the recovery room nurses on the off chance she would want to be the monitor nurse so we could help this patient.

Tracie agreed to be the monitor nurse. I think it was the exposure to the OR, talking to the patient while keeping them calm, and watching the surgery over the drapes that hooked her into the OR. After that case, she talked to the manager about training her as an OR nurse. I am very glad she did. One summer there were 9 babies born to the OR staff over the course of 4 months. This meant that there were 9 people out on maternity leave, staggered over that time. She and I tag-teamed and did ALL the call for the summer. I took the night call and she took the day call. It was grueling but we got through it.

She has been my best cheerleader in my academic endeavors. I went back to school for my BSN, and she said what about getting your MSN and teaching. I had already been thinking about it and she helped me make the decision. When I said I was thinking of going back to school for my PhD she thought I was crazy at first and has been supporting me in this decision the entire time. Through the onerous PhD application process, the interviews, the recommendation letters, through it all.

I’ve heard about her life and her husband and her kids for years. Basically watched the kids grow up through her stories and pictures. Talked at length about her retirement plans in 2025. And we talked and supported each other through the freaking pandemic. She and I both worked the entire time, because someone has to be the OR staff in emergencies.

Tracie, there will never be another OR nurse like you. It is exciting for you that this is your last week in the OR at this hospital but also sad for us, no matter what certain people say. Let’s just say there is a reason that she is leaving the department and the hospital and I don’t blame her.

It’s raining men

It’s raining men and women. Because gravity is a thing and a real force to be reckoned with. Gravity doesn’t mean to hurt us, it is just doing what a force of nature does without caring what we pitiful humans think. Gravity, if it was sentient, would not spare a thought to making people fall.

However, as fragile humans, we have to think about it. How many times have you seen an edge of a sidewalk that has come up because of root action by the nearby tree and thought to yourself “Gee, someone better alert people about the uneven ground? I’d hate to see someone fall.”

Anyone? Just me, then. Cool.

The slip, trip, and falls were the largest percentage of staff injuries last year. Because gravity has it in for us. If it were sentient.

However, and I know I’ve written about this before, there are things that you can do to improve your chances of not getting hurt. Exercises to improve your balance will always be important. Maintaining muscle mass, not only as a cushion but as a way to foster reflexes will always be important. Because if your reflexes are fast enough, you can catch yourself before you fall. Knowing HOW to fall is paramount. I can’t tell you how many times we’ve had a patient with both wrists broken because they put their hands in front of them or behind them as they fell.

Gravity, much like time, is an immutable force. However, you can certainly take care of your vessel by maintaining balance, and reflexes, and learning the proper way to fall.

Maintaining your bone health is also very, very important. If you don’t have an adequate substructure, it doesn’t matter if you have great balance and great reflexes, an injury is more likely to lead to broken bones. Weight-bearing exercises and a good diet will help with maintaining the strength of your bones.

And women. Sigh. After menopause, women lose bone strength, because of estrogen loss. Estrogen plays a very important part in bone turnover.

My advice to you so you don’t end up on the operating room table.

protect your bones by eating a well-balanced diet.
Learn how to fall.
Ask your doctor if there is something that you can do to decrease bone loss.
Weight-bearing exercises are your friend to support the maintenance of your bones.
balance exercises are also very important to maintain your balance to decrease falls.

Bone density loss is a fact of aging. Protect yourself.

Because gravity doesn’t give a shit.

Tuesday Top of Mind 2/13/24-color me surprised, the articles about mifepristone were retracted by publisher

Shocked, I am shocked. This is heavy sarcasm.

Does anyone remember the debunked articles by Andrew Wakefield that began the most recent wave of anti-vaxers nonsense with a widely exposed fraudulent article in the Lancet conflating autism with childhood vaccines? And how every parent clutched their child to their breast and decided then and there that of course the man was telling the truth. With nothing underneath him but air? Yeah, him.

Healthcare workers, such as myself, have been educating parents about how safe vaccines are ever since. But the idea was like an earworm and refused to die. As a society, we are still dealing with the fallout and the consequences of this. Current measles outbreak numbers do not lie.

Herd immunity works very well. But the public has to be 1) vaccinated for it to work and 2) be protective of those who cannot get vaccinated, like the very young, the people who are anaphylactically allergic to the vaccines, or those who cannot otherwise take the vaccines.

Think of what the planet just went through with covid and you have a good idea of how damaging and heartless this was. People who didn’t get the widely available and FREE covid vaccines extended the pandemic.

To be blunt, autism is NOT caused by vaccines. To mislead the public into believing that was a gross malpractice on the former Dr. Wakefield’s part.

Well.

The 2021 paper that the Texas judge used in a ruling against the use of mifepristone has been yanked. By the publisher. Retracted by the publisher. What the judge did was bend the facts to make his ruling that mifepristone was dangerous and should be stopped. And his ruling was appealed and stayed and overturned. Which is what was the intention.

The case that is in front of the U.S. Supreme Court right this very second.

I’ve said it before, over and over again. This lunacy is a war against women and is about trying to control more than half of the population. Control is at the root of this.

Will they care that the original ruling was based on a retracted by the publisher paper?

It remains to be seen. I have an idea about what will happen. Don’t you?

I hope I am wrong.

Post-it Sunday 2/11/24-Sorry, the universe says no

The post-it reads “Sometimes the answer from the universe is no.”

I’ll just let that sink in.

What does sometimes the answer from the universe is no even mean? Can it apply to all things? Can it be applicable as an answer that I can give people who are asking the impossible of me?

I know that when I wrote the post-it it referred to the sometimes crushing inability of health care to solve all physical ills. That sometimes the damage is too great for even surgery to surmount. That sometimes medicine and medication and surgery won’t have the answer that people are asking. Or the answer that the universe gives back is a resounding no.

Heck, even money isn’t the answer in some cases. Well, in most cases. No matter the rich rich rich seeking to live forever.

Wow, this got dark fast. Well, I’m doing a PhD assignment. (shrugs)

But sometimes the answer from the universe is no and remains no. All the pleading, tears, and money in the world cannot make that answer a yes.

To get RREEEEAAALLYYY philosophical, maybe the no is the answer that you need to hear in that moment.

What about that?

School Me Saturday 2/10/23-Fear of failure

The fear of failure is very real for students.

What if I fail a test? Does mean I fail the class? What if I get an F on a paper? Does this mean I fail the class?

What if my alarm(s) fails to go off?

What if I fail to get into the homework study group that I really want into? What if I fail my parents, my significant other, myself?

What if I fail the class? What if I fail myself? What if I fail the class? What if I fail the test? What happens if I fail? Will I have to leave the program?

Calm down. Take a deep breath. Breathe in, breathe out.

Calm.

You can work yourself into a big tizzy thinking about all the things that could happen if you fail. Your mind can go faster, faster in circles. Like a dog chasing its tail.

Failure happens. I am quite certain that all of academia has seen every iteration of failure. All the ways that people fail.

Some people will tell you that failure is not an option. Obviously, it is or we would not be so scared of it. But what to do about it?

Reams and reams of articles have been written on the subject. All I can tell you, with any certainty, is how I deal with academic fear. Because I’ve been afraid as a student. Many times. it is how to meet the fear head-on that allows you to gain the courage to go on. And go to the next class.

I sit with the fear and play the what-if game. What if I fail this class? What if I fail this paper? There are conversations you can have with your instructors about make-ups, or extra credits, or even if the grades will be on the bell curve.

The movie Dune tells us, through Paul Atreides (the main character, AKA Paul Muad’Dib) that fear is the mind killer. This is very true. Fear can be a paralytic.

My very first ACLS (advanced cardiac life support) told us on the very first class, on the very first day that the first thing you do in a code is take your own pulse. This shocked many of us into laughter because my pulse in a code is the least of my concerns. It is the patient who is dead. What she meant is that you have to check in with yourself, and take a split second to calm yourself. This is taking your own pulse.

When you get the test booklet, the first thing to do is to answer the very first question. It will be your name. And you certainly know your name. First question down. On to the next.

When you get your first F, the first thing to do is take a deep breath and calm down. After your panic has subsided, look at the answers that were missed and read the questions. Square in your head why the question was missed. In the days of the scantron answer sheets, I accidentally skipped a page, which made all the questions after that wrong. Plead your case.

Find your study group, talk to your instructor, talk to your classmates.

Take your own pulse. And breathe.

Cookie Thursday 2/8/24-cheese straw cookies

Continuing on February’s theme of Tracie’s Favorites, cheese straw cookies.

I know, I just did a cheese month in January. Yes, there is still that much cheese.

I don’t care. This is what Tracie asked for.

I did ask qualifying questions. Whether what she had in mind was pepper jelly thumbprints, cheese straws, or pimento cheese straws. She chose straight-up cheese straw cookies.

Okay then.

All of these three cookies have the same base. Flour, butter, and shredded cheese.

It is the application of how much and what to do with it that is a bit different.

These are not a roll-out cookie. So there will be no chilling of the dough. As always, I am going to be doubling down on the spices. The recipe I am using asks for 1/8 tsp garlic powder. Um, no. I don’t think so.

Since I will not be rolling these out, I will use my smallest cookie scoop to portion out the dough balls. And bake at 350 degrees Fahrenheit oven.

There is also the question of how crispy do I want to make these bakes? The longer the cookies are in the oven, the crispier they get of course. But I want a bit of chewiness to them.

The cheddar cheese should not be bagged cheese. There are anti-clumping ingredients added to the cheese when it is packaged. I will be grating my own.

Also, my grater was last seen while making Christmas dinner. I have looked everywhere. Either it got thrown out by mistake, or broken and then thrown out, no one knows. Moment of silence for one of the OG wedding gifts. It served me well for over 25 years.

I bought a new one. Did you know that they are not dishwasher-safe? Probably explains why it broke/got thrown away/ran away.

Nursing is tops again for being trustworthy. But…

According to the 2023 Gallup Honesty and Ethics Poll, nurses remain the most trustworthy profession for Americans. Yay, us! I mean, I’m not surprised, are you? This is the 22nd year as the top dog out of the 23 professions ranked.

Nurses are the hardest working, patient facing group of professionals out there. We are at the hospital, at the bedside, 24/7/52. This means 24 hours a day, seven days a week, and 52 weeks a year there is a nurse at a bedside. There are also certified nurse assistants to assist in the work, environmental services to keep everything clean and hygienic, plant engineering to keep all systems like HVAC running, IT professionals on standby to help with software problems in the electronic health record, admission and records people to keep the records straight and admit as needed, dietary people to keep the kitchen running and the patients fed, and pharmacists and pharmacy techs to keep the medications correct and flowing.

Honestly, healthcare takes a village. We all worked together to get the world through a pandemic!

I am not surprised that nursing is at the top again when rated on honestly and ethics.

But…

Here it comes.

But… the ratings, although nursing is at the top, have drifted from their peak. Yes, the peak was in 2020. We all know what happened in 2020.

All the ratings are lower, except for those at the other end of the spectrum, their ratings either worsened or were the same. These are the members of Congress, senators, car salespeople and advertisers and they were all viewed by Americans as the least ethical. I mean, when you at the bottom, is there anywhere to fall?

Surprisingly, yes.

I am sure there will be additional research as to WHY there is an almost across the board decrease in perception of trustworthiniess and ethics. I have a pretty good idea. Don’t you?

Anyway, nurses are on top again as the most trustworthy and ethical profession, members of congress and senators are at the bottom. Fascinating read.

Reference

Brenan, M. & Jones, J.M. (2024, January 22). The ethics ratings of nearly all professions down in U.S. Gallup. DOI.Ethics Ratings of Nearly All Professions Down in U.S. (gallup.com)