Saturday, May 25, 2019

Show Me the Money and I Will Show You Why That CVP Line Stopped Transducing

It really grinds my gears when entrepreneurially minded nurses seek to monetize assorted tutorials for learning clinical skills. Theoretical nursing in an academic environment is ridiculously overpriced and I understand the plight of whippersnapperns facing exorbitant school loans, but bedside procedures should be passed along  with a sense of pride and  respect for the history of nursing. The sense of well being gained by seeing a young nurse confidently perform a procedure you showed her how to do is priceless. It's your extension in time and will bring a warm feeling to your foolish heart when you are old like me.
Image courtesy Maklay 62

Diploma schools were big on ceremony and pageantry with ascent through the nursing hierarchy. Youngsters today may have dollar signs in their eyes, but for us, the ultimate reward was that coveted pin. Dreams of walking down the aisle  with our Nightengale Lamps leading the way to receive our pins were what we thought of in troubled times. Thinking about money was distant in our minds and any mention of financial gain earned you a speedy exit from the program. It was just palin wrong headed thinking and an egregious example of putting your needs before others.

How do you unite nurses from different generations with different values? One  way was  passing on  clinical skills from experienced nurse to novice. The scrub nurse tricks of the trade that I learned from my nemesis, Alice, are precious beyond any means of monetary compensation. I didn't learn how to load a sponge stick one handed or count out ten 4X4s in a nanosecond by paying money to watch a video. No, she never smiled or encouraged me like the glad handing  nursing procedure hustlers selling their videos. Humiliation was a powerful motivator.

I shudder to think of the consequences incurred by  offering a Greatest Generation nurse money for procedure tutorials. They could survive on next to nothing because working as a nurse was a reward in of itself. Their  notion of self care was a 15 minute nap in the lounge after being called in for a middle of the night case and working 9 hours the next day. Life was meant to be difficult and nurse's were destined to a life of poverty. I admired them with unbounded abandon and was a mere sissy compared to their resolve. I wish a few of them were around to deal with today's nurse monetizers.

CVP lines were in their infancy when I was practicing and I made it my mission to learn all I could about central line procedures. Obtaining a central pressure involved a carpenter's level, a three way stop cock, and a manometer. Connecting them to a transducer opened up a Pandora's Box of problems and involved endless fiddling for a reading of dubious value. They were a real pain to deal with. I was thinking of producing a video explaining some of the pitfalls of CVP lines and possible solutions. Of course this is going to cost you, but, in all honesty, I would rather sell a kidney than profit from teaching the next generation of nurses. We are all in this together so let's pause and think about the needs  of novice  nurses before whoring out something sacred like the mastery of bedside procedures.

Saturday, May 11, 2019

Overhead IV Racks Done in by IV Pumps and Controllers

An overhead IV rack in it's safest position-on the ground

Imagine a device that would take advantage of unused vertical space above the patient's bedside and free up congested floor space. Sounds too good to be true?  Well, it was.  In the early 1970s a new fangled device came to our fancy new state of the art ICUs. Designed by architects with decades of office sitting experience, but loathed by nurses at the bedside, the wonderous new creation was overhead  suspended IV hangers.

The ceiling was equipped  with tracks that ran around the periphery of the bed in a semi-circle or as a single diagonal running from the foot to the head. A looped hook with ball bearing wheels roamed the confines of the track. The IV rack  had a pigtail like structure at it's upper most  point  that was carefully threaded through the hook and you were in the  business of IV bottles in the sky.

These clever contraptions utilized a release button that dropped the rack down to working level that just happened to be the height of the average bedside nurse. It was fun and games for all until  a spontaneous release that dropped the loaded rack in a nondeviating  path on the top of a vulnerable cranium below. Talk about Excedrin headache #47, that really smarts. I think overhead IV racks may have been the impetus for semi-private rooms. A nurse was concussed by an overhead IV rack and rather than open another hospital room, an additional bed was wheeled in for the traumatized practitioner.

Another problem with overhead racks was a phenomenon known as "uplifted bottle drift." My recollection of high school physics is a bit fuzzy, but one of the facts of inertia included the notion that once a body is set in motion, it stays in motion. A sudden lateral adjustment of the heavy glass bottles position in the ceiling track sometimes meant the contrivance flew past it's intended stopping point resulting in a most unpleasant crash/bang with light fixtures or anything else in it's path. Twin overhead racks over a single bed were an accident waiting to happen. If both loaded racks collided, a shattered glass shower was inevitable as the bottles self destructed. If you think cleaning up glass IV bottles from the floor is bad, you haven't seen anything, as an occupied bed full of injurious glass shards glass was far worse. A two for one deal of the supremely noxious variety as both nurse and patient were potential laceration victims.

Gravity was a dependable vector to deliver IV fluids, but there were lots of variables when the only controlling mechanism was a roller clamp. This necessitated endless fiddling and adjusting as vascular resistance varied or the fluid level in the bottle dropped. See-sawing IV drip rates were always explained by that ubiquitous "P" word. Positional covered lots of possibilities from the position of the IV catheter to the movement of an extremity.

A revolutionary development appeared in the mid 1970s. Fancy little IVAC machines with glowing electric eyes plastered to the drip chamber began appearing. This clever little apparatus accurately controlled pre-set drip rates. Older nurses thought they would never catch on due to their expense, but to me, they were magic in a box. IVACs and the even more sophisticated pumps that followed required an IV pole for support. IV poles meant the death of overhead IV racks. We did keep a couple of the flying IV racks on the unit because a few of the patients enjoyed posting family photos or inspirational slogans on the overhead racks. It was a genuine boon to patient morale to look up and see a reassuring image and some of the hazards of these racks was mitigated by the absence of heavy bottles.

If you are interested in acquiring an artefact of nursing/hospital history, there are loads of these fickle firmament flying fixtures for sale on EBAY. Just don't forget to duck!

Thursday, May 2, 2019

Custom Made Signage by Nurses

 Hospitals are infested with signage developed by office sitting busy bodies promoting policy, giving direction, or threatening grave consequences for those with the nerve to be non-compliant with their all important edicts. Signs have authority and grab your attention. Who  in the world is going to fool with a red bag tagged with the warning: CHEMO THERAPEUTIC INFECTOUS WASTE? It's enough to scare the daylights out of a Pope.

Bedside nurses  put other's   needs before their own  because they are wired differently at the factory as compared to business minded hospital big shots. Information flows down from the top with a remarkable efficiency, but enlightenment gained in the trenches stays there. Hand made signs posted by harried nurses are an attempt  to break this communication barrier. It's difficult and dangerous to transition a one way street to bidirectional traffic, but that doesn't stop sign maker nurses from trying.

Nurses can be their own worst enemy. In nursing school we had a bulletin board for posting NLN test results that we called the wailing wall. Instructors were also known to publicly humiliate their students by posting signage advertising particularly egregious clinical  blunders. One memorable sign announced with great fanfare that "Gwen had attempted to irrigate her patient's Foley catheter with a TB syringe." That was cringe worthy because the syringe was too small by a factor of 100cc. or more.

Step down units are typically located adjacent to critical care units and the staff members get along about as well as cats and dogs. Step down nurses think ICU nurses are cowboy or girl know-it-alls with overblown egos and are eager to put these hot shots in their rightful place. I noticed a huge poster plastered on the ICU locker room door stating "THIS CAME OUT OF ICU." It was a double heparin locked IV catheter. An ICU nurse was probably doing a gazillion things at once and failed to notice the patients IV was capped with a heparin lock and hep locked the needle previously inserted. I figured out a scheme to convert the sign from an admonishment to amusement by inserting several more needles and hep locking  them in place so there was a series of hep locks about a foot long. A dose of good natured badinage helps improve relations among feuding groups of nurses.

UPMC, the health care behemoth here in Pittsburgh has power. When they acquired Montefiore Hospital which was built into a hillside ala Pennsylvania bank barn style they changed the names of the institution's floors. What nerve!  The hospital was entered from the summit of the hill on a floor called "Main." A, B, and C floors were underground and the floor above main was the first floor. UPMC renamed "C" level as the  first floor and the other units followed in numerical sequence. A series of lengthy, confounding memos and signage flowed from the corporate geniuses at UPMC explaining the new nomenclature. Leave it to a nurse to explain things in simple, straight forward language with her sign explaining, "MAIN HAS MOVED TO 4TH FLOOR AND FIRST FLOOR HAS MOVED TO THE 5TH FLOOR." It may have sounded whacky, but everyone knew what she meant.
Who made this sign? Not me!
Coffee is an essential on any nursing unit and anything impeding it's consumption must be dealt with. Our neuro ICU coffee pot shared electrical outlets with a vending machine and somehow the coffe maker was often unplugged. A nurse attached a sign to the electrical cord running from the coffee maker: "DO NOT UNPLUG-VITAL LIFE SUPPORT EQUIPMENT" Folks honored the official looking sign and we always had hot coffee.