impactEDnurse

also known as Ian Miller, a nurse with over 26 years experience working in a busy emergency department in, Australia. This site in no way reflects the opinions of that hospital. All stories (although based on actual experiences) have been changed to protect patient confidentiality.

I have been writing here at impactednurse.com since around 1999.
But everything has its time, and it is time to move on.

This site will shortly be removed1

I thank everyone for their support and amazing participation here over the years.

I am still actively writing, and you can now follow my journey here:

theNursePath

Take care,
Ian.

  1. I would love to keep it active for  there is much of my nursing life recorded amongst its posts. But basically, I cannot afford to run 2 blogs. []

Just to remind readers who may have not realised yet, that I have started a new site over at theNursePath and will be spending most of my energy writing over there for a while.

This is an experiment in getting out of my writing comfort zone.
I want to ramp theNursePath up to a new level of quality. The goal is to format it more as a magazine than a blog.

I will support you to:

  • Collect a kit of tools that enables you to provide excellence in clinical practice.
  • Build personal resilience.
  • Develop interpersonal and team fluency.
  • Practice with authenticity.
  • Discover what is really important to you as a nurse.
  • And finally, to (re)discover the joy in nursing.

I feel that some of this stuff I have some pretty good experience with. Other areas we will work through together.
This will be a community. A place for non-judgmental discussion, opinion and cross-pollination of our collective experience.

I really hope you will check it out and support my new project.

Much appreciation,

Ian.

 

 

I am really excited to show you a little project I am working on.

>>Please go take a look.<<

 

 

Nominations are now open for the 2013 Social Media Nurse of the Year.

Last year there were a total of 16 finalists who received a total of 2,577 votes.
This year we have seen a huge increase in nurses leading the way in developing their online work.
Work that has inspired, informed, influenced, entertained and educated.

This is an opportunity for us to acknowledge those contributions from around the world who have helped in building an interconnected supportive, professional online nursing community.
It also gives pause to encourage and inspire others to become active and find their own social media voices.

So go check your bookmarks.
Nurses using Facebook, Twitter, blogs, websites, Podcasts or any other form of electronic means of social engagement are all eligible.

How do I nominate?

Simply provide the name of the nurse you wish to nominate in the comments field below.
Please include a short reason why you think they are worthy of the title SoMe Nurse of the Year.
Include a link to their social media stream(s).

Can I vote for myself?

Don’t be shy. You have put a lot of work into your online contributions no?….don’t hide your light under a bushel as they say.

Oh, and do not be discouraged if you think you only have a few followers right now….what we are searching for here is quality not quantity. And this is the perfect chance for you to get your work seen by a larger audience.

Are student nurses eligible?

Absolutely. As are nurses and midwives in every field of our profession.

How will I know who has been nominated?

I will provide a short post on each nominee, outlining their activities and a little about them as well as links to their work.
This will give you the opportunity to check out the online presence of other nurses you might not yet be familiar with.
I strongly urge you to explore the work of the nominees…..you might just stumble upon a NEW must-follow.

When will nominations close?

Nominations will close around mid November (depending on the response to this award).

How can I vote?

Once nominations are closed a list of finalists will be posted and you will have the chance to cast your vote.

We call it a health system, and there are times when it works with an incredible life changing, interconnected fluency.
But far too often what it is….is a complex bundle of separate silo-systems.

Every day there are hundreds of episodes of asynchrony within the patients journey as discrete silo-systems bump and scrape and snag up against each other. Some are minor annoyances that test a patients, well…..patience.
Others are truly exasperating experiences for everyone, demonstrating poor design, a lack of respect for our patients and a lack of advocacy by, well …….us.

Here is one very simple example of the health system at work

Mrs Fleck is a 45 yo female who presents to the emergency department after impaling her foot on a large 4cm splinter of wood whilst walking barefoot in her back garden.

She presents at around 7PM on a public holiday Monday.
The emergency department is experiencing access block, resulting in overcrowding and very long waiting times.

She is finally seen by an ED doctor at around 11PM.
The splinter is removed and the wound is cleaned and dressed.
There is however, some concern that a piece of wood has broken away and remains lodged in her foot.

The doctor books the Mrs Fleck in for an ultrasound, but as this service is not available this late, the patient is asked to present to the medical imaging department first thing in the morning.

Mrs Fleck leaves the ED at 1240 AM.

She presents as requested the next morning at 9 AM.
And gets her ultrasound at 1030.
Indeed, a piece of wood remains lodged in her foot.

Mrs Fleck is told to re-present to the emergency department for follow-up. There are no other management options available to her within the system at this point.
She presents to the Triage desk at 1145 AM.
Again the ED is extremely busy. Mrs Fleck is given a triage category 5 (non-urgent) and queued to be seen with other lower acuity patients in a Fast Track section of the department.

At 3.30PM Mrs Fleck angrily storms (well more of a hobble really) out of the department stating that “I’m sorry, but I cannot wait here any longer, I will sort out this problem myself”.

After presenting with a splinter of wood in her foot, she has spent well over eleven hours in the system. She has left the system with a splinter of wood in her foot.

Despite coming in contact with professional, hard-working staff she has been let down by the asynchrony of the system. It was a relatively minor outcome in the scheme of things. Mrs Fleck eventually went and saw her GP….who of course referred her straight to the emergency department, where it was eventually all sorted out.

As I said, this is an example of a simple problem that did not go smoothly.

How then, does the health system manage problems with more complexity and severity?
And how can we improve cross-links and flow design between the separate systems?

After a successful career as a software developer, I now find myself spending all my free time preparing to be a nurse. This wasn’t always my dream, but the older I get, the more I realized that I needed to do more than write code to develop the next somewhat useful application of which there are already ten available for purchase. So, I returned to nursing which I had abandoned 20 years ago because I thought it would take too long to finish. And now that I’m deep into my nursing education, I know this is the right career for me.

When I was in my fundamentals class, I was assigned to a patient who was very frail. As I went to care for this little-old-lady patient, I touched her and she startled awake. She looked up at me with pleading eyes and said that she was so glad I was there. So glad. She said that she loved me “with all her heart”… repeatedly. She grabbed my hand and held it as tight as her trembling grip could.

I think that’s the love that she needed back. From me. She was projecting it out because she needed it in return. That’s the degree of care that we need to be able to give. Our patients demand it; need it. And if you’re made for this, you’ll respond to it, and not run from it.

They need my strength and my skills. They need to feel confident that I will love them by giving them the best care possible. And by doing it, it fills me with a sense of purpose and reason to excel. That’s the source of my passion. I’ve never gotten that from money… that was always motivated from a position of fear (of lack). I’ve never felt that way from working on software… that was just for money; sometimes a thrill of solving a puzzle. But, never did it come close to moving me closer to who I really want to be: toward looking back on the story of my life and being happy with the content.

I want to help heal. I want to help people accept who they are, and if they want, improve on that. I love to answer questions (my kids could never ask “why” enough to satisfy my desire to teach them). Balance that with listening — otherwise, how will I know what to say?

Maybe I’ll be an ICU nurse where I can provide care to those in the most need of care. Maybe ER? They need quick thinking and a lot of understanding. Maybe something else… there are so many options.

It’s been said that “making progress on meaningful work” is the single greatest motivator in every workday. And, I believe caring for people is the most meaningful work we can aspire to.

I believe that nursing will help me become the person I now want to be.

 

 

Have you fallen down any holes lately?

The thing about falling in a hole is in actuality it is, well……nothing.
In fact you can’t really fall into it, because there is nothing there to fall into.

So. Nothing has made you fall, and now you find yourself at the bottom of it.

OK, back up a bit. I admit…. its not exactly nothing. These holes tend to form when the stuff we rely on to keep us grounded (to keep us on the ground) are removed.

Bit by bit, small scoops of something are taken away.
Or perhaps something big and unexpected comes along and excavates out a giant slab of something.
Or perhaps someone steals a little something (oh yes, there are plenty of someones).
Or perhaps something is just slowly eroded away over time. An almost imperceptible trickle. Nothing really.

However it happens, eventually, you are left with this something shaped hole.

And lets just say you are walking along, wanting something for example,
or scared of something,
or angry at something,
or looking for something (as most of us are)
…well when you get to the hole you simply are not going to see it. Right?

Even though it is something shaped, all the something has been taken away…..so down you go. Do you see what I mean?

Of course the thing is, once you are at the bottom of this nothing, perhaps laying crumpled on your back, or perhaps hanging on for dear life by your fingernails half way down….
Well, it really doesn’t feel like nothing. Not by a long shot.

But even though you are lying at the bottom of this pit of nothing (and perhaps you are feeling pretty down, being in a pit and all), if you look around you closely,  you might just see it is not a hole… it is a whole.

Everything is something.
Everything.

The picture below is of a 26 yo female.
Second presentation over a week following poly-pharmacy and alcohol overdoses.

Can you identify the cause if this traumatic injury?

As part of our neurological assessment ( checking level of consciousness or calculating GCS for example) it may be necessary to elicit some form of noxious stimuli on our patients.

These stimuli may be divided into two categories. Central and peripheral.
It is important to remember that peripheral stimulation may illicit a reflex response, completely bypassing the brain and therefore not giving an accurate evaluation of cerebral function.

So we should assess for a central response first.

Central Noxious Stimuli (in order of preference).

Trapezius pinch:

Stimulated by gripping or pinching the trapezius muscle (above the clavicle and close to the neck).
Alternate sides during subsequent assessments to minimise soft tissue damage.
If no response on one side you may try the other.
May be difficult to perform in patients with really muscular, or short bull-necks.

Mandibular pressure:

Press your first and second finger upwards and inwards just under the angle of the jaw (think: jaw thrust).
Should not be used if suspected fractures of jaw.
Cannot use if hard collar in situ.

Supra-orbital pressure:

The supra-orbital nerve is stimulated by applying pressure to the indentation on the orbital rim near the nose.
It should not be used if there is any facial, orbital or ocular trauma.

Take care if you have long fingernails (which you don’t, right?).

Sternal rub:

If the above noxious stimuli cannot be used, a stern all rub may be considered. However, this technique is losing favour due to its potential for bruising and trauma. Particularly in the elderly.
So consider the above options first.

We want to assess our patients, not assault them.

The correct method to deliver eternal rubs is NOT to rub your knuckles across the sternum like a washboard….but to rotate them into the sternum as if using a mortar & pestle. Moderate prolonged pressure for 20–30 seconds should elicit a response.

Peripheral Noxious Stimuli.

Nailbed pressure:
Firm pressure is applied to the base of the fingernail by placing a pen or pencil across the nail bed and pressing on this. Again, moderate prolonged pressure (20–30 sec) is the key.
Alternate fingers for subsequent assessments.

Just plain noxious.

There is no evidence to support using other noxious stimulations that are sometimes seen such as:

  • nipple twists
  • testicular pressure.
  • Hair pulling.
  • Justin Beiber songs.

References:
Neurological Assessment using the Glasgow Coma Scale (PDF) Liverpool Health Service.

Facing Neuro Assessment Fearlessly (pdf)

Most nurses working in critical care and acute care units carry neuro torches.
We use them as part of our neurological examination and for ongoing ‘neuro obs’ to assess pupil response to light.

But what are we really doing here?
And how should we document it?
Lets look a little closer at this particular skill.

First up, the pupil isn’t actually anything at all.
A hole at the centre of the iris that controls the amount of light entering the eye.
The size of this hole is controlled by 2 muscles within the iris.
The pupilloconstrictor (controlled by the parasympathetic nervous system) and the pupillodilator (controlled by the sympathetic nervous system).
So I guess what we are really assessing here is the iris response.

Pupil contraction (parasympathetic response):

When a light intensity increases across the rods and cones of the retina, impulses travel via the optic nerve to the pretectal nucleus of the upper midbrain.

From here impulses travel to the Edinger-Westphal nucleus, and onwards via the III cranial nerve (occulomotor) to the pupilloconstrictor muscle of the iris… causing contraction (miosis).

Pupil dilation (sympathetic response):

When light intensity decreases, impulses travel from the retina via the optic nerve to neurones on the hypothalamus where it takes a convoluted neuronal journey through the lateral brainstem to the spinal cord, down across the apex of the lung, back up alongside the internal carotid into the skull, through the inferior orbital fissure. Finally, it travels along the V cranial nerve (trigeminal) that innervates the pupillodilator muscle of iris… causing dilation (mydriasis).

How to assess pupillary reflexes.

Ideally, pupillary reflexes should be examined in a dim environment.
If the patient is conscious, ask them to fix their gaze on a target some distance behind you ( If they re-focus on you or your torch, there may be pupil constriction as a result of accomodation).

Use a neurotorch or cheap penlight torch. This is for 2 reasons:

  1. Using a superbright concentrated light will not be appreciated by a conscious patient.
  2. Doctors do not (as a rule) carry neuro torches.
    They borrow the nurses.
    They forget to give them back.
    Don’t get me started.

Size and Equality.

The pupil size is documented as the diameter in millimetres. Tools to help you estimate this size include pupil gauges located on most Glasgow Coma Scale records and many neuro torches.

You may also find it useful in your written documentation to include descriptors such as: pinpoint, small, midposition, large, dilated.

Aniscoria:
Up to 20% of the population have a slight difference in pupil size and is considered a normal variant. This difference should not be greater than 1mm and pupil reactivity should be normal.

Shape:

The pupil shape can be documented as round, irregular, oval or keyhole.
Causes of irregular pupils include cataract surgery or the implantation of intra-occular lenses.

Oval pupils may be a result of compression of the III cranial nerve as a result of raised intracranial pressure (ICP).
As ICP increases, the pupil will continue to dilate and eventually become non-reactive to light.

Keyhole pupils are seen in patients post iridectomy (a common part of cataract surgery). They may still react to light but usually the reactivity is sluggish.

Reactivity:

The pupil response to light is assessed by shining a neuro torch (or low powered penlight torch) separately into each eye.
Tip: shining the torch onto the pupil from directly above may make assessment difficult due to ‘glare’ reflected off the cornea. Instead, position yourself in front of the eye and shine the beam from slightly off to one side.

Document pupil reactivity to light separately.
Reactivity may be:

  • Brisk
  • Sluggish
  • Non-reactive.

At the same time look for the normal pupillary constriction response in the opposite eye. This is called the consensual pupillary response.

Accommodation:

This is the normal constriction of the pupil that occurs when a conscious patient is asked to shift their focus from a distant object, to a close one.

Causes of abnormal pupils:

Unequal pupils:

  • Mydriasis: One pupil is dilated and non-reactive whilst the other is normal.
    May be caused by compression of the III cranial nerve, compression of the posterior communicating artery or by direct damage to the nerve endings in the iris sphincter muscle.

    Following a traumatic brain injury an increase in intracranial pressure can lead to the uncus (part of the temporal lobe) squeezing against the tentorium and pressing against the III cranial nerve resulting in a dilated pupil (mydriasis) on the affected (ipsilateral) side.
    If pressure continues to increase, contralateral dilation will also occur.

  • Horner’s Syndrome: One pupil is smaller than the other and has a decreased response to light and accommodation. There is ptosis of the eyelid on the affected side.
    Caused by loss of sympathetic intervention to the pupil due to a lesion in the brainstem of spinal cord, or damage to the hypothalamus. There is also decreased sweating (Anhidrosis) of some or all of the face.
    Causes of Horner’s syndrome include carotid artery dissection, nasopharyngeal tumours, brachial plexus injury.

Dilated pupils:

  • Drug induced mydriasis: bilateral dilation as a result of drugs including antihistamines, hallucinogens, amphetamines, anticholinergics, dopamine or barbiturates.
    May be caused by medication used for ophthalmic examination such as atropine, scopolamine, or by anoxia or brain death.
  • Mental or emotional stimulation:Dilation may also be caused by sexual arousal or increased mental effort.

Constricted pupils

  • Miosis: Bilateral pinpoint pupils (usually too small to figure out if they are responding to light or not).
    May be caused by disruption to the sympathetic pathway due to intraocular inflammation or direct trauma, a pontine haemorrhage, or due to the effect of drugs such as opiates, pilocarpine or acetylcholine.

Equal pupils:

  • Hippus: Initially react to light but then alternate between dilated and constricted.
    May indicate early compression of III cranial nerve.
    May indicate injury to the midbrain or barbiturate toxicity.
  • Relative Afferent Pupillary Defect (RAPD): When light is shone into the effected eye there is a sluggish reaction. There is a normal consensual reaction when light is shone into the opposite eye, but when the light is quickly shone back to the effected eye it will dilate.
    This is known as the swinging flashlight test (see video below) and may indicate optic neuritis, retinal detachment or infection or direct optic nerve damage.

In conclusion, a pupil assessment is a quick but important skill that can give a great deal of information.
The eyes may indeed be the windows to the soul. But the pupils are the manholes to the ongoing neurological status of your patient.

 

————————————
Reference:
The Pupillary Response in Traumatic Brain Injury: A Guide for Trauma Nurses. Journal of Trauma Nursing.

Pupillary Responses. Stanford School of Medicine.

 

I’m Ally; I’m 23 and work as a Critical Care Nurse in Newy.

My parents pushed me into nursing. That sounds weird. But it’s really, very strangely, true. I nailed my HSC, had always been an academic achiever, and if I had gone with my gut or my guidance councilor’s advice, I probably would have become an economist. But my parents told me for as long as I can really recall, that I should do nursing, despite my personal interest in writing, economics, politics and the humanities.

As a profound sufferer of ‘middle child syndrome’ I felt my parents didn’t believe that I could achieve anything more…you know…’prestigious’. Admittedly, I was a pretty reckless teenager; I felt emotions strongly, and often felt disconnected to my purpose and my place in the world, especially in the insipid country town I lived in. I took the nightly news to heart, I was emotionally invested in the world and I didn’t understand the intricacies of humanity. I escaped into arts and writing because of this disconnection, and frankly was quite narcissistic. Both my brother and sister went into Law with loads of encouragement from my parents: But they said to me; “Al…you should be a nurse”, and half because I’m a bit of a pushover, and half because I didn’t believe I could do anything else…that’s what I did.

I hated uni. I didn’t find the classes challenging; the teachers weren’t inspired; the pracs were bed-making 101; and I felt nothing but despair for what I believed I’d wasted my formative years doing. I took up surfing, sunbaking, and reading economic journals, occasionally showing up for class. I got distracted with a few different boyfriends- a german exchange student, an artsy-poet type, and even a girl. My world was nothing but the blue abyss of the sea.

Toward my last half of nurse training, I met two chicks who were stunning, smart, witty, cool, and totally called to nursing with a passion. I freakin’ loved these girls, and we moved in together. They opened my eyes to the fact that nursing might not be this bottom-rung profession, that people could actually ‘choose’ and not ‘end up in’ (yes, I was very naïve). They were excited about their future as nurses, and out on our sunny back deck, we studied the science, talked about what kind of area we wanted to specialise in, what kind of nurses we wanted to be, and where we might travel with our jobs.

It was after meeting them that I had a prac in ICU (the one I work in now). This place was epic alien world. The staff were super-smart, engrossed, motivated, passionate, caring, funny, talented and just really, really cool. I watched 3 nurses manage an arrest with barely any input from medical staff. In 4 weeks I had had patients with traumatic brain injury; cardiac arrest; multi-traumas; septic shock; respiratory failure; renal failure; the works! I went to a seminar about the future of ECMO in their unit in the coming years (now up and running). Yup. It was on. I was completely and utterly obsessed. But more importantly, I had real exposure to families and patients, saw pain, grief and suffering, as well as joy and hope-and learned that I could be involved, and have a place and a purpose here.

A lot has happened in the last 6 years to get me here to “nurse-adulthood”- many long days, long nights, long cries, long laughs, long surfs and long blacks. Until right now I haven’t really reflected on my journey of how I came to be an ICU nurse- Maybe I was worried that I would regret my choice, or that I never really had one? As I’ve grown up (finally)- I realise I have, at last, become connected. I’ve become deeply linked to humanity at its best and at its worst. I’ve become profoundly connected to my role as a carer, a nurturer, an observer, an advocate, a health-care provider…as a nurse. Just as I really needed to grow up into adulthood, I really needed to grow into being a nurse.

I think back to the way I was parented now, and from a new perspective I can start to see why my parents envisaged me as a nurse. I don’t think it was anything they saw as ‘lacking’ but rather what they identified as my prominent features. I think they identified that I needed something that had a real purpose-not just a paycheck, but a career that meant…something. I think they saw me as an emotional being-able to identify strongly with the human condition. They knew I would never, ever suit a repetitive job, and needed freedom to learn constantly, to grow constantly, and be outwardly expressive.

Despite 13 years of indoctrination in catholic schools, I am profoundly atheist and have no concept of the ‘divine’ or ‘afterlife’ or ‘heavenly-reward-system’-so resisting the urge to become a complete existentialist is quite difficult. Having a tangible purpose to hold onto in reality is important for someone like me. And, so often, I think nursing may have provided more for me, than I, for it. My friends often ask me if I enjoy my job and I find that a really hard question to answer-because nursing isn’t enjoyable, in fact, its often quite devastating. If they asked me: am I right for my job, and is my job right for me?…I would say…hell yes.

  • impactednurse.com will soon be gone. (3)
    • Zeke said: Are you keeping an archive of this site on the nurse path site?

    • jelly said: Just work a few more hundred Sundays!

    • matgrad said: Bye Ian will miss the site but as you say everything has its day. Good luck for the future.

  • Nurses are F*cking C*nts. Verbal abuse in our workplace. (32)
    • Rose said: I have read this article and found it very relevant to me and my own experience.Unfortunately a lot of people think that it is quite OK and acceptable to take out their anger and frustration against a sometimes inadequate health system on nursing staff. I also think that gender is an issue as I often feel that female nurses are...

  • Nominate Now: Social Media Nurse of the Year. (21)
    • Belynda Abbott said: I would like to nominate 3 amazing nurses that contribute to nursing and social media in many different ways: 1. The amazing Philip Darbyshire @PDarbyshire and http://www.philipdarbyshire.co m.au/index.php?option=com_easy blog&view=entry&id=44& amp;Itemid=13&utm_source=b uffer&utm_campaign=Buff...

  • When a patient leaves with cannula in-situ. (17)
    • Andy said: Good thinking! At my hospital the Oncology staff are trained/instructed to bleed CVADs before every use regardless, to remove potential clots, discard, flush, then use. Another excuse if you need it ;)

  • bully nurse. (40)
    • G Boucle said: This is not surprising at all to me! Nurses can and do bully patients, I was on the brunt of this after a surgery with spinal fusion on 5 segments! The pain was blinding, they bickered in front of me over who would change the cath bag on the floor already filled and looking about to burst, I found this extremely upsetting....

  • The art of bleeding. Art, insult…or just plain WTF? (6)
    • Contrarian said: I have seen at least one, maybe two live performances of the Art of Bleeding (they were performing at the periphery of other attention-immersive events). Of course the nurse-slut costume is a standard image, but they turn it on its head and dissect it. So, yes, as they say, while the nurse slut draws in the viewer, the viewer is...