Family in the Recovery Room

Does your hospital allow family members to visit patients in the Recovery Room/PACU?

My hospital does, and some nurses really do not approve. It is all that I have ever known, so I am used to it. I absolutely think that parents of young children should be back there. Also when we have had confused or developmentally disabled adults in PACU, a familiar face and voice truly helped them calm down and relax. However, if a patient is asleep or we have not yet gotten their pain under control, I would rather wait to bring a family member back. What do you think?

Question of the Day

This question was posed to me by a brand new nurse, but is something that I have also wondered about in the past.


"Why do so many Respiratory Therapists smoke?"


Any ideas?

Acronym of the Day

Hospitals have an obsession with abbreviations and acronyms. Every hospital where I have worked or trained has had a list of unapproved abbreviations in order to facilitate patient safety. For example QD, used to state "once daily", could be mistaken for QID, which is "four times daily", or even OD, something to do with putting medicine in one of your eyes or some such thing. Somebody could theoretically get really discombobulated and give their patient their once a day med 4 times in their eye. Just kidding...hopefully that would not happen. But as you can see, that could get confusing, so writing out potentially misreadable stuff  makes sense in that whole "do no harm" kind of way. In times of yore, before the list of forbidden abbreviations existed, patients actually did get harmed from such confusion. Now that that's taken care of, we just have to worry about gathering round the chart and taking a poll on what the doctor has actually scrawled out in his or her funky handwriting.
But I digress. Hospitals and the agencies that oversee them really do love to make up their own abbreviations and acronyms. Some examples:
SCIP=Surgical Care Improvement Plan
CAT=Crisis Assistance Team
PCAT (pronounced "pee-cat") =Pastoral Care Assistance Team
and so on.
Our latest at my hospital is "OAT", which stands for Organization, Attitude, Teamwork. Our management came up with this gem in response to patient dissatisfaction with staff attitudes, "communication between staff members", and "timely response to patient needs". In other words, our Press Gainey scores are in the toilet.
Our managers are running around like chickens with their heads cut off, trying desperately to improve our patient satisfaction scores. All of our managers have started threatening staff with discipline if they have any unsatisfied patients. There have been loud chewing outs in front of other staff, and now actual firings of some pretty good nurses, who for one reason or another did not measure up to their manager's personal definition of "OAT".
So, I have created a new acronym of my own. I call it VOMIT, to describe the latest panicked attempts by the higher ups to fix our staff and resurrect our scores. It stands for:
Violent     Obnoxious     Mean       Intimidating     Tactics

Do you like it? Should it be vicious instead of violent? I wasn't sure.

I Don't Remember this one from Religious Studies Class

Each patient at my hospital has a demographic sheet in their chart. It lists their name, address, emergency contacts, etc.
Last week I glanced at a patient's demographic sheet and noticed an interesting detail.
His religion was listed as "Caucasian".

Good Times

I was floated to the floor this week. This rarely happens, as I am an ER, Preop, and Recovery nurse with little floor experience. However, desperate times call for desperate measures, I guess, so off I went to take care of some inpatients.
A gentleman in his 80's a couple days out from neck surgery was having trouble urinating. I got an order to straight cath him, which I did. He put out about a liter of urine and was much more comfortable afterwards.
I returned a while later, asking him how he was doing. he informed me that he had been able to urinate on his own.
"Are you having burning when you urinate, Sir?" I asked him.
"No, Maam," he replied "and I can tell you I don't have VD."
"Well, that's good to know," I said
"But you know I had the clap once" he started reminiscing, smiling dreamily. "Actually I had it twice when I was in the army. Back in Japan, you know. Goop just started dripping everywhere. Come to think of it, I recall I had the clap three times. Those were some good times, I tell ya" .

Mean People Suck

My oldest child is a middle school girl. Unfortunately I have recently noticed some "Mean Girls" type of activity going on at her school. This kind of behavior is pretty typical of adolescence. I'd like to think that most of these kids will grow out of it and mature into secure, compassionate, productive citizens. I have met too many petty, backbiting adults to take this for granted though. I would also like to think that nurses would be above this kind of childish behavior. In nursing school I heard the saying that nurses eat their young, blah blah blah. I figured I was too nice and too hardworking for anyone to want to eat me up. Wrong. I've encountered a few cannibals in my time, but I'm not so young anymore, not so vulnerable.
I talked to a nurse the other day, however, who reminded me of this issue. I FINALLY took the 12 lead class I have meant to take for like five years. When I walked in, there were already about ten people seated in the auditorium. I smiled in my generally smiley way at everybody, and only one nurse smiled back at me. I recognized her as an RN who used to work on our Orthopedic post surgical floor. I had encountered her in the past when bringing patients to her from PACU. She had struck me as extremely hard working, smart, and helpful. A couple of us had suggested she come to the PACU, but she would need some other experience first, either ER or ICU. So, as I talked to this woman, we'll call her Nicenurse, she told me how she had transferred to the ER to get some experience there in order to hopefully eventually work in the PACU.
I have to explain: like so many others across the country, our ER is a zoo. It is a chronically understaffed, inner city, outdated, underbudgeted, overburdened mess. Staff turnover is horrendous. It hemmorhages nurses like a torn aorta. I know several agency nurses who refuse to go back. They seem to get a new Nurse Manager on at least an annual basis. I already liked Nicenurse, but I know how chaotic our ER can be. Now my respect for her has gone up substantially.
 She is so discouraged, though, she tells me. She has been in the ER for ten weeks and has no intention of quitting, but she says that the other nurses and the techs treat her like crap. This puzzled me, as I know she is hardworking and smart. Nicenurse told me that fellow ER staff criticize her positive attitude and are making bets on when she will quit and who can get her to quit. Apparently other staff have refused to help her at times and have told her incorrectly where items were located. I had no reason to doubt her story, but I just don't get it. In my mind more staff = good. I would want a decent nurse to come on board. Maybe if they could retain some more staff every nurse would not have to have 6 or 7 patients, including ICU holds.
I hope things improve for her. Do other professions treat themselves this way?



Bariatric Sensitivity Training

   Our hospital, in an effort to become a Bariatric Center of Excellence or some such nonsense, is requiring all staff, including physicians, to attend a bariatric sensitvity course. Now I will be the first to say that I could lose a few pounds. I have a "healthy" BMI, but am at the top end of normal, so three or four more pounds and I would be officially in overweight territory. So I am not some skinny girl hating on anyone heavier than me. I could definitely use more exercise and less sugar, no doubt about it. And of course everyone from Michelle Obama to Elmo is talking about America's obesity issue on television. However, I have to say that this class was by far not the most productive hour of my week.
   We spent the first half of the course covering points that hopefully those of us who are not complete a#%holes already knew. Obviously we should provide a larger bed for a larger patient, so they don't fall out.  Another example: when weighing an obese patient, we should not rudely holler out their weight so loudly that the entire unit can hear it. We also should not yell out "Hey Joe, we need to get the Big Boy wheelchair for this one", an actual example from the power point presentation.  We were also instructed to always provide an extra large gown for our bigger patients, which of course we would do anyway.
   Some of the other points, however, confused and disturbed me a little bit. We were instructed, in an effort to be sensitive, to not weigh a patient if they are uncomfortable about being weighed. Really? Many meds are weight based. An accurate weight is pretty helpful. A CHF patient often needs daily weights to determine if they are retaining fluids or not. This is a more complicated issue than it would seem.
   Another idea that seemed a little out of hand was to only discuss the patient's weight if the patient brought the subject up and wanted to talk about it. Apparently there have been a rash of patient complaints lately in which the patient was offended that a doctor or nurse had the temerity to advise that some weight loss might be a good idea if the patient wanted to live a few more years free of strokes, heart attacks and other not so pleasant things. This just flies in the face of common sense. Isn't prevention of health problems what we are going for (ideally) ? Are we not going to tell the chronic alcoholic with the cirrhotic liver that they should quit drinking? Do we not tell the diabetic who neglects their insulin that if they don't start taking care of themselves that little foot wound could result in an amputated leg? There are patients in our ICU right now who would not be there if not for their morbid obesity. That is a fact.
   We have extra large OR tables. We supposedly have "lift teams".  We have a special private preop area for bariatric surgery patients. We generally speaking are not jerks. We don't typically go around  making fun of anyone's weight. Sure, I know the patient probably aleady realizes they need to lose weight. Yes, I know many people would simply choose to ignore our advice. But damn...if we can't even talk about it in a sensitive manner, even raise the subject of possibly trying to lose some weight, how does that help anyone?

Another 12

Off to work to heal the sick! Or at least not make them any worse :)

Scrubs, Caps, and Aprons

I was so envious of the students in the other local nursing programs. Some wore white scrub pants and blue polo shirts. Some wore burgundy scrubs. Students in my program were stuck in a time warp. White polyester high waisted pants with the seams down the front of the legs. A polyester white shirt with a zipper down the front and a peter pan collar. The finishing touch was a blue and white striped "pinafore", apparently a fancy name for an apron. The whole thing came together into an unflattering package.We did have white caps, but were not required to wear them. They did not have the black stripe. Is the black stripe an indicator of graduation? Does it indicate your school? I don't know.
The women in this picture gave me a smile. the two in dark colors are apparently students.  I love the cap of the one in the middle with the Jackie O hair. It looks like it could easily kick the asses of the other two caps.
Thank goodness we don't have to wear whites now. Giving one patient charcoal would ruin the look.  At our hopital we just went to one uniform color for all RN's and LPN's. Respiratory, PT and CNA's, etc have their own colors.What do you think of uniforms?

Medical Terminology

Sometimes nurses get sent to work on unfamiliar units due to staffing problems. I know little about Gynecology, but apparently they just needed someone with a nurse's license who had a pulse. So, while floating to the Gynecology floor a few weeks ago, I met a sweet as can be twenty something CNA/Tech. She came out of a patient’s room and asked me in an exasperated tone “We don’t have sanitary napkins, do we ?”
I replied “Yes, I'm sure we do. They're probably in the Supply Pyxis”
“Really?” she said ” I’ve never seen those here.”
Wondering how a Gynecology floor could possibly stay running without an ample supply of sanitary napkins, I asked  “Are you sure you know what sanitary napkins are?”
She looked at me in disbelief “Of course I do. They are the little square wet wipes like you get at a barbeque place.”
We had a quick lesson on feminine hygiene products that evening.

How to End a Life

These are the words of Dr. Atul Gawande, a general surgeon and writer.
“Recently, while seeing a patient in an intensive-care unit at my hospital, I stopped to talk with the critical-care physician on duty, someone I’d known since college. “I’m running a warehouse for the dying,” she said bleakly. Out of the ten patients in her unit, she said, only two were likely to leave the hospital for any length of time. More typical was an almost eighty-year-old woman at the end of her life, with irreversible congestive heart failure, who was in the I.C.U. for the second time in three weeks, drugged to oblivion and tubed in most natural orifices and a few artificial ones. Or the seventy-year-old with a cancer that had metastasized to her lungs and bone, and a fungal pneumonia that arises only in the final phase of the illness. She had chosen to forgo treatment, but her oncologist pushed her to change her mind, and she was put on a ventilator and antibiotics. Another woman, in her eighties, with end-stage respiratory and kidney failure, had been in the unit for two weeks. Her husband had died after a long illness, with a feeding tube and a tracheotomy, and she had mentioned that she didn’t want to die that way. But her children couldn’t let her go, and asked to proceed with the placement of various devices: a permanent tracheotomy, a feeding tube, and a dialysis catheter. So now she just lay there tethered to her pumps, drifting in and out of consciousness.”

Read more http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=2#ixzz0yxLtNH1R
This is an excellent article that I would encourage anyone to read. Most nurses are confronted with dying patients and their families. Every day we see patients come into our operating rooms at the last part of their lives. I was very saddened last week to see a 95 year old patient no longer able to take food by mouth, with advanced Alzheimer’s, come in for debridement of pressure ulcers on the backs of both ankles and on her tailbone area. She is in constant pain due to osteoarthritis and has emphysema. Her family has kept her at a full code rather than DNR status and insisted on feeding tube placement. The pressure ulcers are from not being able to move herself in the bed. Even with excellent nursing care, pressure ulcers can eventually occur. Now don’t freak out. I am not advocating euthanizing the elderly. We give our end of life patients loving and respectful care no matter their code status or the attitudes of their family. But where do you stop adding treatments? I don’t know what the answer is.
Dr. Gawande advocates early hospice care in his article as well as educating the patient and family on end of life care EARLY in the disease process. He questions the excessive costs of extraordinary measures to keep terminal patients alive. I would be interested to hear the opinions of those not in the medical field, so I can understand some different perspectives. After years in the ER and surgical areas, jaded is a kind adjective to describe us sometimes. What do you think???

Not So Silent Killer

I had an absolutely lovely patient who was getting ready for surgery. However, I noticed her blood pressure was extremely elevated, 176/109. Considering it should be under 140/80, this is an issue. Anesthesia is hard on the body even without the strain of high blood pressure (hypertension) on the heart and other organs. The anesthesiologist ordered multiple doses of IV blood pressure lowering drugs, drugs that dilate the blood vessels, pain medications, antianxiety medications. We gave this woman a ton of medication, and her bp was now up to 192/116, possible stroke territory. Her surgery was cancelled and she was admitted to the hospital for cardiac workup and to get that bp under control. I brought her a turkey sandwich and ginger ale, as she had been fasting for surgery and quite hungry . She was very appreciative and ate it all. I gave her the lecture on how she needed to watch her diet and take her prescribed medications and how hypertension is the silent killer causing irreversible damage to the heart and kidneys before people even take notice. She nodded and said all the right things. She gave me a big hug and thanked me for her care. I went and gave her nurse on the floor a detailed report about the patient and her orders from the physician. When I came back to the bedside, my sweet patient was eating a ginormous Whopper with cheese and large fries. Now I am the first to admit my diet is not perfect, but really. Does anything we ever say make a difference? I hope she will get better.