I recently had the opportunity to see a colonoscopy at a large medical center's endoscopy suite. Here in the wilderness, our little backwoods hospital does endoscopies in one procedure room within the OR, or in one of the actual ORs if we have two docs doing scopes at the same time. On a very busy day, we might do a total of 14 scopes. So going to the big-town medical center where they do 75 a day was quite a change! I've only been working in endoscopy for six months, and until last week had never seen a scope done at any other hospital; I was looking forward to seeing what was done differently and maybe picking up some tips.

The first big difference I noticed: where is the other nurse? For scopes, we always have both an RN and a scrub nurse or scrub tech in the room. This time, there was just one nurse to push meds, monitor, handle the specimens, and help the gastroenterologist. Admittedly, he was very self-sufficient; the RN never had to hold the scope, apply abdominal pressure, or pass irrigation to the doc. She handed him the biopsy forceps, but that was it. There was a separate team to set up and wash the scopes, which the scrub does at my hospital.

Next big difference: where are the ETCO2 and cardiac monitors? Nowhere! Big-town medical center doesn't include these in their monitoring. I was surprised! I thought they were standard practice.

Yet another big difference: where is the paperwork? There seemed to be a whole lot less paperwork involved than what I have to do. No computer charting, for one thing; there was one paper page each for pre-, intra-, and post-procedure. Very streamlined. The forms were used only for GI endoscopy procedures. There were a few other form such as the permit and physician orders, but that's about it. My hospital uses a standard admission form (used for both pre-op and inpatient admissions), and, for the intra-procedure phase, the same form used for all types of surgery. These are both on the computer. Then I have a paper flowsheet where I document meds and vital signs, along with a handful of other papers: the charge sheet, the charge card, the quality forms (2), the SBAR form, the pathology slip. Not to mention the papers I need to pull from the chart to give to the doc: the physician order form, the surgical consent, the conscious sedation consent, the discharge instructions, the H & P. Too much paperwork!

My manager is setting up a time for me to observe in the endo unit of a local hospital similar in size to mine. I'm curious to see what differences I will find there.

Everybody loves enemas!

According to the Associated Press, a spa in southern Russia has unveiled an 800-pound bronze statue of an enema syringe. Apparently, enemas are a common part of of the spa package in the area. The cherubs reverently hold the bulb syringe aloft. "An enema is almost the symbol of our region," the spa's director told the press.

No cash, time, or inclination to travel to Russia for pay homage to the enema? Well, now you can get your very own cute 'n' cuddly stuffed animal enema! Made by the company who brings you Fleet's enemas, the plush Eneman is guaranteed to make you view enemas in a more positive light! 

A is for Airway

A = Airway

B = Breathing

C = Circulation

The ABCs of CPR are embedded deep within the memories of every health professional. In five months of providing sedation in the endo room, I had never had to actively manage a patient's airway. If an airway was questionable, a simple repositioning of the patient's head would do the trick.

That all changed today. My patient had been snowed by our most heavy-handed doc. Her respiratory rate was fine, but her SaO2 (oxygen saturation) kept dipping, and she was doing this snoring that made me think she was partially obstructing. Plenty of chest movement with each breath, audible breaths, but I just had the feeling she wasn't moving a whole lot of air. A chin lift didn't help much. I turned the O2 up to 3 liters, then 4. Still she was hovering around 88-91% -- certainly no emergency, but I was not comfortable with her being so low. I did a jaw thrust: 92.....93......95......96. I let go: 95.....94.....91.....89.....86. I ended up keeping my hands on her jaw for most of the procedure. It worked great! Luckily, her other vital signs were stable despite the huge amounts of Demerol and Versed in her system. She needed some Narcan and a trip to the PACU because she wouldn't wake up when we were through. I have the feeling that we crossed the line past moderate sedation into deep sedation this time. I wish certain doctors would go to the sedation workshop that I just attended!

I love my Palm TX

My Palm TX travels with me every day in the pocket of my scrubs. I bought it a couple of years ago, and it has proven to be a highly useful and entertaining little gadget. Here are the medical apps I tend to use the most:

Davis's Drug Guide for Nurses:

This is the best PDA drug guide I have found. A lot of the others are designed for physicians and do not have info nurses need to know, such as IV compatibility. I can't tell you how many times this has saved me from running back down the hall to the nurse's station to find a drug book because I couldn't remember whether cipro was compatible with morphine.

Taber's Cyclopedic Medical Dictionary:

Is there a nurse out there who does not own or use Taber's? I have found Taber's to be most valuable when I have a patient with a medical condition I am not too familiar with, but it has been helpful for looking up all sorts of things.

These are the only references I have purchased. At $50 each, they are not cheap, but I have found them well worth the money. I got them through Skyscape; there are other vendors that sell the same references. There are many free medical references available also.

I bought the TX to use at work, but I must admit that I have used it for entertainment more than I have as a medical reference tool. Hundreds of games, many free, are available for the Palm platform. It is an mp3 player and video player; one person I know has the entire Lord of the Rings trilogy on his TX. It has wi-fi and can be used to surf the web at any wi-fi hotspot. And of course, it handles all the PIM (Personal Information Management) stuff beautifully.

It is not a phone; if you want a PDA/phone combo, consider the Palm Treo or smaller Palm Centro. Personally, I prefer keeping my gadgets separate; I'm perfectly happy with my little dumb phone. And the TX has a much larger screen than any smartphone, which makes it better for references and for gaming.

To learn more than you would ever need to know about PDAs of all types, check out Brighthand.com. The friendly, funny, helpful and knowledgeable folks there can answer even the most obscure questions.

I wanna be sedated.....

This past weekend I went to a sedation workshop put on by Specialty Health Education. I thought it was very good and well worth the time and expense. I've been providing sedation for a few months now without any formal training; I had a good orientation with a preceptor, but no specific training in sedation other than what I read on my own. I highly recommend "Moderate Sedation/Analgesia" by Michael Kost, who is one of the presenters for Specialty Health Education (note: I am not affiliated with them in any way, just a happy customer).

The presenter who taught my seminar gave us quotes and situations which other students had brought to previous seminars. The scariest quote was, referring to RN-administered Propofol (I'm paraphrasing), "I don't worry about giving Propofol, because we have Romazicon right in the room in case I need to reverse it." YIKES! I would hope that anyone administering sedation would know that Romazicon reverses Versed and other benzodiazepines, NOT Propofol! There is no reversal for Propofol. 

I'm doing a home-study CEU packet through this company, which I bought at the seminar. I figure that the more I know about sedation, the pharmacology of the drugs involved, and the risks to my patients, the safer we all will be.

Warning: novice blogger at work

A basic introduction: I've been an RN for five years, and transferred from med-surg to the endoscopy room in January. The small community hospital where I work had never had a dedicated endo nurse before me; previously, the OR circulators rotated through the endo room, and they still do when I'm not working. I work with a scrub nurse (almost always the same LPN, who is a joy to work with) and four general surgeons. Colonoscopies and EGDs are our bread and butter; because we are a small hospital, we don't do ERCPs or other more extensive procedures. Once in a while we do a small ortho procedure.

I handle the sedation, monitoring, and specimens. Versed and Demerol have been the drugs of choice, but one of the docs just switched to Fentanyl. Hopefully the others will also make the switch. The anesthesia providers will provide MAC with Propofol if necessary. 

Endoscopy hasn't gotten boring for me yet. I was worried that doing the same type of procedures every day would get dull, but every case is different. Also, it is "my" room, and I have been able to set it up how I want and am working on changing the conscious sedation flowsheet. It feels good to have ownership of an area of the hospital, even if it is just one room, and being in charge of the room gives me challenges that will (hopefully!) keep me from getting bored.