12.09.2008

Week after week.

The gas station near my house is playing the theme song from "charlie brown" as part of it's christmas music rotation. Weird.

My work schedule is getting compressed into three days. I enjoy having a four day weekend every week, with the baylor shift on saturday it's turning out to be 36 hours or so a week. Too bad I'm still technically part-time! Hopefully that won't last much past February.

Having all this extra time in my schedule again has me thinking about hitting up the agency for more positions. Most of their offerings seem to be pedi homecare, but they supposedly do SNF placements too, that might be a good way to see the other SNFs in my area and get a good idea of how they work (my DoN suggests this would be a good way to appreciate how "good we have it" in our facility).

The largest benefit of this schedule, however, is still having time for Aikido in the evenings. I can't go four days a week anymore like I was, but being able to go at least twice is still nice. Last night, after the sensei descended the steps from his loft residence into the dojo, loud southern rock music started booming through the floorboards underneath the tatami mats. He arranged himself on his zafu and we sat zazen, music booming through the dojo the whole time. It didn't stop, even when zazen ended and we started training. He explained later that the music was for his plants in the basement, to help them survive the winter I suppose.

Friday is an employee meeting. According to the flier I got with my last paycheck, the iron chef secret ingredient of this meeting is Ginger. I hope they won't expect me to cook anything, but if they do I have two fine pinch-cookers to act as my stunt-double (I tend to burn most of the foods I cook in search of that "flavorful sear").

We also have an employee christmas party later this month, at one of our local resort casinos. I liked the idea of lounging at the bar with my new compatriots, but it looks like they rented out a ballroom or something like that for the event. Should be interesting, anyway. Everyone seems like fun to hang out with, and there's something uniquely useful about the experience of hanging out with your superiors and subordinates outside of work for some drinks...and some important conversations.

I feel like I'm learning a lot from everyone, but sometimes I'm learning conflicting things. This makes things very frustrating sometimes. For example, while I was processing a couple of admissions, I remembered what the night nurses told me about filling out duplicate kardexes so we'd be all set when the next month clicked over. When I started doing this, the day nurses told me that I wasn't supposed to do that. When I related this to the night nurses, they were extremely upset. I'm still in the "hey, I'm new here, sorry" stage, but that doesn't seem like it will last for very long.

One thing I'm pretty excited about is the opportunity to learn Reiki from one of the other RN supervisors. She practices a 10 minute treatment, which she says you normally aren't supposed to do for the young or elderly, but she "asked the universe to let it work", and she gives 10 minute treatments to our elderly Alzheimer's patients. Dementia is her specialty, you see.

I'm supposed to replace her when she leaves our floor to head-up the new memory unit next-door in February, our floor will then convert to mostly rehab. I'm considering following her when she leaves.

After only a few weeks at this facility, suddenly I'm the one telling people where to find a form. My position as the most recently-educated RN comes in handy, too. One RN showed me the lab results for one of our residents with metastatic cancer, she was concerned about the high white blood-cell count. Elevated WBCs might indicate an infection. I glanced at the differential count and then went back to organizing my treatment kardex.

"Maybe it's the neupogen we're giving them." I murmured, barely audible. I was on the floor that day, and had dozens of small emergencies and crises to sort out.

"Oh, right. Thanks."

Another time one of the new CNAs showed me the blood pressure he obtained for one of my craniotomy patients. 60/30, pulse 52...hmm...not good. I summoned the more experienced charge nurse and we got more detailed assessment data, but no interventions were proposed except to pass the info along and arrange for the antihypertensive dose to be lowered or changed to extended-release, and to write a new treatment order to obtain the BP manually before administering antihypertensives.

The charge nurse was puzzling over this out-loud, and I suggested off-hand as I was zipping by the nurse's station (I get a lot of exercise while I'm on the floor) that we obtain a head CT, thinking back to my lessons on the compensatory mechanisms that interrelate blood pressure and intra-cranial pressure.

"Hey, good idea! Thanks!"

I'm spending a lot of time with the lab and drug references, refreshing and applying my RN training. One of the silver linings of having an ungodly amount of paperwork to do is that this affords me some time to browse through a reference (what's another 5 minutes when you're half an hour behind?) and look something up. I think I'll bring my hefty med/surg and pharmacology texts with me this week, write my name on them and just leave them there. Too bad my nursing fundamentals textbook is unrecoverable!

My desire to see computers used in this setting is rising inexorably. As many problems as electronic charting has, the alternative system wastes too much of our time and introduces too many vectors for serious errors. There's no reason why I should have to be hunting down pieces of paper carried by the aides to copy down vitals and I&Os. There's no reason we should have to be highlighting which values we expect the CNAs to record for us. If we had computers-on-wheels, inputting vitals and I&Os can be a shared responsibility, only would have to be recorded somewhere once (and not in 3 different binders) and would be instantly available by everyone.

This would make our house MD's life easier, too. Apollo, Asclepius, Hygieia, and Panacea bless the guy, his willingness to call me back when I page him at 10PM often makes the difference between agony and relative comfort for one of my residents. I'm glad my training included how to organize yourself to ask for and receive telephone orders from an MD, even though our facility lets me write a lot of TOs on my own.

Imagine, though, if our house MD had electronic access to all of our charting and assessment data in real-time? It's easy to do, really. He could even transmit orders electronically, without even tying up our phone.

The biggest obstacle, I'm told, is getting the aides to use computerized charting. This is an obstacle I'm ready to meet head-on. The solution, I think, is one-on-one training. Forget all this sitting in a room and trying to show 20 people how to use it at the same time, it doesn't work for math class and it doesn't work for a reading/critical thinking exercise like using a new piece of software.

There may, of course, be larger obstacles I'm not aware of. Our DoN told me when I was hired that a computerized charting solution is in the works, but that our parent corporation was waiting to see other products field-tested by other facilities before implementing their own solution.

No, I don't want to be a Nurse Informaticist, damnit! I just want to practice in the 21st century.

This blog is coming up on a bit of a defining event. I've added one of my coworkers (who also goes to the same nursing school I graduated from) to my facebook contacts, and there's a link from my profile to this blog.

In terms of the law, I'm not concerned. The 18 forbidden identifiers don't appear here (although there is some gray area that has me thinking I should comb through older entries just in case), but the fact that I'm writing about work where someone from work can read it suddenly makes things much more complicated.

2 comments:

mike spaner said...

I enjoy reading your blog. Watch out for non-science based medicine though. You mentioned "Reki" in this post. Check out skeptical/rational view at: http://www.quackwatch.org/01QuackeryRelatedTopics/massage.html

I also highly recommend the podcast "The skeptics guide to the universe" ... see http://www.theskepticsguide.org/
Dr. Steven Novella and crew are Connecticut locals.
I hope to see you at the go club soon!
-mike

PM, RN said...

I've been working fridays, that's why I haven't been at the go club. Next time I have a friday off, I'm there! My game is getting weaker, I haven't played online much lately.

While reiki doesn't work very well for building jet engines or airplanes, complimentary health care modalities have proven very useful!

It's also true that a good part of my job is governed by science and the scientific process. The "nursing process" is just the scientific process with different window dressing. Everything involving the disease process, the medications and my assessment findings are, of course, governed by science and the scientific process.

What the scientific process doesn't help us much with, however, is things like compassion and holistic care of our clients, which is part of our responsibility. Science tells us a great deal about what NOT to do in these situations but fail to provide a way forward sometimes.

The big failing of this mindset is that it assumes that you start by determining HOW something works, and then set about finding a use for it.

How does reiki decrease pain in sickle-cell anemia patients to the point where they require less opiate narcotics? How can a 10 minute reiki treatment reduce inflammation to the point where someone who's eye has swollen shut can see again?

Even better, how does something simple like meditation help people cope with chronic illness and pain?

Science hasn't quite figued out how these things work yet, but they have a long track record of working, and the health care delivery system is sitting up and taking notice.

Once thought to be "quackery", most major hospitals have a set of acupuncture needles. Accupressure is becoming more commonly adopted, too.

Things like this, referred to collectively as "complimentary health care modalities" have been rigorously studied in peer-reviewed journals, and found to be effective enough that insurance companies now pay for things like yoga and aromatherapy.

Sure, there's no scientific explanation (yet) as to HOW it works, but a lot of interesting clues.

One experiment a friend of mine wrote about in grad school involved qi gong practitioners in a copper insulated room (a faraday cage basically), and there were voltage spikes running in the tens of thousands of volts coming from the interaction between the practitioner and the client.

Another fun experiment involved a rabbit and a russian submarine. The rabbit's offspring were separated from the mother rabbit on opposite sides of the planet. The rabbit's offspring were violently killed, and using synchronized atomic clocks, it was determined that the physiological response of the mother rabbit on the opposite side of the world occurred faster than it would have taken a beam of light to travel the diameter of the planet.

There's plenty of stuff that our Aristotelian "A equals A but not B" mindset balks at. Fortunately the rate of information exchange is increasing rapidly enough for us all to compare notes.

There's a "new inquisition" in the scientific community that doesn't sit well with me. It's not actually new, it's been going on since around the 1960s. Google Wilhelm Reich sometime.