All Nursing

Sometimes the “Critical” in Critical Care is Actually Pretty Basic

I’ve never been a ward nurse. Theatre, then ICU. Lots of nursing roles within those areas, but never ward nursing.

 

One of my favourite nursing roles is the Outreach Nurse. The Outreach nurse is a member of the Rapid Response Team (in our hospital we have RRT’s instead of MERTs or Code Blue – the idea is the same but the focus is on early intervention not rescue and recovery). The usual duties involve going out of ICU into the hospital and working on a referral/followup basis, reviewing patients and contacting (or chasing up) relevant medical teams. Most importantly, we provide clinical support for nurses using advanced assessment skills and education.


Some nurses I meet have the perception that I’m there to check their work (I’m not) or to devise some previously unknown care strategy based on things that we do in ICU. Mostly the role involves two way learning, I teach the ward nurse something that they might not know and I learn from them. Occasionally I get to give ‘permission’ for the ward nurse to do what they think they should do, in situations where they normally wouldn’t – showers at 2am, bed moves at 3am, making difficult telephone calls to family, reminding care teams of appropriate palliation etc.


And increasingly, I’ve been bringing the ward nursing back to ICU.


We had a long term patient, I’ll call Bob (my go-to anonymous name). We really didn’t expect Bob to survive his admission. A long list of complications from surgery resulted in dialysis (the continuous and gentle ICU version, not the large volume suck that is the dialysis of the renal patient). He had very large dressings, poor skin integrity and malaena. The dressings and malaena resulted in further skin breakdown, blood transfusions, and eventually endoscopies for ischaemic ulceraton of Bob’s bowel.

 

Bob had a few big days. He would have a large GI bleed, dropping his haemoglobin about 30 points, and there would be a large amount of malaena in the bed. He’d required intubation and ventilation for an endoscopy, then extubation overnight. This had happened a few times. It was never clear if he could be successfully extubated after each of these events. It certainly looked like there was less of him left in the bed each time.

 

Bob’s nurse noticed she had an opportunity between everything else going on to cease his dialysis for a bit and get him out to the verandah. (We have a balcony with a view, power, oxygen and suction). I was her ACCESS nurse. I knew it would be difficult to organise, but we felt it would be worth it for him to see the outside for maybe the last time.

 

We disconnected his dialysis machine and set it to recirculate (like hitting pause). Recirculation either goes well or it doesn’t. This one was ok for about 10 minutes, then the machine started alarming and after another five minutes we were going to have to replace the circuit.

 

Oh well. The dialysis was now coming off anyway. We were committed.

 

We moved the required support equipment out to the verandah, moved Bob in his bed out there and after two fun-filled hours with family he returned to the bedspace.

 

His nurse ran an ABG on his return indoors. He’d dropped another 30 points on his haemoglobin. And he had more malaena.

 

Another endoscopy. Another intubation.

 

I fetched the FFP, the platelets and the packed cells. His nurse gathered the items required for the cleanup. His family, who were still present, were obviously disappointed. They had just spent two hours with Bob and could see the cost on his health.

 

We paged for the ICU wardies. Our own wardies do regular turn rounds, and are available between times but have other jobs to do outside the rounds. They are very much part of our team, and we are lucky to have them.

 

Two wardies arrived, and the look of horror at the smell of the malaena was telling. These two had enough experience to recognise the odour, and also what it meant for Bob.

 

We discussed with Bob and his family what we wanted to get done (namely, a big clean up, gown and sheet change) and then we asked them to step out, promising we would be as quick as we could.

 

Three minutes later, we asked them back in, we had finished. Quickest everything change I ever saw.

 

On the way out, one of our wardies asked me if there was much hope for Bob. I replied that I did not think so and that assisting in the clean-up of the malaena was probably the most important thing either of us had done that day. He asked if I was serious and that no-one had ever told him his job was that important before.

 

After the blood and blood products were administered, and the GI people were ready to go, we again ushered Bob’s family outside and, once again, intubated him with no real idea as to how long he would remain intubated.

 

Intubation is usually done by the senior registrar, or, if elective and predictable, by the junior registrar as a learning activity.

 

In Bob’s case, he had been intubated so frequently that most of the senior registrars had at one time or another had a turn.

So I was a little taken aback when the consultant declared there would be no learning (medical or nursing), she and I would intubate Bob, on our own, with his bedside nurse the only other person in the room. This one, she said, would be simple, smooth, and efficient. We would do it this way for Bob’s peace of mind.

Bob got his endoscopy. He also got successfully extubated. He very slowly got better, and out of ICU.

He spent a further 3 months on the ward, and has since gone home to his property a long way from the hospital.

Before he left, he told one of the ward nurses that although he was frequently over the whole admission, he knew he would get better the day of his last endoscopy in ICU. He saw the outside world, and he saw the determined calm effort the staff put in to help put him at ease. And he decided that if we were going to put the effort in, he must be worth it, and he would try as well.

 

Our attitude didn’t really fix Bob or get him home sooner. But keeping the dignity and humanity of the patient in mind is one of the most fundamental aspects of nursing. I’ve seen it in many different circumstances, but most commonly on wards where there are no machines that nurses can rely on to help instill confidence in the patient.

 

I think we really got it right that day. And I have the ward nurses I meet as ICU Outreach to thank for it.

Advertisements

The Sellick Manoeuvre: maybe you’re doing it wrong…

I was NEVER going to write a post about cricoid pressure (it didn’t appear at all in “101 Tips for Anaesthetic Nurses”).
It always seemed so…fundamental to practice as an Anaesthetic nurse that there was nothing left to say. Recent controversies in relation to the application of cricoid pressure in the #FOAMed world left me appreciating that this wasn’t the case, especially as the arguments presented didn’t seem to address all the shades of gray…

 

The Sellick Manoeuvre, better known as “Cricoid Pressure”, was first described in 1961 by Dr Brian Sellick in a paper titled Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia – preliminary communication.

The application of pressure to the cricoid cartilage was advocated by Sellick following use of the technique on 26 “high risk” patients during induction and intubation. In 23 cases, no signs of aspiration or regurgitation of gastric contents was found at all during intubation, and in 3 cases regurgitation of gastric contents followed the release of cricoid pressure.

In 1961 there was routine use of high tidal volumes (greater than 10ml/kg), trendelenberg (head down) positioning during intubation, and use of barbituate anaesthesia. (The original “planes of anaesthesia” model described the physiological effects of inhaled ether and was easily modified when barbituates came into practice. With current pharmacology practice has changed so much that neither physiological model has much relevance).

For the next 40 years, the Sellick Manoeuvre was accepted practice in Anaesthetics, Intensive Care and Emergency particularly for non-fasted patients or during rapid sequence intubations. This is despite changes to the practice of anaesthesia (and intubation techniques).

However, in the early 2000’s, some aspects of the use of the Sellick Manoeuvre were found to be not as simple as first thought.

Damage to the cricoid, lateral movement of the oesophagus (not posterior occlusion as intended) and triggering of reflexative relaxation of the lower oesophageal sphincter causing regurgitation may all be physiological responses to the application of the Sellick Manoeuvre (Yao, Fontes and Malhotra, 2012).

Not to mention the difficulty in visualisation of the glottis for the laryngoscopist as a result of mobilisation of the larynx, with associated reduction in first-pass intubation.

In fact, a related technique called BURP (Backward, Upward, Rightward Pressure) was developed to improve visualisation of the glottis and therefore improve the incidence of first-pass intubation.

 
(This man has some serious manoeuvres, but they’re not right either)
 

There has been controversy recently within the #FOAM world in relation to the routine application of the Sellick Manoeuvre during intubation and the evidence for or against. Much of the obvious preferences centre around the difficulty in obtaining first-pass intubation due to impaired visualisation. As the chance of aspiration from gastric regurgitation from all causes is reduced by successful intubation, improving the glottic view is the focus of this blog.

The prevailing thought-leader opinion seems to be passionately and firmly in the belief that the use of cricoid pressure is not justified in routine clinical practice. Opinion had been divided into “tribes”: eg. use of the Sellick Manoeuvre may be justified in anaesthesia, but not in intensive care or emergency. Interestingly, College Fellowship exams of all three colleges require that the Sellick Manoeuvre be applied (or at least considered) for intubation scenarios.

Academia (somewhat more staid than #FOAM) seems firmly out to lunch on the matter. Several sources suggest the use of the Sellick Manoeuvre can neither be recommended nor discouraged, citing benefits, drawbacks, and unknowns.

So where does that leave us?

Before throwing the baby out with the bath water, it might be good to look at what the Sellick Manoeuvre actually involves.

Importantly, Sellick’s description of the technique specifies that pressure should be applied via the index finger, after the cricoid carilage has been palpated between the thumb and the 2nd finger (Sellick, 1961: 405). The original Sellick article does not specify which hand should be used or on which side of the patient the person applying pressure should stand. The thumb and two finger technique was the method I was taught, using the right hand (I’m very left handed), standing on the patient’s right.

The Sellick Manoeuvre was one of the first things I learned as a junior Anaesthetic nurse.I was taught by an Anaesthetic nurse, not by an Anaesthetist. Successful demonstration of Cricoid Pressure during a rapid sequence induction was the end point of my preceptorship in Anaesthetics (after a shift and a half).

Looking after the airway is ultimately the Anaesthetist’s responsibility, but it is also the primary reason for the Anaesthetic nurse’s role. If you ask them during their more honest moments, most Anaesthetic nurses will tell you that they don’t really work that hard for their wages. Except during emergencies such as difficult airways. It’s what they have to know, in order to appropriately do, and when.

Over time I have had many opportunities to apply cricoid pressure during difficult airways for prolonged periods. When tired, it is natural to drag your hand (and the larynx) towards you. This can make a difficult airway harder. The last thing you want is to be responsible for a difficult airway. This is your incentive to communicate with the laryngoscopist, to find out what the view of the larynx is like, to make adjustments.

Since I started, I have seen a variety of Anaesthetists, Intensive Care and Emergency specialists and Senior Registrars demonstrate Cricoid Pressure to junior nurses and residents, or attempt to assist each other…

…and they don’t do it very well.

It’s kind of surprising. Anyone other than another Anaesthetic nurse seems to stand either side of the patient or uses either hand, or uses more digits than thumb and first two fingers. Some just…mash

The lack of practice, consistency and established communication between intubator and assistant mean that it is difficult to know if applying pressure to the cricoid is achieving anything.

It means it is difficult to know if the person applying pressure is moving the larynx laterally, or whether the patient has a deviated trachea.

It means it is difficult to know if the person applying cricoid pressure is applying enough or too much pressure (and the lack of standardisation in technique means it is near impossible to ever ascertain what too little or too much even means).

I’m not suggesting for a moment that there are arcane skills amongst Anaesthetic nurses that no-one else can learn. But I am suggesting that if a group of professionals perform something like the Sellick Manoeuvre repeatedly and as consistently as possible and we still don’t know if it helps or not…

 

Then have it both ways…

Assess the patient and the conditions. Is there another way? Do you and the person you ask to place pressure on the cricoid have the same expectations? Now is a good time to find out…

Put it on. Try it.

Assess the view. See the glottis? Left, right or anterior? Tell the person assisting.

If it helps, leave it on.

If it doesn’t help, you can always take it off.

 

 

 

 

 

 

Bhatia, N.; Bhagat, H.; Sen,I. (2014) Cricoid Pressure: Where do we stand? Journal of Anaesthesiology Clinical Pharmacology Jan-Mar; 30(1): 3–6.

Sellick, B.A. (1961) Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia – preliminary communication. Lancet (2): 404-406 accessed via www.hneed.com/storage/Original%20Sellick%20Article%201961.pdf

Yao, F.F.; Fontes, M.L.; Malhotra, V. (2012) Intraoperative Management in Yao and Artusio’s Anesthesiology: Problem-Oriented Patient Management (7th Edition). Lippincott Williams & Wilkins. accessed via https://www.inkling.com/store/book/yao-artusio-anesthesiology-fonte-malhotra-7th

 

 

 

 

 

 

 

 

“Public Hospitals could save $430m by getting nurses to do some doctor tasks: report” – My Thoughts

My eye was caught today by an article in on the ABC news website.

 

Public hospitals could save $430m by getting nurses to do some doctor tasks: report – ABC News (Australian Broadcasting Corporation)

 

The gist of the piece is that “routine” procedures can be easily carried out by nurses at less cost. The author suggests endoscopies, colonoscopies, and sedating patients for low risk procedures.

The author appears to be an economist and public policy academic. This perspective is the only one in current Australian culture that the report makes sense. The Grattan Institute (http://grattan.edu.au/about-us) states that “it is an independent policy think tank providingindependent, rigorous and practical solutions to some of the country’s most pressing problems.”

I don’t have issue with the article per se (although at no point has anyone thought to ask any nurses what they think…) but I am riled by some of the more obvious comments attached below.

None of the Users commenting actually seem to understand the point of the original report or what the people in the modern health system actually do.

 

 

 

Comments all seem to follow a small number of themes:

  1. Just plain bitchy (“… our definition of a colonoscopy was “six feet of fibre optics with an ar*ehole at each end” … Modern nurses are well qualified to replace the current proceduralists” – User discus49, retired anaesthetist) Let he who casts the first stone, sir. You’d know, maybe having been one of the ar*eholes at some point. And I hope I never worked with you.
  2. The “I nearly died from an anaesthetic and I’m not going to let a nurse near me” response. I’m not even going to address this User’s concerns directly, they obviously had a bad experience which has hopefully resolved. They do suggest that nurses “are not trained specialtists” and several other claims not bearing scrutiny. Although I guarantee that what ever happened it was not fixed by doctors alone.
  3. The “perhaps vocational training at a hospital level (as it was 25 years ago) would be a good way to save resources instead of insisting on degree level training” – User cynical wasp, no occupation listed) line of thought. This comment unfortunately represents a large proportion of the general population who don’t understand what we actually do.

Further comments reflect the original article’s assertation that the RN duties of bathing and feeding could be passed on to vocationally trained nursing assistants.

So I suppose what this post is really about is a rebuttal to the “let’s train nurses as we always have” mixed with some thoughts about why nurse sedationists are a bad idea in modern Australia. If neither of these topics interest you, please read something else (really, my opinions aren’t going to change yours…come back though, there’ll be something else later more your style…)

The obvious response is why do we let the public have a say regarding nurse education anyway? Other professions don’t do this. We tend to invite “consumers” onto our Nursing Boards of Registration (the now defunct QNC used to have two such representatives) and as nurses we engage the community with position statements from Nursing Colleges and policy organisations.

In doing so we may educate a percentage of the population regarding the reality of modern healthcare and nurses place within it, but I believe that is the absolute minority. I feel that the vast majority of society only meet nurses when they find themselves in the unfortunate position of needing nursing care.

So should we go back to the old days of signing our (mostly female) young adults over to a regime of residential curfews, administration spies and vocation (read task focused) based training? Should we remove the rights of junior nurses to go “out” for social events (on own time) without the employers permission? Should we leave them without the ability to advocate for their patients, subservient to the requirements of the medical profession, with all the job satisfaction of knowing that if they keep going and achieve another poor pleb will come and relieve them of the burden of the bedpan?

Rather than answer in the manner in which I normally would (No! with references)…

Would we ever expect that surgeons give responsibility for their education back to barbers?

Would we ever expect that in order to save money, the health system sack all the anaesthetists in favour of good, strong sticks for patients to bite?

Would we ever expect that modern dentistry return to the “everything can be fixed with a good extraction” days of the past?

I could go on…(architects? airline pilots? rocket scientists?)

 

Society has changed. Nursing has changed. There is no real correlation between “what a doctor used to need to know and what a nurse needs to know now” but the body of knowledge involved in both professions does intersect and cover the same ground. One complements the other, not replaces it.

Nurses do and will likely always look after the patient as a person in an attempt to return that person to the best functional state they can achieve. That does involve feeding, and toileting, and bathing. These aren’t things that can always be passed off to another with vocational training. They are further opportunities to assess, to look closely, and they may be the only time available to do so. The fact that these things are not done is not always an indictment on the nurse but a comment on the current conditions in which we work: doing more with less.

The public perception that the nurse is more interested in completing the paperwork (computerised or not) couldn’t be further from the truth to the average nurse. Most could easily have gone for an administration job (without night shift) if that is what they wanted to do. The paperwork is devoted to justifying the hours costed for staffing the ward, and ultimately the costs spent by government in looking after the patient.

Part of my thinking in working in my chosen specialities was the potential for the nurse practitioner role in anaesthetics: the nurse anaesthetist. As alluded to by the Grattan Institute’s report and the ABC article, the role does exist in several countries. One of the prime impediments to adopting such a role in Australia is one of culture.

In the US, nurses have administered anaesthetics (or anesthetics, in American) since the earliest surgeries. Medicine only took responsibility for sedation relatively recently, in the 1960’s or thereabouts (with few exceptions, the people administering drugs to patients during surgery in M*A*S*H* were nurses).

In Australia we followed the English model. Thus doctors have always had responsibility of anaesthesia, and even the anaesthetic nurse role is defined by hospital policy rather than codified by any particular legislation (ANZCA, the College of Anaesthetists recommend that a staff person be provided by the hospital to assist the anaesthetist as required, they shall not be answerable to the surgeon, and shall have 18months ‘suitable’ educational preparation).

In practice, this means that the anaesthetic assistant is a former wardsperson, or some one off the street, or any other background deemed to have satisfied the 18 month rule (no specification is made of what the 18 months should include). Or if you are lucky, the hospital has a preference for Registered Nurses, with their Bachelor of Nursing (3 years) and a Graduate Certificate in Anaesthetic Nursing (1 year). This still isn’t an “I’m better than you are” argument: I can train an anaesthetic nurse in a shift and a half (that was all I recieved at the time) but it’ll take about two years before you really know what you’re doing.

After all that, I could keep someone asleep during surgery whilst the Anaesthetist went to the toilet, I could anticipate, I could intubate and assess, I was handy in an emergency, understood and could administerl all the medications, all the things you would want in an assistant. Once I came to ICU I learned a lot more, all relevant. I have all the experience I need to apply to a US-style program (they call them Certified Registered Nurse Anaesthetists, or CRNA’s).

The US model requires the equivalent of a Masters degree preparation, AFTER the background and preparation and education I currently have. I could do that. But I won’t. Even if we followed the Grattan Institute’s ideas and adopted the system here.

The CRNA model requires supervision. It has been a part of the system since the beginning and the nurses undertake ALL anaesthetics during ALL the procedures a hospital offers. All of them. Patients aren’t always given the choice, and the literature shows there is not a difference in the care from a nurse as from a doctor.

We simply do not have that culture in Australia. Nursing has an image problem (as demonstrated by the comments above indicating a lack of understanding with the staus quo) and the public likely won’t accept nurses in the role (imagine the outcry!!!)

As a child of cost cutting measures, the CRNA model in Australia would be a hard pill to swallow. There are not enough training positions for the doctors, never mind the CRNA’s requiring supervision. It is easy to foresee a potential future where should the adoption of CRNA’s be successful (against all odds) the newly minted CRNA’s are required to fill the backlog of vacancies in rural centres…

Aargh

As a nurse, my interest is in the patient as a person. Not in cost cutting for Government. That’s what the Grattan Institute is for.

 

What You Do Matters

“What You Do Matters” is the essence of why many of us become nurses, doctors, healthcare workers. Rarely do we work shifts, and go through all we do in order to make lots of money (though that would be nice too…)

Rather for most of us it is the knowledge that we DO make a difference to our patients that keeps us going. Unfortunately with the acuity of our patients and the attendant alarms, pumps, and other equipment as well as everything else we deal with in life it is sometimes difficult to remember that this is what motivated us in the first place…

 

Sometimes we don't realise the difference we make to our patients or their loved ones. Often we'll have absolutely no idea, as the healthcare systems in which we do our human-to-human work simply fail to provide the mechanisms required for adequately expressing the depth of involvement and investment we have with the critically ill and they have in us.

In sum, while a thank you card and chocolate is nice, they don't always give us the whole picture. We can easily fall into the thought that whilst each nurse has nearly identical training and access to the same policies we are all interchangeable. And from a clinical skills perspective, that might be a fair assumption. But on that human level, nothing could be further from the truth…

 

Several years ago I was learning how to manage Renal Replacement Therapy (or dialysis machines). I was in the transitional learning stage of being confident with access, changing bags and setting up circuits and was in the process of integrating theories of currents, counter-currents, solutes and filtration. My patient allocations were starting to reflect this, with sicker patients (they actually came sicker than I was already getting???) and more technology.

 

I arrived on a night shift to find that my patient for the night was undergoing dialysis but was using a Hudson mask and not on a ventilator.

Non-ventilated patients were unusual for me at that point – I wasn't the junior nurse I had been, so I could manage with patients who were quite sick and that usually meant my patients were ventilated. There were newer staff in the slow wean patient phase, so I didn't see as many as I had.

(Of course I now realise that this is a huge responsibility on junior staff as our non-ventilated patients can be some our most unstable patients…)

She was sleepy, and it was late, so I used my neuro torch and the reflected light from the bed space examination light to do my assessment and safety checks and let her sleep. I noticed her yellow, jaundiced complexion, registered that that pale white of her eyes had turned egg yolk. She had a big day tomorrow: handover from my late shift colleague had indicated the dialysis would cease in the morning and she would be a ward transfer. We talked a bit, but mostly she slept. I studied my workbook on the dialysis machine and occaisionally changed a diasylate or replacement bag and that was the night.

Bold, golden light flooded the room in the morning. A truly astounding sunrise streaming through the window

We have huge windows, and this bed space has the best view of sunrise at certain times of the year (almost worth working nights for). I had forgotten to close the louvres but it wouldn't have mattered – the golden glow of the full sun would have burned straight through all but thick black plastic. It was glorious.

Without thinking too hard (I was going to bed soon) I asked her if she wanted to see it. She said yes, so I raised the back of the bed as high as it would go.

I noticed that my bare arms had taken on the same yellow glow from the sun as had everything else it touched.

Including, as she sat there watching wordlessly looking out the window, my patients' previously jaundiced skin.

Of course she was still jaundiced, but when everything else is changes to that golden yellow the mind automatically adjusts its expectations of what colour things really are. Again without thought (and probably tactlessly, under other circumstances) I said “see, in this light we've both got the same complexion and everything is normal again, just for a bit.”

My patient smiled at me, and nodded, both of us thinking if only her life were that simple.

I stood next to the bed, and we just looked out the window together for about ten minutes.

Then the wardies came, I moved her off her back, finished my work, wished her well and thanked her for her company during that magical sunrise.

Later that day, my girlfriend (now my wife, and a wonderful RN on another ward) woke me after she had finished her work as an Assistant in Nursing in the same ICU. We had a discussion about her day and a catch up as we do when we are on different shifts. She said she had been involved in cleaning a bed space after a patient death and the AIN team were perplexed by a message on the small whiteboard on the wall. No-one writes messages there. It is used for patient names and ACCESS nurse contact numbers.

 

None of the staff on day shift had understood it.

 

It said simply “thanks for the sunlight and see you in the sunrise.”

I explained my night shift and my experiences with the patient. She had hepato-renal syndrome on top of her end stage liver disease. The night I looked after her she was waiting for some family members to travel from interstate. She wasn't expected to last long after the dialysis ceased, and she hadn't. My girlfriend and I both cried for her and I was grateful for her message. I hadn't realised the difference I had made.

Remember, ALL the things you do make a difference. And you may never know the difference that you DO make.

So to all those who wonder what difference they make, I give you a reminder:

 

 

 

 

With thanks to @EM_educator who presented the above reminder to all at the Social Media and Critical Care conference, Gold Coast, Australia, 2014.

 

The Magic Numbers: The Soldier’s 5 of Arterial Blood Results (Lesson 1)

So you want to interpret your patient’s arterial blood results but it seems a lot to learn and you’re not sure where to start?

Here’s the Soldier’s 5 version:

 

  1. 35 and 45 are the two ‘Magic’ numbers to remember
  2. pH should be 7.35 to 7.45. Lower than 7.35 is acidotic, greater than 7.45 is alkalotic (determining a respiratory or metabolic cause is a bit more complicated – see point 2)
  3. pCO2 should be 35 mmHg to 45 mmHg. Lower than 35 mmHg can drive a respiratory alkalosis, higher than 45 mmHg can drive respiratory acidosis (if pCO2 is normal then a deranged pH has a metabolic cause or is compensated)
  4. Sodium (Na) should be 135 mmol/L to 145 mmol/L. Lower than 135 is hyponatraemia, higher than 145 is hypernatraemia
  5. Potassium (K) should be 3.5 mmol/L to 4.5 mmol/L.(*) Lower than 3.5 is hypokalaemia, higher than 4.5 is hyperkalaemia.

 

 

Interpreting blood results isn’t something that nurses should be afraid of. Don’t be afraid to have a go – talk to the staff you’re working with and ask them to help. Practice makes perfect.

 

If you think you’ve found something abnormal on your patient’s blood work, report it. In the worse case, it’s a great learning opportunity.

 

 

(*) some texts suggest a potassium of 5.2 mmol/L is the upper end of normal.

 

The values listed for Sodium and Potassium are the blood values – intracellular (or cytosol) values are almost perfectly reversed. This prevents osmosis of water into the cell.

 

 

A Soldier’s 5 is good for Clinicians, too

I spent some 6 years as an Army reservist in the Australian Army. Several aspects of my time (and training) have helped me in my career in both Anaesthetic and Intensive Care nursing. I’ll address some of these in future posts.

 

Perhaps the most relevant of these is the concept of the “Soldier’s 5”. It is a choice of 5 seconds, 5 minutes or 5 points that a soldier needs to know NOW.

An example might be using a new weapon:

  1. the pointy end (towards the bad guy)
  2. the safety (how not to hurt yourself)
  3. the trigger (how to actually fire the thing)
  4. The aiming reticle (how to aim it)
  5. Where the ammunition goes and how to re-attach magazines (how to keep the thing going)

Of course in the real world, a soldier would ideally have lessons on new equipment before heading into battle.

 

Much like healthcare.

 

The benefit of the “Soldier’s 5” is that the method can be used from simple points with new practitioners through to more complex tasks with experienced practitioners.

 

A clinical example might be:

 

  1. Synchronous Intermittent Mandatory Ventilation (SIMV) is a form of positive pressure ventilation
  2. SIMV requires the patient breathe through an ETT
  3. It can be volume or pressure controlled (set volume OR pressure)
  4. SIMV allows a set number of breaths/minute but will “Synchronise” with spontaneous breaths
  5. SIMV generally allows PEEP and Pressure Support adjustment

 

It works with auditory and kinetic learners, and the short points can be recorded by visual learners.

 

The “Soldiers 5” is generally highly repeatable: once used, the learner can rapidly become the teacher.

 

Of course, there is no scope for in depth understanding or for learner questioning, so a thorough follow up session relating theory to practice with an educator is recommended.