3Cs: Coffee, Children, and Cancer

A new grad turned pediatric oncology nurses' jump into the fray…

Go With Your Gut

Image Credit: blog.lib.umn.edu

As a new nurse, when things go awry I often question myself first—maybe it’s me, is there something I’m not seeing? Or sometimes there are certain concepts I just can’t wrap my new nurse brain around. For instance, kids on continuous nasogastric feeds—just when exactly are you supposed to check their gastric pH? If you stop their feeds at any random point aren’t you just basically aspirating and testing the pH of the feed itself? But I have found, just as there’s an app for everything—there’s also a hospital policy (albeit usually a long one) for everything as well. Moving on…

So I had a kid on an opioid PCA—Tommy Tucker. He (or his parents since Tommy was just a toddler) weren’t bolusing him much, but he was still getting a basal dose. Tommy was on a continuous pulse ox overnight and seemed to be sitting around 96% on room air (and had been around there when they spot checked him throughout the day as well). Which was fine. But I just had a feeling that Tommy was gonna spike a fever (though we never say the “F word” aloud). His temps were dancing a little too close to that edge, he felt warmer than he was reading, he was irritable and had been tired and lethargic all day according to mom and dad. So I was already extra eyeballing him. Around 3am Tommy starts to desat to like 92, 93%…and sort of hovers there. My antenna goes up (or rather my right eyebrow—sorta like The Rock). So now I’m sitting him up, jostling him around a bit—basically pissing him off a little trying to get his sats to come up. His respiratory rate had been creeping up and he was taking these quick shallow breaths but no retractions. He was a little tachy and had been all day but then again he’d been intermittently febrile. It may have just been that Tommy was about to spike, his hemoglobin was also a little low that morning so he probably would need blood after that morning’s labs came back but I still felt that I needed another set of (more experienced) eyes in the room. So I called my charge nurse and the resident to come have a look-see. The res thought basically what I did and also felt that the opioid was probably contributing to his shallow breathing however “just in case it’s not” she asked me to keep an extra close eye on him. My concerns were heard and discussed, and everyone was on the same page. Go team. Most new nurses are afraid (or let’s just say less than eager) to call the residents/attendings, etc. when they have concerns or questions. My slogan—”when in doubt—call ’em out.” It does get easier, and they don’t bite—well most of them anyway.

My advice is to always go with your gut. So what if you jumped the gun and your patient was fine and now the resident is irritated because you woke him up from his nap in the on-call room—he’ll get over it. It’s all part of the learning process, developing that “critical thinking” they talk about so much in nursing school. But the worse case scenario—if you don’t call, and you should have—could be much worse not only for you, but especially for your patient.

“Trust yourself. You know more than you think you do.” ~Dr. Spock.

Till next time…

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EMRs…Room for Human Error

Image Credit: waynefarley.com

We live in an age of technology. Having a computer with internet access is a requirement for homework completion these days—I asked my 12-year-old son and he didn’t exactly know what an encyclopedia was. But I bet he could describe—in detail—smartphones and tablets, Bluetooth and wifi, voice-enabled this or that, and GPS-powered watches that track your workouts and sync with your sneakers. Even my two-year old patients have iPads. Want to know how to survive an earthquake?—there’s an app for that.

I’m not complaining—I love my gadgets. I like being able to sync my life over “clouds.” I want to be able to start my BMW (when I get one) with my iPhone. With technology saturating so many facets of our lives it was only a matter of time before it inserted itself into healthcare. Enter the electronic medical or health record (among other technology). Besides the fact that I find written documentation to be lengthy and often redundant, I like EMRs’ simplicity and cleanness—click here, check there…with the option for free form text when the situation necessitates it. There’s also no illegible handwriting to decipher—big plus there. We all have a colleague or two (and it’s not just the docs!) whose handwriting looks more like hieroglyphics. EMRs not only allow us to get rid of all the paper charts and MARs and such, but they allow us to more easily share information between healthcare providers and with our patients, scheduling, billing, everything you need can be built in to be right at your fingertips. But EMRs can have their drawbacks…

At the end of the day computers and software—are just a bunch of codes in a machine. We tell them what to do and well, they’re subject to human error via us being behind the wheel.

Which brings me to the story of Jack and Dr. Jill. Little Jack was ordered 200 mg voriconazole every 12 hours, scheduled for 0800 and 2000. Around 1830 one evening Dr. Jill decided to increase Jack’s dose of vori. She “ends” the current order in the EMR and creates a new order for Jack to receive 300 mg of voriconazole every 12 hours, scheduled for 0800 and 2000. No biggie right? Wrong-O. Jack’s 2000 dose for that night essentially disappeared from the eMAR (and subsequently did not show up as a “due med” for Jack to his night shift nurse), as the order was typed in to start at 0800—which would not occur again until the next morning. In any event, the omission was caught a couple of hours later, Dr. Jill created another order—this one with a start date of that night, and little Jack got his vori a little late. No harm done, and a lesson learned—be careful what you type. The computer reads things literally—if you type for a med to start at 0800 and it’s 1830, it’s not going to start until tomorrow. Doses can also potentially be “lost” when meds are retimed—maybe an antibiotic was to be given for seven days and retiming the doses bumps a dose to an eighth day causing that last dose to sort of drop off. So there are still a few kinks (at least within the eMARs) to be worked out…

Maybe vori being a couple of hours late isn’t that big a deal but in oncology some of our meds are a little more timely. I’m thinking leucovorin after methotrexate, or mesna after ifosfamide timely. *Shivers*

What has been your experience with EMRs? Does your facility have any practices in place to help decrease these types of “near-misses?” Is there a way to build some type of flag or safety net into the EMR itself to catch these? Sharing is caring. For some additional food for thought check out Hannah McCaffrey’s article, Technology Induced Errors a New RN Concern, on DiversityNursing.com.

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Don’t Be a Sally Shortcut

Image Credit: The Leadgenix Blog

One of my Clinical Level IV’s often has a “safety tip” at the end of her emails. One that caught my eye and that I really like is “Culture is what we do when no one is watching.” Well isn’t that one of those things that makes you go “hmmm?” Are you really scrubbing your hubs for a whole 15 seconds and then letting them dry for a whole 15 seconds even though your preceptor is no longer breathing down your neck and your patient’s ever-vigilant mother is taking a much needed nap? Are you performing hand hygiene in every one of what WHO in their Hand Hygiene: Why, How & When? refers to as “Your 5 Moments for Hand Hygiene?”—even if that means Purelling your way into your next patient’s room even though you know you just Purelled your way out of the last patient’s room less that 15 seconds ago? I do—and I have the impaired skin integrity to prove it. :-/

So in the words of Beverly Sills, “there are no shortcuts to any place worth going.” Especially if they can lead to nasty healthcare-associated infections such as the “Big Four” (bloodstream, surgical site, and urinary tract infections, and pneumonia). HAI-free is the way to be…

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Difficult Situations, Difficult Conversations

Image Credit: makingovermomma.com

April May was a preschool-aged little girl with a solid tumor whom I cared for over a weekend of night shifts. Most people think that night shift is painfully slow and that the patients (and sometimes the staff) sleep all night—well not in my world. It’s actually one of the things I like about working nights though. Without all the extra hubbub of day shift, you actually get to spend more time with your patients, listening to their stories, holding their hands, really being able to be present, and in this case—helping them to say goodbye.

I spent a lot of time in April’s room. At times I felt as if I was somewhat neglecting my other patients, but it was night shift, and (thankfully) they were actually sleeping peacefully. But just like the triage of patients in the battlefield (I guess we call it “prioritization” in nursing”)—April needed me more right now. We worked hard throughout the night getting her pain under control, frequently adjusting her PCA. It was hard to watch; and it seemed so unfair for someone so small, so new to the world, to have to go through this. I felt frustrated and somewhat helpless, torn between mad and sad, as I struggled to keep it together and be there for April and her family.

I admit one of the things I have major anxiety about as a new nurse (other than fancy chemo protocols and antibody therapies) is end of life. What to do, or not do…what to say, or not say. How do you respond to some of the questions parents/families ask—”How many children have you watched die?,” or from your patients—”what will it feel like/will it hurt?” Does the family want you in the room or do they want their space? You don’t want to be intrusive yet you don’t want them to feel abandoned either. It’s a delicate dance that’s bound to be different with every encounter. Medscape offers some good tips from Cyndi Cramer, BA, RN, OCN, PCRN, in an interview, How to Have Difficult Conversations With Patients, Families.

Monday morning at change of shift, mom sleepily thanked me for everything and asked me when I would be back. I responded that I would be back on Wednesday night. April gained her angel wings Tuesday night.

Yes, cancer sucks. Really bad.

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