I’ve written and illustrated a new post for Off The Charts, the blog of the American Journal of Nursing, addressing the chronic issue of understaffing, and effect on the safety of nurses and patients. Below is the link to the post.
I am cautious when initiating online interactions, with good reason.
Sometimes, being cautious feels uncomfortable, however. I’m talking about the Internet phenomenon of patients asking strangers for Likes, or even donations to cover the cost of their medical expenses on Facebook. Despite a high index of suspicion, like most nurses, I have a soft heart. When I see those sweet little faces of bald children asking me to help them get a bazillion Likes on Facebook, I think, “I’m a cancer nurse, how can I not click Like? What can it hurt?” But I don’t click Like, and I feel guilty.
What I want to know is: How does my Like help these children? Are they really out there anxiously waiting for me, a stranger, to Like their Facebook picture? Have their lives as cancer patients come down to this? Where’s Make a Wish? Wouldn’t they rather go to Disney Land, drive a racecar, or meet a teenage popstar? How exactly does my Like benefit them?
Worse yet, what if my Like does harm? It’s easy for anyone to click on a Facebook photograph, and to add it to a file on their computer. Then they can repost it, adding anything to the original post out of context. What if this cute little kid’s picture was used without either his or his parent’s knowledge, and is passing like a virus throughout cyberspace? Worse than that, what if the child is deceased and a family member discovers the picture unexpectedly?
Perhaps I’m reading too much into it. I only wonder, is this a valid use of social media? Then I feel guilty because some little kid with cancer wants my Like, and I won’t give it to him.
A newer version of Internet donations is crowdfunding, and uses social media platforms such as GoFundMe, or GiveForward. As an artist, I’m familiar with crowdfunding. Frequently, artists raise funds for projects through Kickstarter, but patients collecting donations in this manner to pay for medical expenses is a new phenomenon to me.
According to Crowdfunding a Cure, by Alice Park for Time Magazine, December 3, 2012: “Patients and their relatives are raising thousands of dollars to pay for surgeries, cancer treatments, and more.” The article continues to outline the waging of a successful fundraiser through social media contacts via Facebook, Twitter, and email campaigns. This being the case, it’s not unlikely that I’ll soon feel guilty deciding between emails meriting a contribution, and those that do not.
What do you think? Are you with Likes and donations? If this is the future of donations, how will it affect traditional cancer foundations’ collection and distribution of funds?
When a nurse educator makes the bold statement, “The moderately unstable patient is at the highest risk,” I’m interested in knowing why. I’ve thought about this statement ever since.
She explained that the task-oriented nature of ambulatory care units (ACU) is a contributing factor. While patients in the ACU are assessed by their physician or nurse practitioner for treatment readiness, and again assessed by the infusion RN during treatment, the primary goal of these appointments for patients and providers is to administer treatment, complete the appointment, and, for the providers, to move on to the next patient. The ACU patient then goes home to fend for his or herself until the next appointment.
If you spend only a small length of time at the triage nurse’s desk answering phones, the high risks faced by these moderately unstable patients are clear:
Chemotherapy-induced nausea and vomiting (CINV)
Herpes zoster shingles
This list is not comprehensive. Individual risk factors such as living alone or comorbidities also play a role in overall risk factors.
Some risk factors that might occur during the ACU appointment:
Adverse drug reactions
Patient and nurse are unaware that patient is unexpectedly unfit to drive after the appointment
The above factors often occur because the nurse caring for a particular patient is unfamiliar with that patient’s baseline functioning. This puts first-time patients, and nurses new to an established patient, at an increased risk for an unfortunate event.
So, how can ACU nurses protect patients and their nursing license in this fast paced, and rapidly expanding nursing specialty?
First, stop calling your place of work a clinic. The ACU is a specialty care area requiring its own unique set of nursing skills, and should be recognized as such.
Maintain a high level of suspicion. Asking the right question is more important than having all the answers. What you don’t know will harm your patient. One of the most common examples is explaining to a patient how to care for their back pain, only to later discover that the pain is shingles, which were missed because no one asked to see the patient’s back. Other important questions are: “When did you take your (fill in the blank) medication last?” If they haven’t recently, ask, “Why?” because the answer may surprise you. Asking the right questions is an essential part of a solid assessment.
Continuing education is critical to quality patient care. While ACU nursing may seem less demanding than inpatient nursing, it requires the same level of skill and vigilance.
Has this ever happened to you?
A patient arrives for supportive care. On examination, they describe flu-like symptoms, and general malaise. Their blood pressure is low, but since their prescribed treatment is IV fluids for dehydration, you are not surprised. Perhaps they have a fever, but just as likely, they do not. You note that they received chemotherapy earlier in the week. What is your assessment? Do you consider febrile neutropenia?
I remember taking a patient with febrile neutropenia to the emergency department. Besides malaise, one extremity was red, swollen, and hot to touch. The patient’s blood pressure was low, but still within normal limits, and the temperature was normal for age. I had a difficult time convincing the triage nurse that this patient was experiencing an oncological emergency. Fortunately, the emergency room doctor recognized febrile neutropenia, and the patient received appropriate treatment.
The presentation of febrile neutropenia is often insidious, particularly in the outpatient setting during supportive treatment. However, according to the British Journal of Cancer, not only can it quickly escalate into a medical emergency, but can also lead to a reduction of chemotherapy dosage, resulting in decreased survival rates, particularly for breast cancer patients.
Symptoms of febrile neutropenia can be subtle. Often, the only symptom is a fever in a patient at risk, but in severe cases, the patient may be unable to mount a febrile response. Fever is defined as a single temperature of 38.0°C (100.5°F) or a sustained temperature of 38.0°C for over an hour.
So, when should a nurse suspect that an oncology patient has febrile neutropenia?
Common signs and symptoms of infection are:
- Fever over 38.0°C (100.5°F)
- Red, swollen areas of skin, especially on the legs and arms
- Chills or rigor
- Cough or shortness of breath
- Sore throat or sores in mouth
- Loose or liquid stools
- Increased urinary frequency, burning sensation, or bloody urine
- Unusual vaginal drainage or itching
- Flu-like symptoms, such as head and/or body aches, and general fatigue
Any of the above symptoms presenting in an oncology patient require immediate notification of the oncologist or oncology nurse practitioner for laboratory tests, and prophylactic, broad spectrum antibiotics, or antifungals. Hospital admission should be considered based on the patient’s presentation, and risk factors.
Patients and their caregivers must be instructed to call their oncology office immediately, day or night, if these symptoms occur at home.
What barriers have you experienced in recognition or treatment of febrile neutropenia?
While on vacation, my husband and I waited patiently in a restaurant for our food. In contrast with our leisurely pace, the wait staff swarmed almost cartoony in the effort to serve the endless crowd of customers. Clearly, they were short staffed, but not a single server complained.
Since we work in healthcare, my husband and I were sympathetic. Our server earned every bit of his tip.
Likewise, most nurses feel badly when patients wait too long for their care. Delays occur for many reasons: orders that haven’t arrived, lab results that aren’t back, unexpected admissions, critical changes in a patient, short staffing, unavailability of a medication, clerical errors, the list goes on. Because nurses are at the bedside we take on the brunt of the problem, whether or not the patient complains.
Hospitals competing for healthcare dollars compound a nurse’s frustration by intertwining messages of customer service with expectations for patient safety. In the worst cases, under duress, nurses and patients also confuse the two.
Most patients admitted for treatments are already aware of the potential risks: medication errors, hospital-acquired infections, or enduring the wrong procedure.They come to us for treatment because their options are otherwise limited. So, where is the line between giving patients honest answers about their treatment delays, and disclosing that you are short-staffed on the day of this patient’s very first chemotherapy infusion? Do you tell a patient that their treatment is delayed because there’s a mistake on the orders? If so, how do you do so without intensifying their anxiety?
Putting this conundrum into another context, I’m imagining how I’d feel if a flight attendant announced that our flight is delayed because “The captain heard a funny noise during the landing gear check,” instead of simply saying, “Please remain patient. We’ll take off shortly.” Would you want to know, and perhaps exit the plane? Or would you rather not know, trusting the plane wouldn’t take-off if there is an unresolved problem? How much transparency is too much?
Do you feel patients need to know everything happening behind the scenes about their care? If so, how do you engage in this disclosure? Does consideration for colleagues come into play? For example, has a colleague ever blamed you for a delay or mistake in front of a patient?
In the commercial, three guys are standing around a grill, talking about baseball. One of
them quotes a stat.
Another one says, “Really? Are you sure?”
The first guy says, “I’m 99.9 percent sure.”
The third guy says, “Then you don’t know.”
I don’t remember what product was advertised. I remember the commercial because the question of certainty came up regarding a medication order.
I was reviewing the chemotherapy orders:
- Patient name and identifiers: √
- Orders are dated with today’s date: √
- The chemotherapy ordered is appropriate for the patient’s diagnosis: √
- The dosage is correct: Uh oh. Wait a minute.
The total dose (in milligrams) did not equal the product of milligrams times meter squared (m2). The reason was easy to spot, however.
The chemotherapy infusion was to be administered as a continuous infusion over two days. The order read:
xxxx mg of chemo drug X m2 = xxxx mg X 48 hours = total dose of chemo drug
The doctor meant to write:
xxxx mg of chemo drug X m2/every 24 hours = xxxx mg X 48 hours = total dose of chemo drug
I was 99.9 percent sure, which means I wasn’t certain. Unlike quoting baseball stats, there is no room for uncertainty in chemotherapy administration. Interestingly, a pharmacist felt 99.9 percent certainty was good enough and mixed the cassette sitting in front of me.
To be fair, this was not the patient’s first infusion. The pharmacist mixed the chemo based on past orders. Using a previous record to predict a result in the future is the definition of betting, which works in baseball, but not so much when administering chemo.
I called the office where the order originated. The nurse on the other end of the phone pulled up a copy of the order. “Oh, he meant to write every 24 hours. If I write that and fax it back to you, will that work?”
“Yes it would,” I said. “Are you certain?”
“I’m 99.9 percent sure.”
“Certain enough to sign your name to an order?” I asked.
There was a pause, and she said, “I’ll have the doctor take a look, sign it, and fax it back to you.”
I thanked her.
The corrected order, signed by the doctor, arrived on the fax machine. The checklist was successfully completed, and the infusion started.
I was 100 percent certain the infusion was correct.
Do you ever feel like the nurse holding everything up? What’s your opinion? Would you trust your familiarity with a patient’s past orders and go ahead with the infusion? Does your work environment support nurses delaying treatment while verifying orders?
I attended a chemotherapy and biotherapy course. Most of the nurses attending had administered chemotherapy for years, but a group of nurses new to oncology sat at the far end of the table. By the end of the first day of class, none of them had spoken a single word after the morning’s introductions.
Concerned, I approached the instructor. She had noticed their lack of participation too and told me these nurses had expressed feeling overwhelmed by the amount of knowledge needed to safely administer chemotherapy.
I can relate. I recall, years ago as a pediatric ICU nurse, admitting a patient in anticipation of tumor lysis syndrome (TLS). Although chemotherapy certified nurses administered the chemo, I was responsible for the patient’s well-being in the ICU. I asked a lot of questions, probably too many. Weary of me, the oncology nurse coordinator remarked, “You worry too much. It’s just chemo.”
Somewhere between this coordinator’s cavalier attitude and the paralyzing fear of a nurse unfamiliar with oncology is the middle ground for teaching chemotherapy and biotherapy administration. Here are some suggestions:
Fear is the nurse’s friend. Fear makes you look up medications and regimens you are unfamiliar with administering. It makes you ask a more experienced coworker for help. It makes you call the oncologist for clarification of orders when you are unsure, but don’t let it paralyze you. Fear is your friend. Embrace it.
Build on what you already know. Safe administration of all medications, including chemotherapy, is founded on the cornerstone of The Five Rights:
- Right Patient
- Right Medication: In oncology, this includes becoming familiar with the overarching chemotherapy regimen ordered.
- Right Dose
- Right Route
- Right Time
Right Now is what my husband, a hospital pharmacist, jokingly refers to as the “sixth right,” as in, “the doctor wants the chemotherapy given right now.” While promptness is a virtue, chemotherapy administration is similar to teaching a small child to safely cross a street: “Green means go when safe.” Don’t give the chemo until all the double checks are completed to satisfaction.
Any alumni of Texas Tech University Health Sciences Center out there? That’s my painting on page 28 of their alumni magazine, Pulse. I’m not an alumni, but this image accompanied one of the posts I wrote in support of The Winkler County Whistle Blower Nurses, Vickilyn Galle, and Anne Mitchell, who are, for JParadisiRN.com. The editor contacted me for permission to use the image. I am proud to be connected in a tiny way to these two courageous nurses, who put their careers in jeopardy for the protection of patients.
“You’re a nurse. Don’t you have to do what the doctor says?”
I check my iPhone to be sure the year is still 2012. I have not magically transported to a nursing station in the past, say 30 years ago, because it’s been 30 years since someone has asked me this question. I can’t believe the woman on the other end of the phone asks it now.
She answers phones at a doctor’s office. I want to say, “You have to do what the doctor says, because you’re his employee, not me,” but I don’t. She isn’t being rude. She doesn’t understand the role of a Registered Nurse.
“This is an opportunity to educate,” I says to myself. So I give it a go:
“Nurses work with doctors, administering the medications they order to patients. However, it is my job to also prevent patients from harm as a result of their medications. I am calling to tell the doctor I cannot give this patient her medication today, because of her lab values. We have to reschedule the medication, when the lab results improve.”
“But the doctor wants the patient to get the medication today.”
“I know. Giving it today may harm the patient. I’m not calling to ask the doctor if I can give the medication. I’m calling to tell the doctor the infusion will be rescheduled.”
“You do not understand! The doctor wants the patient to get it today.”
“I do understand. It is not safe for the patient.”
“You’re a nurse. Don’t you have to do what the doctor says?”
Sigh. “Is the doctor available? May I speak with him, please?”
I read the physician’s order carefully, looked up the medication in the nurses’ drug book, and consulted with our pharmacist before I gave it. 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.
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.” 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 a medication I am not very familiar with. That’s why I read the order carefully, looked it up, and consulted with our pharmacist. All I can determine about my confusion after giving the dose is that I had a brain fart. Somehow my eyes and my brain disconnected after I gave the medication, and the order unexplainably failed to make sense. That’s the best I can come up with: a brain fart.
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 that 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.
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.
She showed me how to string nursing tasks together like a pearl necklace, and eventually I gained the confidence needed to stay in nursing these past twenty-four 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.