Of Med Errors and Brain Farts

 

Glasses ink 2019 by Julianna Paradisi

Giving an Unfamiliar Medication

I read the physician’s order carefully, looked up the medication in the nurses’ drug book, and consulted with a pharmacist before I gave it. Afterward, while signing the medication administration record (MAR), I read the order again, and I did not see the same dose I had read the first time.

Accountability for My Actions

Immediately the blood in my feet rushed up to my ears and I was lost in pounding waves of white noise. Fuck, fuck, fuck, I made a med error, and it’s a serious one! Of course, I didn’t say these words out loud. Instead, I carried the patient’s chart and the empty, pre-filled syringe to the nurses’ station. Putting them in front of the charge nurse I said, I think I just made a med error, a bad one. Look at the order and the syringe label. Tell me what I’ve done.

Relief: The Patient was Safe

She stopped what she was doing. She read the order and examined the syringe. You gave the right dose. You didn’t make a med error. Now breathe. The pounding breakers of white noise in my ears subsided into the gentle lapping of my breathing. Another nurse came to my side saying, I know exactly what you’re feeling.

I felt relief. My patient was safe. It was an unfamiliar medication. That’s why I read the order carefully, looked it up, and consulted with the pharmacist. The only explaination I have for my confusion after giving the dose is that I had a brain fart. Somehow my eyes and my brain disconnected after giving the medication, and the order unexplainably failed to make sense. That’s the best I can come up with: a brain fart.

Everyone Makes Mistakes

Later, my coworkers told me their stories of making med errors. We all make them. I didn’t know that when I was a new grad.

It is unbelievable to me as I type this, but it is true: in nursing school  I had an instructor who told our class that she had never in her thirty year career, ever made a medication error. Never. And I was young, and shiny, and idealistic enough to believe her. Seriously, I did. So when I made a medication error during the first couple months of my new-grad job, I was sure that I was not cut out for nursing. At that time, my coworkers didn’t gather around offering support like they did recently. No, I was written up, and had to call the pediatrician and tell him I had forgotten to hang a dose of ampicillin. He was more sympathetic than the day shift charge nurse back then. I made other medication errors too, nothing serious, but enough to consider quitting nursing during my first six months of practice.

Nurses Supporting Nurses

Then I met one of the best nurses I have had the pleasure to work with. For some reason, she decided to mentor me. I confided to her that I considered quitting nursing, because I made med errors, and that my instructor never had.  She laughed. If that instructor of yours never made a med error, then I’m thinking she’s too dumb to catch them. You are so crazy. Let me tell you about med errors… She was a great nurse, not a perfect one.

Eventually I gained the confidence needed to stay in nursing these past thirty-three years. I still make mistakes from time to time. I take responsibility for them. I learn from them. I am compassionate towards my coworkers when it happens to them. Nursing is not a risk-free profession.

And sometimes I have brain farts.

This post was originally published on January 30,  2011. I feel reposting it may be beneficial for nurses new to my blog. It has been updated. 

New Post for AJN’s Off the Charts Contemplates Nurses Missing Time with Our Families Because of Work

My latest post and illustration for Off the Charts, the blog of the American Journal of Nursing is posted. Heralding in the holiday season, it’s a contemplation of missing celebrations and family events when the needs of our patients require it.

This Halloween Teal and Blue are The New Orange for Parents of Children With Food Allergies, Autism 🎃

Autism and Food Allergies Awareness at Halloween

Blue Pumpkin Bucket with Teal Pumpkin watercolor and ink by Julianna Paradisi 2019

This Halloween, Teal and Blue are the new orange for parents of children with food allergies, and autism.

Recently, I learned of two newish movements that merit recognition for championing the health and happiness of children while trick or treating. Both choose pumpkins of different shades of blue to alert the public to their causes.

Teal Pumpkins Help Children with Food Allergies Participate in Halloween Fun

How difficult Halloween must be for parents of children with food allergies! Imagine taking your favorite Disney character or Marvel superhero trick or treating, only to remove almost the entire loot from their buckets or bags at home, because most trick or treat candies contain allergens like dairy products, peanuts, dyes, etc. It must be heartbreaking to have to explain to your child again why they can’t eat the same goodies other kids do.

The Teal Pumpkin Project offers an inclusive alternative for children with food allergies at Halloween. By placing a teal pumpkin outside your door, you signal to children with food allergies and their parents that you are giving out non-food items for treats. The website creates neighborhood maps of homes offering non-food item treats, and you can add your home. Or, simply paint a real pumpkin from a pumpkin patch or grocery store teal, and put it on your doorstep or windowsill.

Here’s a list of inexpensive non-food items from their website:

Glow sticks, bracelets, or necklaces
Pencils, pens, crayons or markers
Bubbles
Halloween erasers or pencil toppers
Mini Slinkies
Whistles, kazoos, or noisemakers
Bouncy balls
Finger puppets or novelty toys
Coins
Spider rings
Vampire fangs
Mini notepads
Playing cards
Bookmarks
Stickers
Stencils

They do caution that some modeling clay products may contain wheat, and avoid products with latex. Age appropriateness and avoiding choking hazards should also be considered.

Blue Halloween Pumpkin Buckets: Be considerate of children, teenagers, and young adults with Autism enjoying Halloween

This Halloween, you may notice children, teenagers, and young adults carrying blue plastic pumpkin buckets. This became a thing last year when a mother wrote a social media post that went viral, asking people to please not require her non-verbal three year-old to say, “Trick or Treat!” to receive candy. She went on to explain that Halloween can be an engaging social event for children, teenagers, or young adults with autism, so be considerate of those who don’t respond verbally, or appear to be a bit “old” for trick or treating. This is good advice even if a person isn’t carrying a blue Halloween pumpkin bucket, because by showing kindness to strangers some have entertained angels unawares.

Blue pumpkin candy buckets can be purchased online.

Celebrations are more enjoyable when no one is left out. I’m grateful for opportunities to make Halloween activities fun for all.

 

 

 

Lovingkindness: My Experience Growing Grandiflora Magnolias From Seed

Magnolia Grandiflora watercolor and ink by Julianna Paradisi 2019

Two years ago, I became enamored of magnolia trees. It began with my observations of a particular tulip magnolia tree I passed by while walking to work and home from work, almost daily.

Portland’s neighborhoods are rich in many varieties of magnolias, and soon I found myself fascinated by the multi-lobed pods of other varieties such as Little Gem, and of course, Magnolia grandiflora, also known as the southern magnolia, or bull bay.

I collected a few fallen pods from sidewalks, and decided to try growing seedlings. I’ve grown houseplants and gardens most of my life, and supposed growing magnolia grandiflora from seeds would be as simple as planting them into potting soil, placing them on the windowsill, and providing lovingkindness. After a couple of months of trying to cajole growth from the pots, I was disappointed: Nothing sprouted. So I did some research. Magnolia grandiflora seeds require several steps of preparation before planting. There’s actually a 6 month process to starting magnolias from seed.

A year ago this autumn, I collected new pods with fresh seeds, and tried again. This time I was successful, but magnolias seeds are so fussy, it’s a wonder to me they are able to survive in the wild at all. They require a great deal of lovingkindness.

I planted nine seeds, and this spring eight of them sprouted, but not without complications. Three broke ground upside down, roots skyward. With the gentleness of a nurse who once cared for tiny, premature babies, I replanted them roots down. Only one survived the procedure.

Another pair could not break free of their seed casings even though I had removed the tough outer shells with sandpaper before planting as instructed. Their tender leaves withered within their tiny prisons.

Four hardy seedlings survive. I gave one to my mother-in-law, who is a master gardener and I suspect will have the ultimate success with her tiny charge. It sits on a table facing west, with a view of the Pacific Ocean; what or who wouldn’t thrive with expert lovingkindness in such a favorable location?

The other three seedlings face east on my windowsill in Portland with a partially obstructed view of the Willamette River. So far, they too are thriving.

Above is an ink and watercolor painting I made of the largest of the trio.

According to Wikipedia, magnolias produce their first seed pods at ten years of age, but the height of production occurs at 25 years.

Really, it’s a wonder magnolias have survived through the centuries at all.

Memorial to Nurses Who Served in the Spanish American War

Memorial Honoring Spanish American War Nurses in Portland, Oregon, photo by Jparadisirn 2019

I’ve been running through Portland’s Tom McCall Waterfront Park for years, but this morning I discovered something there I’d never noticed before. It was a war memorial to nurses serving the Spanish American War. The memorial was erected on September 14, 1938.

The small memorial is part of a larger monument to the USS Oregon, a battleship commissioned on March 19, 1898 to serve its country. According to this article in the Oregon Encyclopedia  the USS Oregon (and her crew) made a significant contribution towards the US winning the war. Her captain was a veteran of the Civil War.

At one time, the entire ship docked at Portland’s waterfront, but it was taken back by the US government during WWII and its hull was used for munitions storage in Guam. Eventually, most of the vessel was sold for scrap, and today only its mast remains in Tom McCall’s Waterfront Park.

The above article doesn’t mention the nurses’ memorial, and I’ve not been able to locate more information. Still, it was a pleasant surprise to find nurses serving in a war recognized over eighty years ago.

My Wild Oregon: The Wreckage of The Peter Iredale

The Wreckage of the Peter Iredale watercolor and ink by Julianna Paradisi 2019 (sketchbook)

David and I spent several days in Astoria, Oregon last week. The town is steeped in history, and not only as the final destination of Lewis’ and Clark’s historic cross continental trip, wintering at Fort Clatsop.  Astoria is notorious in Maritime history through the present for the difficulty encountered by freighters and fishing vessels crossing the bar, the point where the mighty Columbia River and the Pacific Ocean converge. In present day, crossing The Bar requires the expertise of pilot ships and their captains to navigate safely. And yet, occasionally there are mishaps

If you’re interested in the history of the Pacific Northwest, I am, and the history of Astoria in particular, I recommend reading Astoria: John Jacob Astor and Thomas Jefferson’s Lost Pacific Empire, a Story of Wealth, Ambition, and Survival, by Peter Stark.

David and I drove to the Clatsop Spit to see what remains of  the wreckage of the Peter Iredale, a cargo ship with an empty hull that went aground on October 25, 1906. It was sailing to Portland to load with wheat for export in the UK. Although the ship was a total loss, fortunately, the crew survived.

The weather was beautiful this particular day, and lots of people had the same idea as David and I. There were children joyously climbing the rusted steel and iron wreckage as though it were a jungle gym, laughing and playing while their parents supervised.

The Wreckage of the Peter Iredale watercolor and ink by Julianna Paradisi 2019 (sketchbook)

I found a spot in the sand and began to draw…

 

Nurses Week Blog Post for Off the Charts

I wrote and illustrated a post for Nurses Week for Off the Charts, the blog of the American Journal of Nursing. It’s title, One in 4 Million is a reference to this year’s theme.

Has there been an influential nurse or mentor in your career?

Discovering Our Inner Lewis and Clark

Centennial Mills Snowscape II oil, wax on panel 2019 by Julianna Paradisi from an image of the 2017 Portland snowstorm

Those of us living in the Banana Belt of downtown Portland were spared the large amount (up to 8 inches) of snow dumped onto adjacent neighborhoods and outlying towns this past weekend.

Michelle Obama cancelled her trip to the Rose City because of the weather reports predicting Snowmagedon, after Seattle was blanketed in 5 inches of snow in only a few hours. Flights between Seattle and Portland were cancelled.

On Friday night we got a dusting of powder. Saturday morning, although air temps only reached 30° F, the sidewalks were clear except small patches of ice here and there, gone by noon.

The rest of the weekend was pretty nice, in terms of weather. In fact, the sun shone gloriously most of Sunday. I got a slightly pink sunburn from an hour’s worth of it shining on my face through the window during barre class.

The Internet guffawed mercilessly at the forecasters. Twitter and Facebook popped with snarky photo memes. Portland weather forecasters are used to the heckling, similar to our local sports teams when they lose.

Unpredictable weather is a part of life in Portland, treated like a personality participating in all social events like that crazy relative everyone suspects will act out but is invited to the wedding anyway.

It was reported with great humor that all the kale in Portland grocery stores had vanished from the shelves as panicked Portlanders stocked up on essentials to sustain them during the predicted week-long siege of Snowstorm 2019.

I hadn’t planned to go to the studio on Saturday, because we had tickets to see Michelle Obama. When she cancelled Friday afternoon, I still  didn’t plan to go because of the predicted inclement weather. When the snow accumulation proved slight, I still didn’t go because something inside me suspected foul play on the part of the storm: It was just an unexpected break in the weather; the really bad stuff could start any moment. These thoughts were somewhat fueled by reports and photos posted by Facebook friends attesting there was significant snow in selected Portland neighborhoods.

So I adapted. I scheduled barre classes instead of my weekend runs along the river. I did laundry. I meditated. I read my Tarot cards, and then journaled about what I thought the reading meant. I read a book. I took a nap. I made a pot of soup. I texted my husband who had to work the weekend. I told him I loved him and missed him, adorning the texts with happy faces blowing kisses emojis.

It didn’t snow.

On Sunday there were occasional light flurries of powdery snowflakes that melted on contact into tear drops falling from the railings of my deck. I took another barre class, but ventured no further from home than that.

We ate leftover soup that night for dinner.

The whole weekend was entirely anti-climatic.

I wasn’t alone in my feelings I discovered on Monday morning at work. When the topic of “the snowstorm that wasn’t” came up, and it did often, everyone said the same thing. They had been unable to reorganize their weekend plans to make use of the unexpectedly good weather. Almost everyone made soup. Lots of soup, too much soup for one family and they shared portions with their neighbors.

Disappointment was the most commonly expressed emotion. We had looked forward to being homebound by the snow that never fell.

In my mind, we were mourning our inner Lewis and Clark. A snowstorm gives us a cause to focus on as a community. But more than this, a snowstorm provides the opportunity to test our inner resilience, because in reality, Portlanders are closet survivalists. Note that stores ran out of kale, bread, milk and bacon. There were no shortages of parkas, snow boots, traction devices to put on the boots, or of generators, or snow tires, That’s because households already have these things, and every neighborhood has a neighbor with a big sturdy truck with all-wheel drive who will happily volunteer to take you to work at the hospital or wherever it is you need to be.

Oregon is home to the last of the pioneers headed west. Europeans discovered Hawaii long before Lewis and Clark arrived on the Oregon coast. In Oregon, we have travelled as far west as one can on the continent of this great country.

Those of us who came to Oregon from other places as young people came because we wished to connect with our inner Lewis and Clark; at least I did. I learned to start a fire from kindling I split myself from wood taken from the cord I stacked in the fall to get me through winter. I came because I love the change of seasons, the colors of fall, the damp, grey mossiness of winter that breaks into the brilliant smile of spring. I left the monotonous days of the state where it never rains to experience the full palette of nature.

Like my fellow Oregonians, I relish the threat of a Snowpocalypse for its gift of revelation: who I am, and what I am capable of.

And like my fellow Oregonians, I’m a little lost when the Snowpocalypse doesn’t arrive.

A Random Encounter: Nurse, Artist, and Tree

The Embrace oil on panel, 8″ x 8″ 2019 by Julianna Paradisi

There’s a tree I walk past often, and on my way home from work one day I decided to take a picture of it. Turning to face the tree, I took my phone out of my coat pocket.

As I did, a young man stopped and asked if I was going to photograph the tree. When I said yes, he asked what it was I saw. I looked at him closely before speaking. His question, his wool jacket, the way he stood told me what I wanted to know.

I asked, Are you a photographer?

He was.

If he’d asked, I would have told him I’m a painter.

The setting winter’s sun outlined the silhouette of the tree. I showed him how its bifurcated trunk created the illusion of an embrace.

At first he couldn’t see it: Show me the nose.

Pointing with my finger, I outlined nose, brow and lips for him.

He looked intently, the way artists and poets do. After a pause, he said, I have a friend. She talks to trees.

I told him once I heard a grove of trees singing. Two weeks later, they were gone, having been cleared for a housing development.

He told me he will never not see the embrace of this tree.

He went on his way. I took the picture of the tree, and from it, several days later, made this painting with its story of a random encounter.

Random Thoughts of Crows, Butterflies and Transformation

Crow, Magnolia, and Moon by Julianna Paradisi 2019 pastel on tea-stained paper

Last Fall I watched a murder of crows scavenge through a city park, mingling with a flock of pigeons. One crow ambled closely behind a singular pigeon, comically mimicking its head-jiving gait.

It was molting season for the crows. Their normally sleek, iridescent black chests were marred by bare patches evoking the image of clowns dressed in rags. The indignity of their molting got me thinking about enduring molting as a process of transformation. Birds molt their feathers. Snakes shed their skins. These are transformations of self- renewal.

Some creatures undergo complete metamorphosis, however. Water-bound Tadpoles transform into amphibians, growing legs while their tails wear away to nothing along their journey towards becoming frogs.

Then the metamorphosis of caterpillars into butterflies came to mind, and it occurred to me I had no idea how a caterpillar transforms into a butterfly within its shroud of chrysalis.

When I was going through cancer treatment, the image of a butterfly was often suggested to me by others as something to consider. In fact, butterfly imagery is popular among survivors for its message of transformation from lowly caterpillar into a beautiful winged creature with the ability to fly.

While I liked this imagery, the truth is, with my bald head and surgery scars, I identified more with the imagery of an egg: something smooth, round, and hairless holding within it the dramatic creation of a transformed life.

After watching the crows for some time, I went home and looked up on the Internet the process of how a caterpillar transforms into a butterfly. It was startling to learn it isn’t like some quick-change artist act on America’s Got Talent.

It’s a pretty gruesome process. Caterpillars don’t spin a cocoon around themselves like silkworms do. They molt their outer skins and the chrysalis bursts forth containing their innards. Until recently, scientists believed the caterpillar was then digested by enzymes within the chrysalis into a soup-like yolk, with cells programmed to become the legs, eyes, wings, etc developing into their assigned organs.

Chrysalis (sketch book) by Julianna Paradisi 2018 Ink on paper

It was difficult for scientists to accurately study the metamorphosis of caterpillars into butterflies because they had to cut open a chrysalis or x-ray it to see what was happening inside, thereby killing the embryonic butterfly and preempting further development.

The advent of micro-CT enables scientists to see inside a chrysalis without killing the caterpillar/butterfly, and study the metamorphosis without destroying it. It turns out the caterpillar does not actually self-digest into a soupy yolk, but its parts shift in size and form within the chrysalis, molding into a butterfly. At maturation, the butterfly takes breaths into its thorax, until its wings swell with air and the chrysalis bursts open, releasing it.

Last Fall, I began drawing and painting crows, attracted to the idea of transformation and how it applies to my life. I’ve completed a twenty-year cycle, a mini-lifetime within my lifetime since cancer treatment. It’s time to begin something new. I’m not quite sure what. I sense a shedding of old ideas and roles like the molted feathers of a raven, and an internal metamorphosis like the shape-shifting of a butterfly. I’m developing a stronger sense of self, a lighter heart, and healthier boundaries.

There is evidence butterflies retain the same aversions to noxious stimuli they were exposed to as caterpillars right before the metamorphosis, implying sentient awareness. I wonder if caterpillars have awareness of the end of life they as they knew it while molting their final skin, and the chrysalis envelops them like a grave?  Do caterpillars understand what’s happening to them, or do they “die” like we humans do, without concrete evidence of what happens when we no longer inhabit our bodies?

Does a caterpillar in its chrysalis dream of an afterlife with wings?