I think the funniest thing I ever heard our current President's father say was in response to a common arrthymia encountered in nursing today, atrial fibrillation. I cannot remember the exact circumstances of the address, whether it was a speech or a press conference, but he said this " I thank you from the bottom of my recently fibrillating heart." That just struck me as really funny. But the condition he referred to is one that we see in medicine very frequently and so need to have a working knowledge of in our intellectual arsenal in assessing our patients. 

  When assessing a patient , the first thing you will notice when checking the pulse is an irregularity of the rhythm. If you patient is on a cardiac monitor, the visualization of the irregularity will give you a clue as well.
In assessing the rhythm, the first thing you look for is P waves. Is there a P wave in front of every QRS complex? Are the QRS complexes regular?  Do you see additional P waves between QRS complexes where there should be none? And then of course, how about the rate? How does the patient look? Are they symptomatic ? Vital signs? Oxygen saturation?
 
  FIRSTLY, treat the patient if they are symptomatic!
 
  THEN,  the question becomes why did they do that? I had a friend of mine tell me that the easiest way to run through possibilities is with this little jewel of a mnemonic.....CPRHEARTS.

C  Coronary artery disease, acute MI or acute CHF
P   Pericarditis or myocarditis
R  Rheumatic heart disease or valvular cardiomyopathy
H  Hypertrophic or Hypertensive cardiomyopathy or severe hypoxia
E  Embolism,principally pulmonary
A  Alcohol
R  Rule out other causes
T  Trauma, theophyllin toxicity, thyrotoxicosis
S  Surgery (post coronary artery bypass grafting CABG), sick sinus syndrome, sympathomametic toxicity

  This really helps me in the trenches when I am figuring out what is going on, or what could rear it's ugly head if I see someone has a history of any of these things.

  We run into people that are in chronic Afib all the time. They are frequently on some combination of Digoxin, aspirin, warfarin, diltiazem, metoprolol, and more recently we are seeing them on Amiodarone. We need to know Digoxin levels and the PT/INR if appropriate. Knowledge of whether or not these folks have had previous elective cardioversions is helpful. They may be more resistant to chemical cardioversion on your watch.

  But for the sudden or acute onset of Afib, you need to be able to recognize what is contributing to your patient's stress at that moment in time that could set up the right conditions for this to occur. Is it something that you ,as a nurse, can work towards relieving and therefore decrease the overall systemic stress? Can you increase their oxygen some to decrease hypoxia? Are they ventilating adequately? Are they volume overloaded therefore increasing myocardial oxygen demand? Are they having pain? Could they need some steroids for inflammation if appropriate? Do they have any symptoms of a pulmonary embolus? What about a urine tox? Are they a post op CABG or valve? What about blunt chest trauma?

  You may need a chest xray and some labs. You definitely need an EKG and possibly some cardiac enzymes. You may need some ABG's. This depends on the situation.You may need an Echocardiogram, again situationally dependent. And, last but not least, you may need to cardiovert....NOW. Again, depends on the patient.

  If a cardiologist is not yet involved with this patient, it may be a consideration. All of the things mentioned above are things that you can bring forward to the physician when treating the patient. In some areas, like ER, Tele, and ICU, there are guidelines to work under when these situations occur. On the floor, these are just some things that you can run through your mind to figure out the puzzle that is facing you and your patient
 

  I wanted to write a bit more on fractures, specifically upper cervical because of Grandma. She is, by the way, doing much better and has been moved from Seattle to our local area and is currently rehabbing (is that a word?) at a nursing home. She was able to play the guitar a little the other day and is able to partially dress herself, so things are moving along. Thanks for wondering.

  She had a C1-C3 posterior fusion, because of stability concerns and because she had broken off the pedicle of C2 so therefore the possibility of shift and movement was too great without surgical intervention. She is able to move everything, and walk some and has good fine motor dexterity distally, hence her Bon Jovi imitation. No, she has always been a guitar player so this is great rehab for her.

  But I wanted to review the stability a bit more. I had initially written quite a piece on that, and lost it somehow in cyberspace. So the one I did enter was not the best. The C1-C2 area is the most mobile of the cervical spine. The bottom part of the skull, or the occipital condoyles, rests on C1,s lateral masses. This allows for most of the flexion and extension of the head as the condoyles articulate on the top of the body of C1. C1 has no vertebral body as we picture them farther down the spine,but it is connected with C2 with the pedicle, AKA odontoid. Most of the lateral rotation of the neck occurs at the C1-C2 junction. The mobility here is high, and stability of that area is mostly supported by ligament structures.

  I think I mentioned that C1 is a closed ring and that fractures result in disruption of this structure. The pieces do not have to be out of place to disrupt the inherent stability. The strength of the ligament structures can pull these pieces out of place and can result in weight displacement that is uneven. Now in someone Grandma's age, or those with curvatures of the spine close to the area, normal alignment can be altered and injury can be atypical. Just an added bonus for those trying to repair the problem.

  Grandma had a burst fracture of C1, meaning the pieces stayed in place. My orthopod described my L1 burst fracture a few years ago as very much like when you are cooking a hamburger and you press down on the meat, sort of squishing it but that all the pieces stay in place. The main structure is the same, but there are fractures in the integrity of the original mass. And we all know that fractures weaken. A Jefferson fracture they called Grandma's. Forgive me if there is repetition here, but diving accidents are the main cause of these fractures. The can also occur in motor vehicle accidents if you are thrown against the roof of the car, I may have originally said dashboard...regardless, the forces are distributed to the body through the neck.

  Stabilization is the key to prevent further neurological damage. Edema will certainly be present in the area, and like any other injury site, that will initially impair function on varying levels, differs with each injury. This edema will go down, back to baseline in 6-12 weeks. But the edema itself can effect function, depending of course, on severity and particularity of the injury. Depending on severity of injury, there can be complete spinal cord injury necessitating intubation and eventually tracheostomy to support respirations. Severe injury can leave the person with only sensation to the face and motor control of the facial muscles from cranial nerves.

  This I can say...Grandma was damned lucky. Whether God was on her side, as I suspect may be the case, or she was lucky, who knows? But her guitar playing days are not yet over. Bon Jovi has nothing on her.

 We got a call the other day at work that our 87 year old Grandma had fallen and broken her neck. Now, this was third hand and no one seemed to know the extent of the break. All they knew is that she was being airlifted to a level 1 trauma center in Seattle for treatment. we were able to talk with the physician that treated her in the community hospital and found out she had sustained a C1-C2 fracture but was still moving, talking, and complaining when she left on the helicopter ride north.

  I spent my first 12 or so years in nursing working with backs and heads. I knew where this could head, but also knew that she could have an injury that was survivable and recoverable. It all depended on the details, so to speak. Meaning, just having a fracture itself is not the really bad part. The bad part is what else happened.....muscular tears, additional fractures, vascular injuries, facial fractures, closed or open head injury, and God knows what else.

  My partner found Grandma on a stretcher in the ER alone and crying. She hurt, she was scared, she was overwhelmed. She was able to talk to the docs and get a better picture. Grandma was still moving and feeling and they were planning surgery perhaps the next day. This was all good news.

  But I had a million other questions...what about spinal cord injury. It was apparent to me that she had not sustained severe spinal cord injury because she still had the ability to move and feel and that the docs were comfortable with delaying the surgery a bit. Other questions might be had it sustained a bruise, did it tear anywhere, could compression be a factor at some point. And what about vascular stuff. the most likely circulatory impairment would be of the vertebral-basilar artery. But there are others, and a lot of them. Sustained circulatory impairment of these could lead to paresis or locked in syndrome and even on to death.  What about muscular injury? Tears, seperations, hematomas. Ligament damage? The same concerns.

  C1 is also called the atlas. It is a bony ring that does a lot in stabilizing the head. Fracture results in cracks or breaks and may separate the ring into pieces. If it fractures yet the pieces stay in place it is called a burst fracture. but those same breaks can shift and the begin to separate.

  We deal with emotions on varying levels all the time. In almost any sort of health care, you deal with emotions stressed on many levels. There is fear, anxiety, grief, depression, emotional and physical pain, loss of control of many aspects of your life and decision making....and that's just the staff. That's an exaggeration, but not much of one. As health care professionals, we are given the responsibility of being the ones who have empathy not sympathy. you have to be able to be in some heart wrenching, gut tearing bedside scenes and stay focused and meet the needs of the patient and the family. Each situation so different because  of the different families and different situations. And you have to be able to handle whatever you are graced with.

  The pace of our jobs is ever increasing, the demands growing, the regulation increasing, and the technological systems ever more complex. I may have mentioned that before sometime. The stress is always growing, like an insidious white noise in your environment. The higher the level of continuous stress, the higher that is tolerated on a continuous level. Up to a point that is. I can start to feel mine coming on. I never seem to recognize it right off the bat. It then occurs to me what's going on. Sort of like realizing you have PMS symptoms...oh, so that explains it!

  I start to think about not wanting to do certain things, just kind of lay low, do my job and not have to interact very much. those are days when I would prefer to have two complex and vented patients that require a lot of physical care compared to emotional, and one that have low maintenance family dynamic situations. I get a little more impatient with my co workers and myself. Things sometimes get me close to tears, mostly of frustration and anger than sad or upset. I want to sleep a little more, I don't sleep a lot really anyway so a little more for me is a lot.

 

  But that's me. There are some things that you may find yourself experiencing that could indicate you are feeling some stress on your job. Firstly, you could be feeling like you want to sleep more too. Maybe not want to get out of bed in the morning. Also feeling fatigued all day long. 2)feelings of also not wanting to do things, not that you won't do them, but perhaps with less enthusiasm or involvement 3)a decrease in your productivity, not completing tasks on time... stuff like that 4) Missing work more frequently. Now sometimes that best thing you can do is take a day to regroup, but you have to use this judiciously. 5) Substance use and self medication of any sort. That one can sneaks up on you. Be careful. 6) Additional anger or impatience with co workers...yeah, I know , guilty. 7) Boredom with your job. Lack of intellectual stimulation or the grind of routine can be indicators you meed a change because this is getting to you 8) How about if you can't sleep? Reliving things, running through feelings about the job, your co workers, the corporation, and on and on. 9) And how about not being able to mentally take the day off on your day off? This one gets me too.

  So if you do recognize that some or all of these things are present in your life in an unbalanced proportion, what next? Pat yourself on the back for your moment of lucidity. Then, talk to someone, a friend, a trusted co worker, pastor,counselor. Sort it through. You may find that it's enough that you are considering a career change. You may find that you need to change units. Or, you may find that a toothless grin of a little old man that you just helped get out of bed washes it all away.

  But know that it will come. In the environment in which we work, it is inevitable.

  Twelve hour days can be very long. Most of the time the time goes by quickly. These days, with workloads as they are, the days go very quickly. In a typical 12 hour shift you can put some miles on. I have always thought a good fund raising idea would be to put pedometers on nurses for a select period of time and then pay per mile. Maybe Bill Gates or some mystery Arabian oil man could afford it...a little exaggeration but illustrative of my point. We are on our feet and moving for 12 hours, mostly on concrete floors. We put a lot of stress on our feet and lower legs. Some wear support hose. But the best answer is a pair of comfortable shoes.

  When I first graduated from nursing school, it was still expected that you wore "nursing shoes". Usually they were clunky and cutesy, They were however, leather and therefore durable, and well padded. You had to buy the little white polish bottle and pretty much keep it within arms reach because scuffs just somehow magically appeared all the time. One trip from the hospital door to the car and it looked like you had been in a stampede.  Then, the appearance of more trendy and expensive tennis shoes happened, and more and more facilities, in their dress code revisions, began to allow them. They were comfortable and were pretty snazzy as well. Still governed by OSHA regulations (www.osha.gov), strapless were still a no-go and that is a good thing.

  Then, the Birkenstock revolution began. What a great thing for tired and aching feet. The individual molding as you wore them, the comfort of slipping your feet into something so wonderful made me happy to be tromping around in them all day. But they are not the most attractive things, that's for sure. And I found myself looking for that old white shoe polish bottle a lot. I wore the cork down all sideways and had to finally pitch them.

  Now because they are about 120 bucks or so, I have yet to spring for another pair. My Reeboks and Nike tennis shoes are nice, but I yearn for the days of stupid looking, round toed shoes that make my feet happy. Maybe this year for Christmas Santa will remember.

  As a nurse in the ICU, we see death frequently. I think probably that ER nurses see it more, certainly more graphically, but we see it a lot. I have seen thousands of people die in my 26 years of nursing. It gets easier, but still is a very sad and somber event for me. I will not allow someone to die alone. Something inside of me will not allow the last breath of someone to be exhaled into the loneliness of a sterile hospital room. I have been that way throughout my career, maybe it's just me. I cannot remember the first death I was present for, I only remember the last twenty or so. I hold the hand of the person and talk to them, I don't know if it makes any difference at all in the big picture, but for one moment in time...all that matters is that individual and their journey home.

  The ICU is a place where sudden traumatic events are precursors for their stay with us. Families are worried, some shattered, some have come to terms with events, some not prepared at all for events to come. Since so many end up with us through unforeseen events....car accidents, debilitating heart attacks, severe intercranial bleeds and hemmhorages, traumatic falls...there are few times that families are ready for their loved one to die.Their pain is evident and so raw. They search for any sign that could be a positive one, perhaps indicating improvement. I think I would do the same. Sometimes we as nurses are helpless to make the situation any better. We can make sure that the patient is as comfortable as possible, try and provide emotional support for the family members, and just be there for whatever may come up.

  We become calloused about  things. Continued exposure to something does desensitize you, but I have found that when I am about to lose someone all of that falls away and I feel small in a big world. But at that time, I always feel as if the ONLY job I have at that moment, is to escort that individual to their appointed destination. I feel a bit like a military honor guard walking beside a casket. Actually, to be with someone as they die IS a honor, at least to me.

  The grief of family members is so painful to watch sometimes. The wife or husband of 45,50, sometimes 60 years, the children, grown or not, the grandchildren...watching their grief is difficult. Tears are sometimes present for nurses, either you have made a connection with the patient or family, or something strikes you in a way that touches you deep inside. I cried a lot in the months after my father died with families as their loved ones died. It was grieving for him all over again. But I have not cried of late.

  I think it is more difficult for new nurses to handle. I remember how it felt when I was new. Now I know that i have done everything that I could have done, that we as a team have done everything, the rest is out of hands. I have witness various cultural rituals at the bedside in preparation of passing. Perhaps the most memorable was the Native American Shaker ritual of bells and chanting, because even with the door closed the haunting sounds of chanting voices and muted bells drifted through the dimly lit hallways. As I write this I can see and hear it in my mind.

  I write this as an obituary for Pavarotti is on TV, and his voice plays through my living room. I will remember now for the rest of my life, sitting at this computer, writing on this subject, and Luciano's voice as it drifts to the land of perpetual silence.

  As nurses we are all feeling the ever tightening belt of fiscal allotment in the budgets for staffing our units, whatever they may be. The acute and long term care sectors, the home health care sectors, the government health care sectors...every one of us has a small bite out of tails in this area. Some moreso than others. I feel fortunate that I am working in a non-profit hospital, the almighty dollar is present, but there still is some tempering of it because of the nature of the beast. but it is there, and over the years it has come more to the forefront. I really am not sure if it is because the non profit area has become more business astute, and has been changing systems to accomodate the financial fray in which it is involved...actually probably more like survive in the fray, or if it because the old guard had retired and the new guard had taken over.

  I work in a corporation that has multiple facilities, and I would imagine it has become quite a juggernaut. Reversal of direction is not a small effort, so I would think that raising awareness of financial responsibility makes us all more conscious of our day to day actions and their effects on the bottom line. Nurses don't really like that sort of thing. If we did, perhaps we would have chosen another profession. We are all conscious of the fact that the care we deliver is expensive, and we do make efforts to minimize that when we can. But we also strive to deliver the very best care we can in the environment we are in. And I think this is an across the board statement.

  Are we part of the problem? Some say we make too much money, that we are lazy and want to do as little as possible for our money. That, my friends, is a bunch of crap. Granted, my salary must be figured in to the mix when budgeting and planning, so it is a factor.  We still pay the certified car mechanic more to fix our cars than we do those who stay at the bedside and save our lives. We pay the timber worker more, the steel worker more, the computer geek more( no offense intended),the construction worker and pipe fitter more. There are the priorities of this society, in things not people. And they say that we are greedy and materialistic. Some rapper gets paid astronomically for whatever it is that they do, but that is okay. Just don't raise those salaries much of the nurses. Okay, maybe that was a bit extreme, but there was a point to be made.

  Money rules the staffing. There are multiple models and systems all trying to achieve the purpose of adequacy in staffing. But they don't live and breathe like the flow of a nursing unit. They can't stretch minute to minute to accomadate turnover. They don't take into account radical jumps in patient needs over the period of just a few minutes. We all work within inflexible walls and strive to make them stretchy and pliable. We must look at the systems we use, scrap them for new ones if they don't work. Keep trying to solve the problem.

  I've decided to go global. Not literally, at least at this point...although Egypt and Isreal are still on my wish I could visit there radar. So I've decided that I'm going to start expanding the horizons of this work. I've registered this blog at the following

  Part of me has always wanted to do some travel nursing ( or is it traveling nursing)? It would accomplish two purposes I think, the need to feel as if I was making a difference if volunteering, and the need to satisfy me overall health and fitness by the change of scenery and breathing different air. I can remember when I was about 8 or 9 and we were living in Pakistan, seeing the conditions that so much of the world outside of the United States lives in and wanting to make it better. Helping those who scooted around on cardboard begging on the streets. Wanting the families that had mud huts they carved out of the ground to have the conveniences that I did.

  But the travel nursing that I come in contact most currently are those brave individuals who take contracts of varying lengths in different areas throughout the country and work from area to area. That takes a bit of courage in my book any way you cut it. A bit of the vagabond and some wanderlust sorely lacking in most of us as well. We get attached to our surroundings and have families, or build financial responsibilities that keep us from moving. We get older and don't want to deal with moving again. We build a life for ourselves and then can't find a good enough reason to change that. Now, all that being said....and I apologize for offending anyone in advance...why does it seem like there are so many travellers who are a bit odd?

  Usually, they are perfectly nice people. Oh, occasionally you get a sour one, but for the most part they are pleasant enough. There are some you are glad to get rid of for one reason or another. But it is rarely a professional one. They don't make it long enough in the unit. if it is determined that you have no idea what you are doing, that you a truely a danger or a portential one to some one, you will be removed form your assignment. Nurses do not tolerate incompotence in their vicinity. Something dangerous, or someone dangerous, to patients is not tolerated. There are some you don't want to see leave, and hope that they get another contract so they can stay longer. or better yet, that decide theywant to stay and hire on at your facility.

  But there are some....well, they are just odd ducks. There was a perfectly delightful woman to work with, pleasant with patients, helpful, compotent...but thought that aliens were controlling us through the power grid. There was a woman from Minnesota or North Dakota who loved running naked in the mid winter there because she felt planetary connection. Not just occasionally, like a couple times a week. There was the retired army nurse who just would not shut up, and always was a better nurse than you...he had delsuions of grandeur. Now that I think about it...maybe most of them are not so odd. Maybe just some of them are odd.

  Okay, just back to the top for a moment.The time is coming closer to the fact that travelling now may be a possibility...I find myself financially imbedded in where I am, the thought of moving again annoys me, I am comfortable where I am. So I live vicariously, to some degree, to those folks who momentarily share my ICU space. And maybe someday, some nurse will be saying about me " you know, that woman who always went to that volcano".

  The reason I don't work in th ER is simple. I can't stand things sticking out of people; like bones sticking out of skin, and intestines....well, you can fill in the rest. There is just something about that. I will gladly take the helm when people are so ill or injured their survival is questionable or in doubt. My love in nursing had always been the most complex and difficult patients that are in my area, what ever that may be. The more tubes, wires, medications, IV's, monitors and machines the better for me. But that is me.

  Nursing is a profession that is one of the most versatile, flexible, creative, advancing, and sustainable around. There will always be a need for nurses. There never will be an end to those who need medical care. As the population grows, so do future requirements for those who can care for them. As technology advances, so does the need for experienced people to run the equipment AND still keep the individual in the bed the primary focus.As medical costs continue to balloon, so does the necessity of finding workable and cost effective solutions to continue to provide care.


  These situations stretch across the board....they effect all sectors and levels  of governments, businesses,
charities, educational institutions, socioeconomic brackets, and the list goes on. Every single individual is effected by a health care need in their life. Some more than others. And it is well known that there is a huge outlay of resources for people late in life regardless of how healthy they have been. Because of all of this, our profession stands to be one of the most important links in the chain.

  There are nursing jobs everywhere. Not only in a geographic sense, but also in the way in which nurses are used to achieve a purpose. There are school nurses, insurance company nurses, nurses who do physicals, travel around and draw blood, nurses who work in the home health care sector, skilled nursing facilities, psychiatric facilities, doctor's offices, ambulance companies, flight transport nurses, hospital nurses,nurses who work in medical research, drug company reps and sales personnel, and I know there are more but I just can't think of them.

  My point is this....you can do anything pretty much anywhere with this profession. Now most of the time you do have to work with people, so enjoying that would be a benefit. The money is decent...better in some aspects than others and the more experienced you are the more money you make. With that experience, the windows of opportunity expand.

  I know that I can go anywhere and have a job very quickly. Within 24 hours most of the time. I can go anywhere....a-n-y-w-h-e-r-e. So in the winter when the weather may be dismal, if I choose Florida or Hawaii to Arizona could work for me. Wyoming in the summer? Vermont in the fall? Southern Utah in the spring? The Navajo reservation? These are all real possibilities with a nursing job. This job is for me.