Archive for July, 2009

How I use my iPhone for working as a nurse

July 24, 2009 at 11:51 am · Filed under Health care, Nursing, iPhone, productivity

Software Advice e-mailed me a survey (go take it) about smartphones in health care, and it reminded me I’ve been meaning to blog about how I use my iPhone for my job. No time like the present, or so I’ve been thinking for about 2 weeks.

  1. Epocrates. I use Epocrates a lot. Lot. I pay the $$ for the premium services because I like having the IV compatibility information and the extra lab value and disease information. I’ve used Epocrates on the Palm and Blackberry platforms, and it’s about a hundred times better on the iPhone. I love the pill identifier feature during the many admissions when the patient says, “I take a blue pill for my blood pressure….” It works about half the time, which is half of my admissions that don’t necessitate a note to pharmacy.
  2. Calculator. I use the calculator quite a bit for adding up I&O’s and converting weights. Every time I weigh a conscious patient, they want to know “how many pounds is that?” Most phones have calculators, so this isn’t iPhone specific, but I do use it quite a lot.
  3. Ratios. This program is one of those where I thought, “I wish I had a one-trick pony program to do this thing,” and it existed on the App Store for $1. All it does is proportions, which are easy enough with pen and paper but are nice to have confirmed when you’re exhausted and in a hurry. Say you have a vial containing 5 mg of Haldol in 2 mL. You need to give 1 mg of Haldol. Fire up Ratios, poke in 5, 2, and 1 and hit Solve, and ta-da! You get how many milliliters to draw up. YES, I can do these in my head, but it gets harder as the night wears on, and this program is a really good buffer against medication errors.
  4. DrugInfusion. This program calculates weight-based and non–weight-based drug infusion rates. You can solve for dose, concentration, or IV rate, and it comes preloaded with a list of common drip drugs. We have pumps that calculate this, but sometimes they don’t seem right or the drug is particularly potent (or the shift before me didn’t start the drip on that mode so I can’t change it before changing the bag) so, again, I double check.
  5. Instant ECG. I use this program when I have a few minutes to learn new things, because it actually gets pretty in depth and contains good diagrams for contiguous leads and such. However, I end up using it quite a bit as a quick-and-dirty comparison against rhythm strips I’m unsure of. If I think it MIGHT be, eg, a junctional rhythm, I fire up this program and compare. It has videos, explanations, and actual 12-lead images, so it’s been helpful to me a number of times for narrowing down what the heck my strip is.

Would I be crippled without this stuff? Not really. With some extra time, some paper, and a calculator and reference books I could do all this. Problem is I don’t have extra time, and reference books get lost. It’s having the capability right in my pocket that makes a giant difference.

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Docs and nurses: can we play nicely together?

July 21, 2009 at 11:10 pm · Filed under Health care, Nursing

I read the July AJN article about residents’ attitudes toward nurses with increasing dismay. Seems that residents think nurses are there to plump pillows and carry out orders and that they couldn’t tell the difference between CNAs and RNs. This bothered me. Part of it was plain defensiveness: I’m smart TOO. I work hard TOO. If it weren’t for nurses, doctors wouldn’t have eyes and ears on the patients at all times. Doctors would have no safety net. All true, but it felt to me like stamping my foot and sticking my lower lip out, and I examined my reaction further. Am I really defensive? Is there a need to be?

I really don’t want to be a doctor. Nurses aren’t doctors who just couldn’t cut it. I don’t doubt my ability to do it; I just don’t have the drive and dedication. In some ways, nursing is taking the easy way out if you want to be in health care, because you can have a complex and rewarding job while skipping spending a decade of your life in school and $100,000 in student loans (I only skipped 3 years of my life and spent $30,000). Furthermore, I haven’t seen this broken down anywhere, but I wonder how much more money per hour doctors actually pull down when you figure in all the on-call hours. They appear to work all the time. This is admirable, but it’s not the life I want. I bring work home, but they like literally BRING WORK HOME. I’d rather wipe butt than be on call all the time. Obviously, since I do!

The work I do requires a different skill set. I think the initial defensiveness occurred because occasionally I envy the doctors when I see them doing their thing—rocking and rolling with codes or troubleshooting crazy diagnoses. I love that stuff, and although some doctors listen to nurses’ ideas, most don’t, and I wonder if those who do are humoring us for the purpose of collegiality. However, I am good at doing my thing—treating the patient while the docs treat the disease. I like having time to talk to people (sometimes), and since I spend far more time both with the patient and with the patient’s chart/history, I actually am in a position to bring things up quite often that have been missed. I enjoy the opportunity for thoroughness.

Also, the major issue for me is this: I worry constantly about making mistakes and have a poor risk tolerance. Doctors have a ton of responsibility that I just would not want.

That said, it seems to me that both fields have a lot to learn and that both need to develop more respect. There are some physicians’ names that make eyes roll at the very mention. Probably it’s the same with nurses. And we get mad when they make no effort to consider our workflow, but how often do we consider theirs? I do, but it’s mostly from self-interest. I want orders before 10 PM so I don’t have to wake anyone up because I don’t want to get yelled at.

The article leaves much to think on. I’m dubious that true egalitarianism can exist between theses professions, but surely the complementarity can be better recognized and respected.

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Rhythm du Jour: Accelerated Idioventricular

July 16, 2009 at 11:34 am · Filed under Cardiology, Nursing

Rhythm strip

Idioventricular rhythm, courtesy of iPhone Instant ECG app

Idioventricular rhythms occur when all overdrive pacing fails and the ventricles are left to pace on their own, and they do it verrrrry sloooooowly (20 to 40 beats per minute). Weird thing is, even if overdrive pacing fails and the ventricles are all on their own, they can get worked up and develop an accelerated rhythm (up to 250 beats per minute). Guess what that looks like? V-tach. Bummer if you call the cardiologist reporting V-tach when it’s really an accelerated idioventricular rhythm masquerading as V-tach. Happily, the accelerated version generally stays <100 beats per minute, so it seems that you’re on safe ground calling it accelerated idioventricular if it looks and smells like V-tach but isn’t fast enough. It also looks more like a long run of PVCs.

These accelerated rhythms are tricky. I had some good times with an accelerated junctional rhythm recently; it took meds to slow down the looks-like-SVTs-but-we-don’t-know-what’s-lurking-beneath rhythm. This is a nice sleight-of-hand used by cardiac folks, by the way; if a patient has a fast rhythm that could be this, could be that, we cheat and give the patient drugs to slow it down at least long enough to see what it really is. Adenosine is probably the most common drug (warn your patient “you’re going to feel kind of sick for minute”; do NOT warn your patient “your heart’s gonna stop for a few seconds”—this produces an even more accelerated rate), but I’ve pushed beta-blockers and hung Cardizem drips for essentially the same purpose.

Fascinating stuff.

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Nursing is like driving

July 14, 2009 at 4:23 pm · Filed under Nursing

I’m on VACATION. I’m not really going anywhere, but I’m not going to work, and I’m getting paid anyway. How freaking cool is that? I was self-employed my entire adult life before this job, so benefits are just weird to me. But that has nothing to do with the title of my post.

I’ve decided that comparing beginning drivers to beginning nurses is appropriate. It’s a good metaphor for me because now that I’ve been driving for, ah, a few years, it doesn’t freak me out, but when I was 16, I trembled behind the wheel (“I’m in a giant machine that goes crazy fast and could kill me or someone else any time I drive it”). Now, I am able to look ahead and anticipate traffic changes and adjust my own driving accordingly before I come up on it and am surprised, whereas when I was a beginner I was so occupied with the physical operation of the car and with my immediate surroundings that I had near misses (near HITS) a lot.

Nursing is feeling like that to me. I am developing the ability to sense what is about to happen and adjust my approach accordingly. I’m less focused on the immediate pieces-parts of nursing (there are a lot of technical things to BE preoccupied with in nursing) because I’ve “learned to drive” IV start kits, the charting system, and so on.

This comparison is comforting to me because sometimes I get in situations at work that just freaking scare me. Scary things happen when people’s lives are on the line just as you can suddenly have to slam on your brakes because the eejit in front of you suddenly decided to switch lanes to right where you are. My reaction time is good with driving. So it’ll probably get better and better with nursing as well. Perhaps I will similarly cease to tremble with anxiety at work, too. We can hope.

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