Are we clear?

Clarifying orders is usually no big deal, but one night I had the hardest time doing so from one of the doctors.

Patient presented with chest pain that resolved in the ED with no medications. Has no history of cardiac issues being under 40 years old nor significant family history. The admitting doctor ordered an chest CT to rule out PE but the patient has an allergy to fish. Orders were given for CT prep with Prednisone and Benadyl. The comments indicated specific instructions in terms of timing of the medications. However, they were unclear to me and to my charge nurse. Neither of us have ever this a patient going through this before.

I called the doctor for clarification. The doctor gave me different instructions than what was written on the order. I asked for a new order, but the doctor said that the order was clear and should be followed. I told the doctor that if I had to call and ask about the order the order was not clear. No new order with clarification placed. I wrote what was told to me over the phone as a note and started preparation for CT scan.

As morning and shift change approached, the admitting doctor came to my floor to tell me that it was inappropriate for me to call and ask for clarification for an order that was clear. I reminded the doctor that if the order was clear there would be no need for me to call. I still asked for a new order with clarified instructions. Doctor refused to do so.

When the team of doctors came in the morning I told them my situation. They suggested consulting the radiologist for correct preparation of a patient for a CT scan with an allergy to fish. The radiologist made it even simpler for me to understand what needed to be done. The team of doctors were notified and orders were placed.

Notes:
-Communication: I communicated with the admitting doctor about what was going on and made contact with other disciplinary teams.
-Documentation: I made sure I wrote down what happened with a timeline to cover myself.
-Rank: The admitting doctor tried to pull rank on me saying that there is no need to call a MAJ for an order such as this. I reminded the doctor that my concern was communication and patient safety. The order was not clear. It needed to be clarified and rewritten. If it wasn't the next shift may not follow the instructions correctly and harm could have come to the patient.

Lessons learned:
-Patient safety comes first
-If you can't find your answer, seek elsewhere
-Stand your ground with respect

Jump Night @ WAMC ED

Night jump
Originally uploaded by Army.mil

Jump night at WAMC is a huge deal. Lots of preparation goes into making sure that soldiers who have jump injuries are taken care of. Here's some of the things that are needed to make jump night in the ED happen:

- Extra staff: doctors, PAs, nurses, clerks, etc
- Extra equipment: beds, chairs, supplies
- Rooms: in case of need to admit for surgery
- Energy replenishment: food, energy drinks, water

ED has their own flow of taking soldiers in when the injured arrive. First ED gets report on number and types of injuries. Nurses get the heads up and on standby at triage that is set in the back where soldiers come in. Soldiers come in and triaged based on acuity. Walkers are assisted to the chairs and higher acuity patients are assisted to gurneys. Focused assessment, vitals, and history of injury is done at this time.

After the nurses assess the pt the PA or doctor comes by to assess the soldier with the jump injury. If a fracture is suspected x-rays will be taken. Head injuries will be given a c-collar if not already placed and will have a CT scan. Any serious injuries will be treated accordingly based on acuity.

Being my first jump night I was nervous. I've only been to the ED several times and haven't worked triage before. I was paired with an experienced nurse and was guided through the night as far as assessment, documentation, and assisting with ortho for applying splints.

I liked how everyone was helpful in getting things moving. I didn't hear anyone complain about having to take an extra load or needed to take extra time out to help out someone else who had a higher acuity patient. There also wasn't any yelling and screaming from the staff. The night was stressful enough and all that extra noise wouldn't help anyway.

Communication was essential to a smooth and successful night. The flow of communication must be constant and consistent. Situational awareness was also a must amongst the organized chaos.

Last night was fast, furious, and intense. And I liked it. Working in the ED has got me really thinking about the M-5 course in my career.

Report sheets

Reporting off to the next nurse is important in maintaining communication regarding the patient's care. Reporting off can be done any time and in different formats; there is no set way.

I've been looking for an effective method in reporting off to the next nurse for the end-of-shift report. I've tried different methods having followed various people including my preceptor for several weeks.

Having previous experience in the ICU I learned to report a full detailed physical assessment of each body system. Currently in a med-surg setting with up to 6 patients at a time, I learned that I cannot apply that method of reporting here.

Looking around online, I found this one via Allnurses.com, a great resource for nursing knowledge and for networking.

I'm still trying it out, but so far I'm liking it. Here's my pros and cons:
Pros:
-Labs + legend: Easy place to put important labs for the next shift to know
-Diagram: Good place for putting important assessment findings
-White space: place for extra notes

Cons:
- Pain control times
- Allergies

Just minor cons that I found with this sheet. It's been useful for me. If I find another one I'll review it here. Also, if you have any report sheets you find send a link underneath the comments section.

Nursing Superstitions

While I was charge nurse last night I had an enjoyable conversation with my staff. I was happy how everything was going well, after all, I'm still fairly new to the position of being CN. Then I said something that was forbidden, taboo: the "B" word.

I was puzzled when my fellow colleagues gasped and looked at me with their eyes wide open. They shook their fingers at me, put my name on the white board, and put a tick mark by my name. My colleagues began telling the other nurses about what I had said. I was still confused and puzzled about what was going on.

My coworker called some of the other nurses over to the nurses station. She told me to sit down. I thought they were going to tar and feather me! She began explaining the horrible deed that I had done. I was shocked to know that one simple word could mean so much to the rest of the staff.

My coworker brought up nursing superstitions that she learned in nursing school and throughout her experience. The other nurses added on as each person began sharing their experiences on certain nights.

Here are some of the things that were dicussed:

• Women go into labor more often when it's raining because their water breaks with the storm.
• If a patient is perspiring profusely (and is already on antibiotics and antipyretics) place a pan of water under the bed to stop the fever.
• A penny above the door of a patient in ICU ensures good luck.
• There seems to be a "full moon effect" whereby one experiences increased workload, stress and general chaos.
• Codes, deaths and births happen in threes.
• Certain rooms are unlucky.
• Never say the "Q" word. If it's been a quiet shift, don't say so or, it is told, the dam will break. (This is, hands down, the most popular nursing superstition I have come across.)
• Never say the name of a frequent visiting patient aloud or s/he will miraculously appear.
• If one has turned down the bedding for an expected admission and the admission is canceled, pulling the linen back up will ensure an immediate unexpected admission.
• If a patient may code, place the crash cart outside the door of the patient's room to prevent the code.
• Have a lucky pen? You're not alone. Apparently it ensures patients' well-being and a good shift.
• Place a penny above the door of a patient in ICU for good luck.
• If a knot is tied in the sheet of a dying patient during the night shift, that patient will not die until morning.

I find it humorous that a profession that is based on evidence based research and scientific findings would have some beliefs related to superstition. I still don't believe in the "admission gods" or keeping lucky talismans with me at all times. However there may be some truth in some of these matters.

Hey, what do you know, the next full moon cycle is this Thursday. I guess we'll see what happens then yeah? [Circus Nurse]