Nurse Jess in Top 20 Nursing Blogs

Top 20 Nursing Blogs 2018

I received an email about a week ago from Theresa Frost stating that I was on the Top 20 Nursing Blogs list on the Online Nursing Degrees website. I feel honored. But more importantly, I’d like to introduce two other blogs that are great for learning more about CRNAs (certified registered nurse anesthetist).

  • Life as a CRNA – There are some detailed information about what to expect on a day to day basis as a CRNA. There is also some advice for getting into anesthesia school.
  • CRNA Career Guide – It provides a comprehensive guide along with advice from several presidents of state associations of nurse anesthetists.

The Speed of Trust

I recently subscribed to the Blinkist, an app that summarizes nonfiction books and gets to the core of the book. I highly recommend it if you enjoy learning (and being a human, you naturally have curiosities in your life, right?).

One of the books is called the Speed of Trust by Stephen Covey. It tells us that trust affects everything, especially how fast communication and events go. For example, if you trust that the restaurant prepared your food safely, you’ll have no problem eating the food. However, if you had concerns over the food safety, you will hesitate and question the chef before maybe consuming the food (or even throwing it away).

Trust is one of the most powerful forms of motivations and inspiration. People want to be trusted. They respond to trust. They thrive on trust.

You must have self-trust so others can trust you. Because if you don’t trust yourself, then who will?

The way to gain trust in yourself is by following the Four Cores.

Integrity

Integrity is gained by making commitments to yourself and following through on them. Integrity is being honest with yourself. For example, if you tell a patient that you will return to them with information, then do that. If you tell yourself you will go to 50 crunches, 20 squats, 10 burpees, and jog a mile, then commit and do it! If someone blames another person for your mistakes, own up to it and take the blame. If you commit to waking up to the alarm clock and getting to work or school on time, then do it.

Intent

Having positive motives and behaviors will point you towards good intentions. Are you listening or do you just want to “win”? In many circumstances you can increase trust if you have good intentions.

Capabilities

Developing capabilities will improve your confidence. And life is always changing which requires you to keep learning. In the health field, learning what is the latest evidenced based practice and working towards incorporating it in your practice will keep you on the top of your game.

Results

When you build a track record of your results, you build self trust. In the world of anesthesia, you are constantly evaluating your actions– how well did the induction, maintenance, emergence go? How well did the patient do? What could I do differently to improve my results?

 

After developing trust in yourself, you develop trust in others

You develop trust through your actions and your truth. This includes understanding yourself — your strengths and weaknesses, your moods and behaviors, your actions and inactions. By knowing yourself, you can better understand others’ critiques of you and owning it.

You will also demonstrate trust by caring about others. Giving others credit when due. Being thankful for others’ actions. Showing that you are aligned in the same goals.

This will increase your credibility. This is important especially in the healthcare field and in the OR. You trust that the scrub tech stays sterile. You trust that the circulator nurse has the room and everyone responsible ready. You trust that the surgeon is able to safely complete surgery. You trust that the pre-op nurses get an IV and come talk to you if they have any questions. The more you trust yourself and gain trust in others, the faster things move and better the outcome.

With the lack of trust, everything and everyone is questioned. Only more delays occur. And that is why it is so important to gain trust in yourself and in others.

As a side note and reference to what’s going on in the real world…

Christine Blasey Ford showed tremendous courage in speaking out about her experience with Judge Brett Cavanaugh. She was incredibly credible — she had nothing to gain and everything to lose by speaking out, and the fear that her world would shatter and none of it would matter.

On the other hand, Judge Cavanaugh may have been a credible judge with many people who backed him up. He may have had a very credible record and people trusted his judgment. However, I feel that after his hearing, the American people, or at least me, do not feel that he would be impartial. He doesn’t seem like he would have the temperament of a judge. While one hearing doesn’t seem like it should change the fate of this candidate, he is also up for a LIFETIME job as a Supreme Court Justice. In my humble opinion, I believe that there are other candidates who would be better suited for this position. If he is confirmed, I believe that the American people will continue to lose faith in its institutions. Instead of trying to work together, we will continue to divide the nation.

I feel that problem with Judge Cavanaugh is not that he necessarily was a horrible drunk as a teenager and college student, but that he denied it and lied to the Senate. I believe that our principles and values are more important than ‘which party’ sits on the highest courts of our land.

Awake Fiberoptic Nasal Intubation

So all the times that you practiced your craft (handling a fiberoptic scope such as during the difficult airway class weaving down the bucket with little holes; placing double lumen tubes),

all the times you’ve asked experienced providers what they did (for an awake fiberoptic intubation),

all the times you watched one (once for an awake fiberoptic oral intubation),

all the times that you performed one (under optimal conditions with a Glidescope and an asleep patient),

and all the times that you did something similar (nasal intubations),

it prepares you for this moment — for this call:

“There’s an emergency intubation for you and it must be done as an awake fiberoptic intubation nasally.”

You call your partner who’s already bedside and workout a plan

He’s optimizing the patient – Afrin drops, nasal trumpets, racemic epi nebulizer, and 4% lidocaine nebulizer

You’re ready – 7.0 oral ETT in warm saline, lubricated tube and fiberoptic scope, ketamine, precedex drip, an ENT surgeon and team for possible trach

The patient arrives, looking more perky, sats 96%, sitting up, switch monitors, fluids, ETT on the tip of the fiberoptic, suction on, sedation is in

Standing in front of the patient on the right side with the camera on the left

ETT inserted 1/3 in, cameras in, orientation, following the bubbles, past the epiglottis, vocal cords, tracheal rings

Holding still, inserting the rest of the ETT, cuff up, fiberoptic scope out, circuit on, positive end tidal CO2, sats 99%

Smooth, success 

Optimizing Patients for Urgent Surgeries – Non-Elective Surgery Triage

Urgent surgeries — such as appendectomies, cholecystectomies, are common. Sometimes the patients are healthy and other times they are a train wreck. When they are of the latter sorts, the goal should be the optimize the patient for surgery so they are prepared to undergo the stress of surgery.

Understanding the classifications of semi-urgent, urgent, and emergency surgeries informs us of the time that we have to optimize a patient. For example…

It is the weekend call shift with limited resources. The surgeon schedules a laparoscopic cholecystectomy on a patient. Great, you go and look up the patient and find out that:

  • She’s scheduled for a CABG (coronary artery bypass graft) aka open heart surgery next week
  • There’s no echo, angiogram report, no cardiology note on the patient
  • BP 160/110, HR 115
  • Diabetic
  • On the kidney transplant list

So what do you do? The surgeon insists that it is urgent and must be done that day (later you find out that he has scheduled long cases for the next day).

Well, first the goal is to optimize the BP and HR so the BP is below 140/90 and HR below 100. We titrated in metoprolol to effect. We waited for vitals to stabilize before we went. Unfortunately, the surgeon later insisted that it was an emergency case so we had to go on the weekend.

However, was it really an emergency case? Could the case go the next day when there are more resources?

Without additional information, the goal for the patient was to do a slow induction, maintain perfusion, and gentle emergence.

Based on Non-Elective Surgery Triage (NEST), the acute cholecystitis could’ve been scheduled the next day on a Monday where there are more resources.

Non-Elective Surgery Triage (NEST) Level
Non-Elective Surgery Triage (NEST) Classification

Nurse Jess in Top 30 Anesthesiology Blogs

Anesthesiology Blogs

This morning I woke up to an email sent by Anuj, the founder of Feedspot. I will admit, I haven’t heard of Feedspot before today (and maybe for you as well). I’ve never been listed as a top blog so I was surprised and honored to be awarded one of the top 30 anesthesiology blogs.

As I browsed the list, I noticed that I was the only personal nurse anesthetist blog. The rest consists of anesthesiologists and larger organization blogs. I will do my best to continue to represent the nurse anesthesia community.

As I transition from a graduate to a new nurse anesthetist in a new community, I learn a lot. Part of becoming an anesthesia professional is

  • recognizing your limitations and when you need an extra set of hands,
  • asking your colleagues for their professional opinion as you develop your anesthetic plan (especially for cases you’re less familiar with, for cases with different surgeons, for cases with different patient populations),
  • asking for mentorship and help for improving your weaknesses, and
  • knowing that the health field will change.

For example, the United States has a shortage of several anesthetic drugs. And there’s an opioid epidemic that has torn this country apart. The healthcare costs continue to rise, and the length of stay continue to decrease. To help prevent potential complications such as respiratory depression and opioid addiction and to improve pain management strategies, I believe that it begins preoperatively with the patient, continues intraoperatively, and postoperatively.

After the Enhanced Recovery After Surgery (ERAS) protocol came out for colorectal surgery, many more ERAS protocols have developed for different surgeries (and each institution has their protocols). The ERAS peaked my interest in providing opioid-free anesthesia. Part of that process requires providing blocks (or ‘numbing’) for a specific area of the body. Tom Baribeault, one of the founders of the Society for Opioid Free Anesthesia (SOFA), spoke at the University of Michigan-Flint’s anesthesia conference last year. He added fuel to this fire.

After speaking with several of my colleagues who already provide opioid-free anesthesia, reading peer-reviewed journal articles, and completing the American Association of Nurse Anesthetists (AANA) course on enhanced recovery after major abdominal surgery, I set off to do just that. In between my cases, I’ll follow up with the patient and the post-anesthesia recovery unit (PACU) nurse and see how the patient did. I will continue to improve this technique.

In the end, the goal is to provide safe and effective patient care for every patient.

Happy Chinese New Year, the Winter Olympics, and the Florida high school shooting

Happy Chinese New Year!

Ruff. 🐶 I will be spending it on a 12 hour shift.

On the brighter side…

Watching Red Gerard win the first gold for the USA in the snowboarding event was amazing.

After falling in his first two runs down the slopes, he has a near perfect execution and beautiful flips and turns on his snowboard in his final and third run.

It just reminds me that even if you fall, you get back up and you keep pushing to be the best version of yourself. When you do that, you will get better. What can you do to improve? Where are your strengths and weaknesses? What are the steps to get better?

***

On the sadder side…

The Florida high school shooting with 17 dead just makes me so sick. After reading the statistics of mass shootings in the USA in the New York Times, I cannot believe that there’s a mass shooting every day.

I can’t imagine going to school not knowing if I’ll make it out alive that day. It is ridiculous.

If we really care about safety, then we should care about gun safety. It should not be that easy to buy a gun for anyone. Just like you need a license to practice nursing, you should need a license to purchase a gun. The process of getting that license should require safety training, mental status checks, and the requirement to renew the license.

I mean, just to fish professionally, you need a license. To do someone’s hair or nails, you need a license. To buy a gun and be a safe and responsible user, you need to have a license.

I get that the 2nd amendment gives Americans the right to carry a gun, but we also have the right to be safe in our communities and guns are lethal weapons. Especially AK-15s. Why is that kind of gun sold to lay people? What do the gun shop owners expect lay people to do with those guns?

When people own things, they tend to use those things. Those things include guns. This obsession with “our right to gun ownership” needs to let up. We should focus on improving the safety of our neighborhoods by getting guns to licensed personnel.

A gun is not just an object like a TV, or a fishing pole. It is meant to injure or kill living things, including people. It should be treated as such.

I do not want to become numb to the reality of mass shootings. I want the US to be safer than it is now. I do not want to go to a school, a theater, a nightclub, a concert, and worry if my life will be in danger. It should not be that way. We need this to change.

It may involve the government asking for guns to be returned for compensation, and start to enforce gun safety classes (including accuracy target training), assessing mental health and other harmful associations (for example if they are on the no-fly list, terrorist, etc), and require a license, just like you need to drive a car. And like a driver’s license, you will need to renew it, proving that you’ve received updated information. Just like a driver’s license, there should be a gun registration for the gun owner’s license so it is much easier to keep track of how many guns are being sold.

Just like how cars can kill people, the guns’ intention is to kill. Why is it not regulated more?

It is our “right” to drive and it is our right to own a gun. It is also our right to pursue happiness. We can only do that if we feel safe in our communities. And that includes keeping track of gun owners and the type of guns they own.

We need to change America for the better.

Do you agree, disagree? What do you think can improve the gun safety in America so there isn’t a mass shooting everyday in the USA?

Sticking up for yourself

It’s been awhile since I last posted back in August so here it goes.

I graduated, took boards and passed in August. I took a trip to China for my fiancé’s grandpa’s 90th birthday. On the same trip, we went to visit Xian (the terra-cotta warriors!), Taiwan, Osaka, and Tokyo. It was such a great trip to be with my fiancé and visit all these places.

At the end of September, I was getting ready to start working at a hospital. I made the mistake of not asking for a contract before deciding to work there.

Unfortunately, unless a contract is signed, verbal agreements don’t count. I didn’t trust the “man in charge”, especially since he changed the terms only a week before starting work.

At this point, I could’ve started working for him, or leave and stick up for myself.

Fortunately, I was in a position where my family supported my decision and me financially. At this point, I left for California as my fiancé began his schooling at UCSD.

For the next couple of months, it consisted of several interviews and difficult decisions. It also consisted of me actually cooking some food to eat (it had been while!). I finally decided to pull the trigger and move to Northern California.

I started working a couple weeks ago and I’m enjoying it so far. Of course I asked myself, do I still remember everything that I learned? It takes a little time but a lot comes flooding back, even after months of not working.

If it was not for all the support of my family and friends, all the CRNAs and anesthesiologists, all the nurses and support staff, I wouldn’t be where I am today.

Anyways, the biggest takeaway is to stick up for yourself.

Also, happy belated CRNA week. And happy anesthesiologists week. Go team go 🙂

Two weeks from graduation

In two weeks

anesthesia school

is over.

Is this real life?

so much more

needs to be done.

Studying for boards

Completing clinicals

Presenting at M&M

Securing a position

Emptying my apartment

Attending graduation dinner

with family flying in.

This chapter of my life

is almost done

and a new one

is about to begin.

Can’t wait.

The Dark Side of Nursing

In the spirit of learning through social media, I’m inspired to follow up on Dr. Eric Levi’s post on The Dark Side of Doctoring.

In case you haven’t read about it, it is regarding a physician who committed suicide. It is about how something is wrong with the basis of our healthcare system. It’s about how nearly 1 in 12 people who go into healthcare — to help people — end up needing help themselves because of our system. Our system continues to fail us because we push people to — and then beyond — their limits.

It is not simple enough to say, take a mindful minute.

It is not simple enough to say, just take a break or two.

It is not simple enough to say, get the help you need. Because even when we are surrounded by the resources that we need, we still fail. People often see a healthcare provider within 30 days before committing suicide.

We are in a culture where it is expected to be short staffed. We are in a culture where it is expected to:

  • squeeze each healthcare provider —
  • do something a specific way dictated by people who have never taken care of patients before,
  • refuse to discuss changes to an OR schedule because it’s mandated by the administration,
  • take call and expect to be a fully functioning person the next day.

It is one thing to be resilient. It is another thing to damage the human spirit.

One of the worst experiences in my career started at the beginning. I was a brand new nurse working at the nursing home/rehabilitation center. The LPN (licensed practical nurse) who worked there for years, knew her residents, knew the medications that the residents received. But one day, she called in sick. Of course, that meant I had to give all of the medications. 50 residents. 6 with PEG tubes. In 2 hours.

It takes at least 5 minutes to verify the resident’s name, the medications in the paper copy of the medication records AND the electronic medical record, give the medication, wait for them to swallow. Nevermind that medications still needed to be popped into the cup. Nevermind that I had to find each resident (because they do move around). And the patients with PEG tubes often require more time to crush and dilute. And don’t forget that when the tubes get clogged that it took additional time to rinse.

5 minutes x 50 residents = 250 minutes. Yeah, I was on a path to failure.

By the time I finished giving the morning medications, it was already time for noon or afternoon medications to be given. I didn’t go on break (no one was there to relieve me). I didn’t eat lunch. I didn’t have any support. I cried that day. Shortly after that, I never went back again. I was lucky enough to quit.

I couldn’t deliver quality nursing care. I felt that I could lose my shiny new license. I knew it wasn’t the right way and I knew I didn’t want to practice this way. I didn’t have any support.

And this situation doesn’t just apply to me. It applies to nearly every nurse giving medications. Giving the appropriate amount of time for each nurse to talk to their patients regarding their medications, their medical condition, and spending time with them when their loved ones aren’t around is vital. Giving each nurse the appropriate patient to nurse ratio is so vital.

The appropriate patient to nurse ratio gives the nurse more time, effort, and energy to take care of each patient. There needs to be more time

  • to provide nursing care,
  • to educate,
  • to prevent medication errors, infections, falls, deaths,
  • to question, coordinate and provide treatments,
  • to monitor the patients’ status,
  • to be the patients’ advocate, and
  • to be a resource for patients, their families, and other healthcare providers.

Michigan is currently pushing for a Safe Patient Care Act to decrease the patient to nurse ratio. If we want to reduce readmissions, preventable deaths, and provide safe and quality care, then we should pass this act. There have been multiple studies that prove this to be true. We need to care more about patients than the bottom line.

Changing Culture

The healthcare culture needs to change. To take care of others, we must take care of ourselves. But we cannot take care of ourselves if the culture does not allow us to do so.

We value being a hardworking person. That’s why we say it’s ok to do overtime, then being on call, then being at work the next day. That’s why we work way over 40 hours a week — pushing 60-80 hour workweeks.

We value being helpful. We want to help patients, and if we don’t do overtime, then we would be abandoning patients.

We value money. That’s why hospital administrators short staff the hospital and push up their profits.

These are our primary drivers. Instead, we should shift our fundamental values to:

Healthcare providers’ health.

  1. Valuing the healthcare providers’ health should be one of the most important values in healthcare. We are people and require a work-life balance (including students, interns, and learners of all type). We need time to be human, time be with friends and family, time to eat, exercise, and sleep. We need time when we aren’t thinking about healthcare and can destress.
  2. Depression and substance abuse is, unfortunately, high among healthcare providers. In media, we have an image of a drug addict. But healthcare providers have access to high potency drugs and can easily and quickly abuse substances. Addiction can hide behind a mask, a suit, and highly intelligent, functional people. A couple of weekends ago, I attended the Michigan Association of Nurse Anesthetists Spring Conference, and one of the topics was on addiction. It was eye opening. This was one of my favorite videos on addiction.
  3. If being on call is required, that they should be off the next day. Or there should be a rotation system so that you are not constantly called every night.
  4. That every effort will be made not to be short staffed.
  5. That working 40 hours a week — and not much more — is the norm.
  6. That means giving people adequate vacation time, paternal/maternal leave, and not making people feel bad about it or making it hard to take time off.
  7. That means giving 2 15 minute breaks and a 30-minute lunch for every healthcare provider for a 8 hour day (this does not happen on a medical-surgical unit, let alone over a 12 hour day).
  8. That means providing in-house educational opportunities.
  9. That means encouraging healthcare providers to do or implement research.

Patient’s health.

All of us have been a part of the healthcare system and therefore should care about this tremendously. A huge part of the problem is communication errors. Now instead of a scarcity of information, we have an abundance. We need to have a streamlined process. Electronic medical records (EMR) is a part of the solution, but there are still problems. Often, the EMR technicians have never worked in healthcare and are the ones putting together these systems. Instead of a single page where there is the patient’s history, treatments, labs, diagnostic reports., information is scattered. It requires going through several different tabs and is very time-consuming. And even then, it is still easy to miss information.

Instead of being focused on coding for such and such, it should be about improving the patient’s health. Giving enough time and energy for each patient will improve the patient’s health. Sitting down, understanding each patient’s situation, and developing a course of action together. We need to focus on patients’ health, and not on patients’ paperwork.

Healthcare providers’ input.

To improve healthcare, it requires input from those in the trenches. It does not make sense to ask outside consultants who have no healthcare experience to improve healthcare. Yes, this does happen frequently. And these consultants are expensive. Why are we so focused on making healthcare into a business model rather than a patient care model? Instead, we should ask the providers themselves on what they think needs to change.

Price Transparency.

What blew my mind the other day was reading an article about how parents who were worried about their daughter’s cut took her to the emergency room. The emergency physician said it was a nothing to worry about and put a bandaid on and sent them home. A month later the bill comes out to be $626 for a band-aid. It happened to be that there’s a facility fee for emergency rooms. But it is still ridiculous. Most people (especially those not in health care) need help triaging, or deciding how bad their condition is. When you’re the one in pain, it is always the worst thing that’s happening to you.

Part of the this problem is the blaming game. The doctors blame the insurance companies. The insurance companies blame the doctors and their coding. The patients blame the doctors, the insurance companies, the greedy hospitals and the government. I think what would help solve this problem is transparency about the cost of care. There’s a disconnect between the cost of healthcare and the services provided. For example, most people have no idea how much it costs to stay in the ICU for one day. Most people have no idea how much it costs to do one elective surgery. Sure, it’d be nice to call up the insurance companies and ask them but they come back and say, it depends on what your doctor bills. You ask your doctor and they say it depends on how much the insurance bills you. For the same exact surgery, the insurance will bill differently at each hospital (even surrounding a 50 mile radius). The cost of healthcare is just way too high because there’s no way to ‘shop’ for healthcare or healthcare insurance like you can with other services.

Transparency, or having a sticker price up front, would help patients decide where to go. In fact, there are already some places that often a total knee replacement for $15,499 that covers everything — the surgery, the rehabilitation, and any complications that occur afterward. Price transparency encourages facilities to provide high-quality care and decrease costs while still earning profits.

 


So I would like to ask, what is the ‘dark side’ of nursing for you? What do you think can change? Please comment below.