Digital Medicine

It seems as though the cold weather is finally looking like it is going to end. I have some exciting projects to get done this summer and am looking forward to some warmer weather so I can get started on them.

Things at the hospital are about the same. The young lady from the Med/Surg floor started this past week. I haven't worked since she started, so I haven't heard how she is doing. I guess I will get the update this week.  I have Friday off this week (Yay!), but they have a manditory 4 hour training session I have to drive into attend (Boo!). Sometimes it sucks living an hour away from the hospital. 

I worked two days with home health this week. I usually only work one, but this was a special case. They hired me to do IVIG therapy PRN, but we haven't had a lot of that to do. So, I have been filling in doing routine visits, admissions, discharges, recertifications, and whatever else they needed me to do. Wed, I did my regular routine of routine visits, then Thursday morning while I was lounging around looking forward to the day off, I got a call that they had an IVIG case that they needed me to do. I couldn't refuse it, so I was out on my day off. 1.5 hour each way, and a 4 hour infusion not counting set up, starting the IV, etc... So much for my day off. So I had two days off this week and the hospital messed up one, and home health messed up the other. What else can you do except grin and bear it?

I wanted to talk a little about the IVIG therapy I do. IVIG made by taking the antibodies out of many different units of blood, and mixing it together. Infusing it increase the immune system of the recipient. It can be a great treatment for someone with compromised immune systems. There are some pretty powerful side effects however, so it takes some caution in administering it, and close supervision during the administration. As it is a blood product there is a very real danger of anaphalaxis occuring. Also, headache, chills, nausea, vomiting, and fever are all common. You have to watch closely to make sure these are simply side effects and not a more violent (and dangerous) allergic reaction. Always have an emergency kit on hand with IV Benedryl and Epinephrine. My patient I saw this week is an organ transplant receipient. They get therapy avery few months. The experience chills, slight fever, and headaches everytime. The also occasionaly have nausea and vomiting. I try to get them started on Tylenol and Benedryl early on in the infusion to try to head off these symptoms. I don't pre-medicate them. This is my logic. The infusion ramps up in speed. It goes like this.

30ml/hr X 30 minutes

60ml.hr X 30 minutes

120ml/hr X 30 minutes

150ml/hr X 2 hours.

This patient usually doesn't start having symptoms until the last hour of the infusion, or sometimes even after the infusion is over. Benedryl's onset of action is 30 minutes, with a peak of 1-4 hours. So, I usually give it about 1 hour before the infusion is over. That way it is starting to work as the infusion is finishing up, and is just hitting it's peak as the infusion ends. This way my patient is getting the maximum benefit, just when the symptoms are at their worst. I always try to work this way. Sometimes in the hospital I have seen patients who are to be given pain meds before a painful procedure such as a wet to dry dressing change. I have seen nurses give them the pain medicine, then perform the procedure 5 minutes later. Way sooner than the pain med becomes effective. When I am in that situation I grab my trusty drug book and look up the pain med. What ever the onset is, that is the target I use to perform the procedure. That is what I would home my nurse would do for me.

Well, as the title implies I am looking to make some changes this year. My wife and I are getting sick of never seeing each other and doing nothing but work and watch TV. Night shift is very hard on a personal life. I enjoy the people at the hospital better on night shift, they seem to be much more laid back and easy going. The problem I have is with my personal life on night shift. Even when I am off I am sleeping throughout the days, I am tired all the time. I spend all night awake and alone (it's 03:00 right now). So I am going to start working toward finding a day shift job. I had thought maybe I would eventually go full-time with home health, but I am unsure about that. I like it, but I am not sure I like it that much. Also, their medical insurance is not nearly as good as the hospital's, and I would hate to give that up. We had some substandard insurance a few years back and my wife had to have some surgery done. We ended up with quite a bill on our hands as a result.

I am not looking to leave the hospital, but I am going to start looking for other opportunities within the hospital to move to day shift.

We had a nurse hire on with us about 8 months ago, she lasted 6 months before she quit. So, now we have been working 48 hour weeks (plus I still work one day a week with home health), for some time now. They finally hired her replacement. It is a young lady from out med-surg floor. She has a great attitude and I think she will be fun to work with. She is going to start out part-time until they get her replaced on the M/S floor. I think it will probably be a couple of months before the overtime dries up, but at least there is light at the end of the tunnel. I am enjoying the overtime, but I could make as much by working an extra shift with home health, and that would be day shift. So I would prefer to do that.

Things are going good in the ICU. I have been enjoying work more lately. I think as I near in on the 2 year mark I feel more confident. My stomach doesn't drop when I hear the word "Admit". I feel like I can handle what is going to come in the door. I used to have butterflies in my stomach when I first came in until I got in the door and saw what acuity level our patients were at. Now I don't worry as much. I deal with whatever is there. They only thing that gets me is when I come in and it is obvious someone isn't going to make it through my shift. I handle that as well, but no one wants one of their patients to die. For obvious reasons, but also dealing with the family. If they have accepted it, then it isn't as bad. But I hate making that phone call at 02:00 to someone who thinks Mom is coming home from the hospital in a day or two. I also hate trying to judge when to call. I have called once to a someone who was about 15 minutes too late to see their father take his last breath. They were heartbroken at first, but they were a nurse and I explained how fast his condition changed, and they were understanding. I also once called in some family saying "you better get in here if you want to say goodbye", only to have the patient make a fantastic recovery and be stable within a few hours.  It is a hard judgement, and I hate having to be the one to make it.

Well I noticed how woefully out of date these posts are, and figured I should start out the new year by updating them.

My new job at home health has been going well, although it is different than I expected. I have actually only done one IVIG therapy case. The way insurance companies reimburse for this therapy has changed, and we have not been doing nearly as many cases. So, they have been trying to find more stuff to do with me. So, they have had me running all over the place doing routine visits, admissions, recerts, discharges, taking call, etc... I was working 3 days a week there, and 3 nights at the hospital. I did this for almost 3 months. It was getting hard to keep going. So, I had a talk with my boss and said they were going to have to back off a little. So, now I am only working one day a week for home health when they do not have any IVIG cases, and I only do routine visits in a smaller geographic area. That has reduced my income a bit, but made life a lot more enjoyable.

Admissions have picked up at the hospital this past month or so, and we have been a lot busier. However, I found out that we had 90 fewer admission this year than last year. For a small 6 bed ICU that is quite a few. That is 1.7 admissions per week. We are rarely full anyway, we usually have 3 or 4 patients at a time. So although it isn't a huge deal, it is noticable. I don't know why admissions are down. I know they are down on the floor as well, because staffing levels are quite a bit lower than they were last year. It will be interesting to see what the new year brings.

I changed my schedule at the hospital to working fri, sat and sun. This freed me up during the week to pursue extra work. I landed a job with a home health agency administering IVIG therapy. I am excited about this opportunity and will keep you all updated.

I had a patient the other day that overdosed on acetaminophen. Their level was quite high, over 200 mcg/ml, even after 8 hours. They were treated with Acetadote administered IV. It was quite a production with a loading dose, then a 4 hour infusion, followed up by a 16 hour infusion. I posted up a link to the manufacturer's website that outlines the infusion procedure, and provides some great information about acetaminophen overdose. I am seeing this more and more often, so it's good information to have.

Yesterday I was adding a new form to the forms page and the whole page crashed. I had to completely redo it. While at it I decided to take down a couple of the forms that were very specific to my nursing program. I just didn't feel like anyone that wasn't in my particular program would use any of them. If per chance someone is looking for something in particular that used to be up on the site, email me and I will send it to you.

Also, I added a new video page. Right now I only have one video up, it is a great one about injections. Look for more in the future.

I have the weekend off, our census has been so low this week that I am lucky to have gotten to work. We have had one patient in our ICU for the last week. Without that one patient we would have had to close the ICU down. We've actually only had a handle full of patients in the hospital. We are a small, rural hospital. So it's not uncommon for census to drop very low during the summer months, but this has been much lower than ever before. A couple of our nurses who have been there for over 25 years have said they have never seen it so low. I am unsure of the cause. One speculates that it is due to medicare changes that require MD's to shorten patient's length of stay to get reimbursed. So the MD's are trying to not admit many patients. I am unsure if that has anything to do with it or not. But I hope things pick up soon or times may get hard.

I had planned on picking up some extra money this year by giving flu shots through Mollen immunization clinics. I had signed up with them, but I had heard it was hard to get hours due to the amount of new grads who cannot find jobs who jump on these opportunities to work. Well, they posted their schedule online for the next 2 months, and sent me an email. I logged on 4 hours after the email was sent, and every single shift within a 3 hour drive from me was already taken, In 4 hours! So, needless to say that isn't going to happen this year. It's a shame, I was looking forward to doing that. There must be a lot of unemployed nurses out there.

So, now I am looking for alternatives to making money. I have thought about picking up a few extra shifts at a nursing home, but it's hard. First I would have to find one that is needing someone to pick up a few extra shifts. Then, they would have to work around my work schedule which is different every single week. That's hard to do. Our new manager was attempting to put us on a block schedule which would have us working the same schedule over and over again, but it's not worked out well. I am the oddball there because I don't mind working weekends. I had proposal put forth that myself and another nurse could work every single Fri, Sat and Sun, then be off Mon - Thu. I said I would be interested in doing that. So it's going to get tossed around a bit, and we will see if anything comes of it. That would free me up to pursue a second job with a little bit more flexibilty in my schedule.  

Here is something I learned today. I have a patient with a yeast infection who was prescribed Diflucan. Well, they are also taking Coumadin, and Diflucan acts to potentiate the effects of Coumadin. This means that the Coumadin works much more effectively when the patient also takes Diflucan. When the patient's PT/INR was checked, it was very high, meaning their blood was too thin. So the Coumadin had to be stopped for a while to get the PT/INR level down. So, if you have a patient on Coumadin and they are prescribed Diflucan, make sure the MD orders PT/INR's as part of their labs. I have posted a document in the forms section detailing some of the medications that affect Coumadin patients. It is called "Major Bleeds Checklist".

This month has really flown by. They are already talking about school starting back. I am hoping to start back this time next year to start on my BSN. I can't really afford to do it this year. Next year I think I can qualify for my hospital's tuition reimbursement, and can hopefully get my BSN for little more than a work commitment. I am not planning on leaving them anyway, so a work commitment will be fine with me.

I had in interesting patient a while back. I have avoided posting anything about patients on here for fear of violating HIPPA. However, I read other sites that have case studies and the like, so I am going to try to start posting more on here about intersting cases. I will just have to be careful and not put any kind of patient indentifiers on here.

This was a case where the patient had a bladder problem. The treatment involved keeping the bladder empty. There was a foley catheter in place, but the patient had also had a Nephrostomy. This involves making a surgical incision of the skin over the kidneys, then placing a catheter directly in the kidneys to drain the urine before it reaches the bladder. The catheters worked much like a foley, but they are placed in the lower back on the sides. Around the area known (on some of us) as the love handles. It made positioning the patient intersting as it seemed nearly impossible to postition them where they were not either lying on one of the tubes, or seemed to be pulling on the tubes. The tubes drained urine into bag much like the ones attached to a foley catheter. So, when draining the patient's urine you had to drain the foley bag as well as both nephrostomy bags. It wasn't diffucult to take care of them, but it was just a new experience for me, and now I won't have to be nervous when I come across this again.

I added some more interesting (and hopefully useful) links tonight. Two of them deal with drips used in crtical care. One is a nice overall reference with drips rates and concentrations. The other goes into much more detail about cardiac drips and the differences between them. The last link is from a community college's paramedic program and offers some tips one interpreting cardiac rhythm strips.

Linux mint is working great so far. I am very happy with it. I am sure I will continue to update you, but so far so good. Not much to talk about. Everything is just working exactly the way it is supposed to. Boring, but when it comes to computers, boring is good. I like stuff that just works.

Work is going good. Our census has been way down the last month or so. They actually closed the ICU in one of our sister hospitals and merged it with another one. It had me a little nervous, but things have picked up the last couple of weeks. Our ICU is small and we only staff it with 2 nurses and one monitor tech. We only have one nurse and one monitor tech if we have <3 patients. And if we have no patients we still have to watch the monitors, so we have one RN come in to do that. We have a few LPN's in our ICU, and this entire schedule I work almost exclusively with LPN's. So, since there always has to be an RN in the ICU, I am always working. Whether we are full or empty, I never get put on call. So, even though census is down, I have still been getting to work regularly. So that has been pretty cool. Of course I feel sorry for all the others who are getting call so much. I worked with one of the LPN's from our med/surg floor the other day. She said she had only work 2 shifts in the last 2 week pay period. That makes it awfully hard to pay the bills. I feel sorry for all the new grads out there. This is an awful job market for nurses. I have been reading on Allnurses.com for the past 2 years how hard it has been to find jobs. It hasn't been as bad around here until the last year or so. I got a job right out of school, and most of my classmates did as well. This year I don't think the new grads are fairing as well. For example, I came back to my hospital the beginning of Feb. It is now mid July. They have hired ONE nurse since I came back. Although they have lost 10 or so.

This post is 100% computer/tech related. So, if you are here for nursing stuff, you probably want to skip over this one. OK, now I want to rant a little bit. I have 2 almost identical laptops. One, I keep very stock with Windows 7. The other is my daily use laptop that I use Linux on. I have been using Opensuse on this one for the last 2 years (since I got the laptop). Suse has been a pretty good distro. It was a little harder to get everything set up one, but once I got it set up it was pretty solid. Except that upgrades tended to break things and require a day or two of "tweaking". But if that bothered me I wouldn't have been using linux for the last decade or so. I always heard linux was a hobby not an operating system. Anyway, on this laptop I dual booted between Suse and Windows 7. Well, after yet another Windows update the thing crashed and wouldn't boot into Windows. While trying to recover windows it screwed up Suse where it wouldn't boot either. So I finally decided to do away with Windows on this computer completely and make it a Linux box. So, while doing this I also decided to switch distro's. So I decided to go back to Ubuntu. I have always had pretty good luck with Ubuntu and figured it would be a good solid choice. I installed the 12.04 LTS release a week ago. Man, am I disapointed. Pretty much all my hardware worked out of the box, but man the software is buggy as hell. I have had to reboot this thing because of it locking up at least 20 times this past week. I didn't reboot that much in 2 years with Suse/Windows. I am really disapointed with Canonical on this one. And, although my computer is over 2 years old, and wasn't the most powerful one on the market when it was new, it runs Windows 7 and the other *nix's just fine. So I am going to spend the day installing another distro. I am going to try Linux mint. I have heard good things about it, but have never tried it. I am hoping it works better than Ubuntu. I used Redhat many years ago, but haven't tried it in quite a while. Maybe I will give that a go. I actually wanted to try Opensolaris when it came out since I am a big fan of Sun and their battle against Microsoft. Plus I thought that would be closer to true Unix, but I read lousy reviews about it, so I never tried it. I will update you on what I end up trying.

Well, the title says it all. It has been a rough week. I have worked 5 nights due to people calling in. And to make things worse, the last couple of nights have been pretty rough nights. I am glad to be off for the weekend. I have some stuff to do around the house, but I just don't have the strength today, maybe tomorrow. My manager has started the block schedule. I like the way it has gone so far this first month. There will still need to be some tweaking since we are still short handed, but I like the way it is looking.