Monday Musings 2/6/23-the family and the peri-operative world

When I am calling for a patient, the first thing I ask is if they have a family member at bedside. There are a variety of reasons for this: comfort for the patient, the person that the surgeon needs to speak to immediately after surgery is present, if the patient is confused, or has had medication that means they can’t sign their own consent, well the person at bedside most likely can.

Of all the reasons, the last is the most important.

And also, if the surgery is a dire one, they won’t be separated from their loved one until we are ready to head back. And if the surgery is dire, they probably can’t sign their own consent.

Have I called for a pause when the loved one arrives late to the hospital and fetched them so they could say goodbye to the patient.

You bet I have.

And I’d do it again.

Hell, I have done it again.

Does this delay the inevitable in the case?

No.

Does this delay the case?

No.

Does it give the patient who is about to undergo emergent surgery a measure of comfort? Absolutely.

And I will continue to call for a very slight delay so that the loved ones can see their patient before they head back for emergent surgery. Or I will hold the phone up to their ear so the patient can hear their loved one.

I do not regret it. One bit.

Post-it Sunday 2/5/23-Mirror, mirror

The gown card reads “holding up a mirror to the actions of nursing will allow open transparency in healthcare. We have to do it ourselves, no one else is doing it for us.”

No idea what prompted that gown card.

But it holds true every day.

The nursing profession must continuously put a mirror on the actions of the profession. This will lead to openness and honesty in healthcare. And this can only be a good thing and lead to safer patient care.

Do we all want the same things? Safe patients, safe employees?

Yes. Well, most of us.

But it is not ingrained in some of the healthcare workers that this is a job, yes. But their actions lead to more than a paycheck. For too many healthcare workers, their job is only to get paid. No more, no less.

It begs the question, has something been lost in healthcare today?

If we don’t ask the hard questions now and show these paycheck-only healthcare workers that nursing is so much more than the paycheck, what does nursing become in the future?

Everyone who has ever been in the healthcare system, as a nurse, as a worker, as a patient, should be concerned about this slide.

School Me Saturday 2/4/23- January report

I know, I know it is February and I had this planned for LAST Saturday and then the pay for diplomas news came out and Operating Nightingale. Obviously, I had to talk about that.

Anyway, it makes more sense to do the monthly report of my personal school journey after the month has ended. Sue me.

The Spring semester has started! In fact, this is the fourth week, well, we are one day into the fourth week. And statistics is still continuing. Think happy thoughts for me.

The new PhD class I have this month is Theory Analysis in Nursing. I had to do a theory class for my MSN but this one is completely different. Then I had to choose a theorist to write be part of the scaffold of my final project. Now, we are taken all way back to what is theory, the metaparadigm, and how nursing knowledge is constructed. Heavy stuff. My brain feels very full after this class; to say nothing of the deep reading for this class. As expected this is a very paper-heavy class. That’s okay. I like writing papers.

And I know I have been calling it a cohort class. That is incorrect. The proper term is cognate. These are graduate level classes, meant to be taken in a field that I find interesting and that I might be able to use in my dissertation. I took a financing longevity class last semester. Not sure how I am going to be using that in my dissertation but I learned a lot.

The cognate class for this semester that I choose is Informatics in Healthcare. The OR is so very technical and information-driven. I hope that the work I do with Epic and continue to do on the advisory committee will help with this class. And this is a full semester course. We’ve already had a quiz and a discussion post. And a group project to go. Again, think happy thoughts for me.

And then panic-inducing class- Statistical Applications for Nursing Research II. Math just does my head in, you know. Project in this class as well. And the first homework assignment is in. You’d think I would have good recall since the last class was only 8 weeks finished. You’d be wrong! If you don’t mind me, I am going to be reviewing ALL of the first class lectures and my notes for the rest of the week. And working on my project. And doing statistics crunching using SPSS. AND preparing for the presentation of my project. And doing more homework.

Oh, boy! It’ll be okay.

On the scholarship front, I submitted my grades from last semester and a copy of the tuition statement to the hospital for my tuition reimbursement. Hopefully, I’ll get that next paycheck. I also submitted the same grades and tuition statement to AORN for the scholarship I had from them. I got an email that I should expect a check in two weeks. All of that money will go into a savings account in case I cannot teach after graduation and I have to pay back the grant money. Fun fact, I thought I had a 3.0 GPA, but apparently, I had a 3.4 GPA. I’m not complaining.

New semester, new opportunities for scholarships. I submitted another application for another AORN scholarship. I also submitted another scholarship application for the White Rose scholarship which is for the healthcare market that I work in. If I win the scholarships, that would be lovely. The money would still go into the saving account with the rest.

The first semester of the month is always busy. It doesn’t help that the call job has had some very long nights this last couple of weeks.

That’s the round-up for the first month of the new semester. Busy, busy time. But only one class is planned for summer. And it’s ONLINE. Score.

Mantra time- the only way out is through

Cookie Thursday 2/2/23-Eggceptional cookies

This month on Cookie Thursday is a Thing I was going to first do International and then Leftovers take 2. And then I changed my mind, again, and declared this month’s theme to be Eggceptional.

Remember last May and June when the theme was Inflation Baking for two months in a row? Yeah, it is kind of like that.

Mostly as an acknowledgement of the price of eggs has more than doubled here in the US, but partly because of a recipe I found where one of the eggs and half of the butter was replaced in a chocolate chip cookie recipe with yogurt.

Y’all know that I panicked a bit last year when the price of butter doubled. I go through a LOT of butter. And now my fridge and freezer have 16 pounds of butter. Bought on BOGO and on deep discount. I’m not mad at that.

And I usually only use eggs for Cookie Thursday is a Thing.

I will get to the chocolate chip cookies with yogurt. But this week I am going to do a yogurt cake, no butter at all, 3 eggs but that’s okay as I anticipate using fewer eggs than normal for the entire month.

Also, a bit of Leftovers because this is Greek yogurt in my fridge from December.

Lots of more research to do. I wonder if I can use mayonnaise as a butter AND egg substitute. I have seen a chocolate cake recipe with that.

The cake was moist and resisted baking in the center. If I do this again, I would add a citrus note, maybe lemon. And some zest would not steer the cake wrong.

Stay tuned for more eggceptional cookies. Or cakes. Or bakes.

Some of the weeks might not even have eggs in them, focusing more on the Leftovers theme.

Monday Musing 1/30/23- 1095 days of covid

Happy Birthday to you! Happy Birthday to you! Happy Birthday, dear covid. Happy Birthday to you!

It’s your third birthday, covid! How do you want to celebrate?

If you could celebrate gathering your things, you know, your variants, and get the hell out of town, that would be great! Thanks!

You have WAY, WAY, WAY, WAY, WAY overstayed your welcome.

There, there. I know some people don’t even think you exist. Who think they know more than scientists who have been studying infectious diseases like you for years. What was that? Oh, they read an article. That their friend who also doesn’t believe in you sent to them. Along with a little computer virus, you scamp.

The CDC believes you exist. In fact, it was 3 years ago tomorrow that they declared you a public health emergency.

Please go away, and take your little dog, M-Pox with you.

Yes, I am well aware that those viruses are completely different and don’t even belong to the same classification. Yes, but have you heard of artistic license?

And the US is going to drop end the covid emergency on May 11.

Only one million, one hundred thousand, eight hundred seventy-two Americans have died. Not that the number we are have been getting for months is complete, since states started changing their report dates.

Even the WHO said today that you remain a threat but that the world is at an inflection point.

What is that?

You know, you can either keep going away. Or get super bad again. I know which one I would choose.

Please leave and don’t let the door hit you in the spike protein on the way out.

Counting basics #1-sponges

New series alert: Counting Basics.

I go on and on and on about counting. I thought I would take this time and this platform to introduce people to what exactly I mean.

No. Not one, two. Buckle my shoe.

That is a nursery rhyme to teach toddlers how to count.

Prior to the start of a surgical case the circulator (that’s me!) and the scrub tech count.

What do we count, you ask?

Well, that depends on the kind of case and how many body cavities will be entered into.

Yes, there are more than one.

Basically, as the odds go up for leaving something behind, the count gets more layers. And by that, I mean more counts.

And the something that could get left behind gets its own category.

At the most very basic, we count sponges and sharps.

This is for every case that has an incision.

Yes. Every case.

No matter what the surgeon or the staff say.

Once upon a time, there was a patient who was coming in to have an incision and irrigation of what was thought to be a localized abscess that had developed after surgery. This was on a forearm, just below the AC, a bit laterally. And the lump that was on the patient’s arm?

A sponge that had been balled up very small, to about the size of a grape, and shoved in for whatever purpose at the time. And then forgotten. And missed on the count. Did the previous surgical team even count? No idea. Oh, they might have documented that they counted.

But did they really?

No way of knowing.

Much of the OR is built around the honor system. If an action is charted, then it had been done. Right?

Right?

There are several types of sponges. These can vary from the very little, the appendix tapes which are skinny enough to go into an appendix incision but long enough to be able to pull them back out again. There are ray-tecs sponges. These are thin sponges that are folded and open up to 4-inch by 18-inch single-ply sponge. They are called ray-tecs because they are x-RAY deTECtable. There is a seam of material that is visible on x-ray. And then there is a large lap sponge at 18 inch x 18 inch. These get their name from the type of surgery they were designed for, the LAParotomy surgery. Or a large incision into an abdomen, the laparotomy incision. They also have an x-ray detectable tail.

This is a run down of the basic sponge that must be counted.

Post-it Sunday 1/29/23- Emergencies outside of their knowledge

The post-it reads “What happens if there is an emergency outside of their experience/script?”

How to be a nurse is taught by examples of the usual. A cause and effect story. If the patient has pain, nurse administers pain medicine and patient’s pain diminishes. If the call bell has gone off, the nurse answers the call bell and helps the patient to the bathroom. If the oxygen saturation upon taking the vital signs, the nurse increases the oxygen and the O2 goes up.

Event, response to the event, event decreases or goes away.

Some nurse go their entire careers this way. And they always have the proper response to the event.

But what if the event is outside of their knowledge? Outside of their script?

How do they cope then? (hint: the answer is not always notify the provider)

Precptors, and mentors, and schools need to teach nurses to expect the unexpected.

AND

How to react appropriately to a situation outside of their knowledge or their script.

Because, after 22 years in this business, I know that normal is not expected. And we best serve the patients by being flexible enough in the mind to react to all events. No matter how out of our knowledge it may be.

To go off script is to be able to improvise solutions on the fly, outside of the expected trajectory of events.

I bet you didn’t know that nurses were so adept at improv.

On no shift is this more evident than the shift where the support staff and management involvement is limited. I’m looking at you, evening and night shifts.

School Me Saturdays 1/28/23-fake diplomas for sale harms patients

The news dropped on Wednesday that some nursing schools in Florida were selling fake diplomas for upwards of $15,000 apiece. Two nurses I’ve worked with and respect sent me the articles. And I read more on the subject, cross-confirming like you should.

I’ll just let that sit there a moment.

(silence)

I hope that everyone is as outraged as I am.

I hope that all nurses are as outraged as I am.

This is despicable.

And the perpetrators of this scheme should be charged and convicted at the highest level.

The public has tremendous trust in nurses. And now some people out for a quick buck in Florida have decided to shit upon that.

Apparently, the name the investigators gave the investigation was Operation Nightingale.

This goes far beyond the college admissions scandal that caused so many people to be outraged just a few years ago.

The people who bought their nursing school diplomas then sat for the NCLEX. And some even received their RNs.

It is a thing of great fun right now, joking about checking nurses from South Florida. Jokes galore.

But we have to remember that the real victims here are the patients.

Who deserve nurses who have actually been to college to learn to care for them.

I can hear people now if they passed the NCLEX they must know something.

Yes.

They know how to pass a test.

They know how to get around the rules.

Did they pass? Really?

And how do we know?

Cookie Thursday 1/26/23-Boundaries

No Cookie Thursday is a Thing this week.

I worked until 0700 and the White Whiskery Wonder known as Dot woke me up at 1020.

I mean, cool, I made my 1045 meeting.

But I had already informed the OR that there would be no cookies today.

Because in the past couple of weeks, I’ve been writing about kindness in Dispatches from the Evening Shift. The first post was about being kind to the patient who is scared. The second post was about being kind to yourself. Another post was about being kind to the patient who is going to be in the hospital long term (meaning more than a couple of days, this can be because of IV antibiotics, or chemo, or not quite recovered enough to go home) and who just wanted to stretch their legs a bit.

Today’s post will be a further exploration of practicing kindness to yourself by the creation of boundaries. Before, I would absolutely have slept only a few hours, gotten up, made cookies, brought the cookies to the hospital, and returned home to nap. Or slept a few hours and gotten up to buy cookies and bring them in.

No matter how close you live to the hospital this is a bit unhealthy.

Especially for a thing you created and do 99% of the baking.

As I was leaving this morning, I told everyone that Cookie Thursday is a Thing needed to sleep. And there would no cookies.

Could I have made cookies when I got up? And brought them to the hospital? Yes, thanks to Dot.

But that would have been a terrible lesson for me. Instead of setting the boundary I had already created and sticking to it.

No Cookie is a Thing today.

Setting and keeping boundaries can be healthy too.

And a very hard lesson for a nurse to learn. You see, we are used to doing all the tasks, and caring for everyone else.

I will make the Leftovers recipe next week. Because I kind of already spilled the beans on what I was planning.

Anticipation whets the appetite sometimes.

Did I whiff and forget I had a meeting at 1400?/ Thereby missing it? Yep.

Also did I rudely wake up Dot this afternoon during her nap by wedging my freezing feet under her warmth when she was napping on top of the covers when I got under the covers to take a nap?

Absolutely.

When a patient goes missing, no matter how innocently

This happens.

A patient decides not to go through the entire rigamarole of leaving AMA.

Sometimes it is a confused patient who slips away unnoticed.

Sometimes they are just in another department, getting a test, or an X-Ray, or a treatment. The Epic EHR that the hospital I work for uses has a system in place that shows where the patient is in real-time. But sometimes this is buggy and places can’t show where the patient is. But they try.

And sometimes there is an alert that goes over on the PA, explaining what the patient looks like, and what they were wearing at last sight.

Sometimes it is a room-by-room search. Because you know that the computer system just may not be capturing their location.

Depending on the patient’s needs and condition this can escalate to a full-blown, all-hands-on-deck search. Maybe they are late for a test, or maybe they need their meds.

Sometimes a patient who has been weeks in the hospital and is finally feeling better just wants to stretch their legs. Maybe see the hospital a little. Maybe they want a snack from the cafeteria that is different than that on offer for their lunch. Maybe they have a hankering for Frito chips and they know that the vending machine in the basement has it.

It is best for the patient to explain that they are going for a walk. Of course, depending on who they tell, the message is not passed on.

I happened upon such a patient. They had done everything right, informed someone of their destination, not gotten something they shouldn’t have on their diet, stayed plugged into their IV, took the IV pump with them. They did it all.

And were still scolded like a child who was late for dinner.

This was not the best reaction from the nurse. The patient is an adult, and had informed someone where they were going, and was only gone a half an hour.

It turns out they were only looking for a phone charger as the one they had with them broke. And the promised replacement never appeared and the phone was nearly dead.

And the nurse reacted in exasperation.

Stop.

Think about what is going on from the patient’s point of view.

And stop scolding an adult like a child, threatening to withhold a treat after dinner.

And maybe follow up when there is a problem and a promised solution.

The confused patient who slipped away unnoticed? That was more problematic than an adult looking to solve a very real problem.

Thankfully the confused adult happens very rarely.

But don’t get mad at someone who was seeking an answer to their problem. And maybe tell them about the charging stations in every waiting room.