In Defense of On-the-Job Learning in the ICU

Image via Wikimedia Commons

By Marcy Phipps, RN, who is a regular contributor to this blog. She emphasizes that the identity of the impatient practitioner described in this post has been altered in significant ways to prevent any chance of recognition.

“This is why new nurses have no place in critical care!” said the trauma physician. “I’m sure she’s a fine nurse, but she should be getting experience with these situations on the floor!”

The issue of whether new nurses should work in critical care comes up from time to time. It seems to polarize people, and it always touches a nerve with me. I was hired directly into the ICU upon passing the boards, as were many of the nurses I work with. My hospital offers a program to new graduates that includes training and education specific to critical care and an extended clinical experience with a preceptor. Admittedly, there is a steep learning curve, but I wouldn’t consider it unsafe—and comments that suggest the contrary irritate me, because they undermine new nurses and foster negativity.

This patient probably would have pulled his PEG tube out no matter how experienced his nurse was, and I’m not sure the step-down floor would have been a “better” place for a new nurse to manage that situation. The patient acuity is lower on the floor, but there are also fewer nurses around to help out, and a […]

2016-11-21T13:11:33-05:00November 2nd, 2011|career, Nursing|6 Comments
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Nursus Paradoxus

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

Black Hole Paradox/ Angel’s Gate, via Flickr

We’ve been using a new piece of hemodynamic monitoring equipment in our ICU. Considered minimally invasive, it uses an arterial line to measure fluid balance status by measuring stroke volume variation (SVV). The derived values are useful in guiding fluid resuscitation, and are based on a principle with an interesting and contradictory name. Instead of pulsus paradoxus (variations in arterial pressure during spontaneous breaths), the SVV is calculated based on reverse pulsus paradoxus (variations in arterial pressure during mechanical, positive pressure ventilation).

I’m a “numbers” person. From a scientific perspective, I totally get this. But the concept of monitoring hemodynamics using a principle described as a reverse paradox is unsettling. I don’t want paradoxes, especially reverse paradoxes, to exist in nursing; I don’t need or want circular logic to confound and muddle my days. And yet, as I’ve considered paradoxes in general, I’ve found nursing-related situations that seem to fit the definition:

2016-11-21T13:11:43-05:00October 17th, 2011|nursing perspective|1 Comment
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Blind Spot – At the Intersection of Mother and Nurse

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

Being a nurse has changed my reactions to situations at home. For one thing, I don’t get overexcited about non-life-threatening medical problems. I can hardly stand the thought of going to an emergency room (Steri-Strips and ice are my usual “go-to” treatment plans). I’d like to blame this on working in a trauma center—it makes sense that seeing catastrophic injuries every day tends to make less severe injuries look insignificant—but I’m not sure that completely excuses my recent diagnostic error.

My son, who’s 12, came home from school last week complaining that his hand was sore. He’d hit a wall in gym, he said, but it was a padded wall, and he hadn’t hit it very hard. Still, he was absolutely certain that, at the very least, he’d dislocated something, and that, most likely, he’d broken his hand.

To my defense, he has a history of overdramatizing situations, and I took his self-assessment with a grain of salt. Although the side of his hand was slightly swollen, nothing was bruised, and everything seemed to be moving all right.

We iced it, of course, and although hand pain didn’t seem to interfere with his usual activities, he proceeded to tell anyone who would listen that he’d broken his hand.

“Stop saying that!” I told him. […]

2016-11-21T13:11:48-05:00October 6th, 2011|career, Nursing, nursing perspective|7 Comments
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The Priceless Clarity of Inexperience

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

Heartstudy by James P. Wells, via Flickr

I was precepting a senior nursing student last week. During an idle moment, I asked her why she’d decided to go into nursing.

She shrugged, averted her eyes, and mumbled something like “I’ve just always wanted to.”

I didn’t press it, but I’m sure there’s more to it than that. I probably shouldn’t have asked, given that I cringe when posed the same question, and usually give a faltering and inadequate “I like helping people” kind of answer . . . when “that’s too personal of a question” would be more honest.

I’ve been a nurse for years, and there are certain aspects of the profession I wouldn’t attempt to broach in casual conversation. I doubt that I could have articulated my motivations when I was a student, even if I’d wanted to. That exchange, though, calls to mind one of the most defining experiences of my nursing career.

I was a senior nursing student, doing a clinical rotation in the ICU. My preceptor and I were caring for a patient who’d been in a motorcycle accident. He’d not sustained […]

2016-11-21T13:11:53-05:00September 22nd, 2011|career, Nursing, Patients, students|8 Comments
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We’re Not Going to Lie to You

By D’Arcy Norman, via Flickr

By Marcy Phipps, RN, whose essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

“Hgb 4.1,” the lab tech said, and we jumped as though someone had fired a starter pistol. While one nurse called the on-call trauma doctor, the rest of us mobilized in preparation for the interventions we anticipated.

The “critical results” call wasn’t a surprise. The teenager’s pelvis had been crushed when he was run over by a delivery truck. His blood pressure was holding fairly steady, but we didn’t put much faith in that. In cases of hemorrhagic shock, young patients tend to compensate until the very last second, and we knew that.

His heart rate was soaring and his color was terrible. In the 15 minutes since he’d been wheeled into the unit, flat and flaccid on a stretcher, he’d gone from barely arousable to completely nonresponsive. Aside from his shallow, even respirations, he looked strikingly dead.

A good nursing team functions like a choreographed troupe, and we were at our best that day, moving with staccato precision. Massive transfusions can do wonders; still, it was amazing how quickly he improved. He lost the gray-white pallor and his heart rate stabilized. Then his lashes fluttered and he opened his eyes.

He regarded us working over him for several minutes. The air of urgency remained, and the gravity of his condition was no secret.

“This is bad, isn’t it?” he asked.

And it wasn’t a time for platitudes.

“We’re […]

2016-11-21T13:12:12-05:00August 8th, 2011|nursing perspective, nursing stories, Patients|3 Comments
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What’s That on My Stethoscope?

by rosmary/via Flickr

By Marcy Phipps, RN, whose essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN. She’s a frequent writer for this blog.

The long shifts in the ICU are often chaotic. The days are packed with procedures, “road trips,” transfers, and admissions. The high acuity of our patients adds to the emotional intensity, and even the relatively smooth days are busy. Assessments, medication administration, and charting are all pressing and time sensitive, and there are a lot of strong personalities among us, resulting in occasional combustible strife.

Nursing is a high stakes occupation, no matter the unit, and the stress can be overwhelming. I’m grateful to work with a group of nurses who have excellent senses of humor. The levity provided by a quick laugh can be priceless, and sometimes a pointed stare or quick comment provides an essential release to a tense and pressurized situation.

Lately, along with our usual quips and sideways jokes, we’ve been inventing new nursing games with compelling names. They’re spur-of-the-moment games, usually inspired by whatever’s currently happening. My favorite, so far, is “What’s that on my stethoscope??” […]

2016-11-21T13:12:18-05:00August 1st, 2011|Nursing, nursing perspective|2 Comments
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Giving Noise a Red Light

By Marcy Phipps, RN, whose essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN. She’s a frequent writer  for this blog.

This stoplight noise meter showed up at the nurse’s station last week.

I have to admit—we didn’t take it too seriously, at first.

It looks like something you could buy in a novelty shop, shelved next to lava lamps and strobe lights. And it’s modifiable; buttons and dials on the back of the gadget allow not only for sensitivity adjustments, but also give the option of changing the type of alarm that sounds when a noise infraction is detected. The default alarm warning is a soft-spoken, female “quiet, please!” that can be translated into Spanish, French, or German—but there’s also an option for a shrill siren, which seems ridiculous, considering that much of the cacophony of critical care is owed to noisy alarms and ringing phones.

We even discovered how to record our own admonishments (which opened the door to countless mischievous possibilities . . . not that we’d indulge in that sort of thing, of course).

In seriousness, noise reduction is vital to promoting a healing environment. In a recent article in Critical Care Nurse, the links between sleep deprivation and altered physiologic processes specific to the critical care population are reviewed. Noise reduction guidelines and recommendations from […]

2016-11-21T13:12:28-05:00July 8th, 2011|Nursing, nursing perspective, patient experience|2 Comments
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Stillness and Violence: The Dog Days

By Marcy Phipps, RN, whose essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN. She’s a frequent writer  for this blog.

If I had a crystal ball, I might have called in sick. Or at least gotten more sleep.

They brought the patient up at the start of our shift, and he was a ‘train wreck.’ He’d been shot many times and he was bleeding out before our eyes. I don’t know how much blood we gave him—I can only say it seemed endless . . . blood and fresh frozen plasma and platelets, volume expanders and fluids. The room was packed with trauma surgeons and nurses and jammed with equipment: the rapid transfuser, ventilator, Bair Hugger, pressure bags, pumps and coolers.

Our tech must have covered miles, running to the blood bank for one cooler after another full of blood products.

From the outside, the melee must have looked like chaos. But it was actually a calculated and very effective frenzy, for a while. Amidst the rushing and crowding, the shouting and alarms, amongst people and equipment, spills and blood splatters, we were staying ahead of the game. He was perfusing and his blood pressure was adequate. But it wasn’t long before his pressure was barely adequate, and he was just barely maintaining, and then, despite our urgency and expertise, despite science and wings and prayers, we were losing. His blood pressure was dropping, no matter what we did. […]

2016-11-21T13:12:33-05:00June 24th, 2011|Nursing|5 Comments
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Swimming from Alcatraz

by jitze couperus via Flickr

By Marcy Phipps, RN, whose essay “The Soul on the Head of a Pin” appeared in the May 2010 issue of AJN. She’s a frequent writer  for this blog.

I’m going to swim from Alcatraz.

It’s daunting, yet irresistible, and a challenge I’m not taking lightly. As part of my preparation, I’ve purchased the book Open Water Swimming: Lessons from Alcatraz. In it, Joe Oakes and Gary Emich deliver a wealth of information and practical advice in a very direct way. They’ve provided much to mull over during my long training swims—and I’ve been struck by how well the principles they stress can be applied to nursing:

“Never swim alone and always swim with a competent pilot.”

It would obviously be unwise to attempt a treacherous swim alone. Similarly, it’s vital to work with a team who can be trusted to back one another up. It’s also vital to know who the resource people are and to have a mentor, whether formally or informally.

“There are plenty of sharks in San Francisco Bay.”

Unfortunately, there are occasionally sharks amongst hospital staff, as well. Shark-like behavior should be identified for what it is, and handled accordingly. It should never be taken personally.

“Wet suits are the most obvious way to keep yourself insulated.”

The […]

2016-11-21T13:13:23-05:00April 25th, 2011|career, nursing perspective, personal health practices|6 Comments
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Laundry

I remember feeling just as wide-eyed and excited as she looked. And I like having students with me, especially ones who are so teachable that they soak up everything around them like a giant sponge. My student’s willingness to do “everything” served her well, as far as learning experiences go, and she approached tasks without trepidation. She was elated with success (insertion of a nasogastric tube) and mortified with failure (insertion of a rectal tube; she actually vomited). There were moments of fascination (touring the ICU and helping settle in a trauma admission) and boredom (attending a pain management process improvement meeting). There was also frustration; at the end of the day, she ruined her new scrub top with a spill of dark orange rifaximin.

2016-11-21T13:13:52-05:00March 10th, 2011|career, students|6 Comments
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Views expressed on the blog are solely those of the authors or persons quoted. They do not necessarily reflect AJN’s views or those of Wolters Kluwer Health/Lippincott Williams and Wilkins.
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