Thanks for being a nurse

Douglas Terrell  RN
CEO CDI
© Critical Difference Inc. 2007
10/1/07, 6/24/07,3/19/07
Newsletter
CRITICAL DIFFERENCE INC.
PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
3/19/07   Issue L  850-477-1234   Toll Free 866-CDI-NURSE
Making A Difference
Imagine what has been offered the
Grim Reaper in return for a few more
days of life.  Unimagined riches, power
of every type and repeated over
thousands of lifetimes.  What is it
worth to know how to cheat death
and keep your immortal soul?...Plenty.  
It’s a big deal when one finds out how
to make another organism live 50%
longer.  
Endocrinology 147 (12) 5690-
5698 reports that by manipulating one
chemical they were able to not only
prolong life span, but during the extra
time on earth, the animal looks and
acts young.  The chemical…Insulin.  We
know Insulin because of the
devastation that occurs when we can’t
manufacture or utilize it.  What
happens when it is too abundant is
linked, as well, to how long we live.  
Foods that are converted into sugar in
our systems push up the Insulin serum
levels.  We already know most of
them, flour, rice, corn, potatoes, sugar
and even high caloric intake.  We were
not designed to eat big meals, but
rather many, snack sized meals.  
Dump a Twinkie in our system and
Insulin is on the way, splitting LDL
molecules (bad cholesterol) into artery
penetrating bullets.  Not just in the
heart and brain, but the entire body’s
vascular system.  Insulin is also
empowered to lay down fat stores.   
Ignore insulin and we invite death
ever closer to our door.    Humans are
bad at this kind of dietary change.  So
if you can convince one person,
besides yourself, the two of you will
out live your mortgage, car payments,
debt collectors, the whole shooting
match.  Money put into investments
today will look a lot better if you can
save for 40 years instead of 20.  Every
time you are able to avoid one of
these foods, you prolong your life.  
Convince another to do the same and
you have made an incredible impact in
someone else’s life.  Better yet, when
the hand of death comes to rest on
your shoulder, you will have had time
to figure out something clever to tell
the reaper.  

28,000
The number of patients that die each
year from central line contamination.  
New England Journal of Medicine reports
that there was a median
contamination rate of 2.7 infections
per 1,000 days patients had the
central line in place.  A study in
Michigan almost wiped out all central
line infections by insisting staff and
M.D.s wash their hands, don
protective clothing and disinfect the
catheter site. The study also advised
avoid using groin site insertions
whenever possible.
Small Study-Big Change
Depression is a diagnosis that carries
many issues.  Insurance companies
poorly reimburse for inpatient
treatment.  
The length of time it takes for the
medication to make a difference is
measured in weeks, during which time
the loss of productivity is staggering.  
So, news that a single dose of the
anesthetic ketamine  (Ketalar) can
drastically improve symptoms in 2
hours is huge news.  
Arch Gen
Psychiatry
63 (8),856 reports 71% of
those receiving the med showed
improvement within one day. None of
the patients receiving a placebo
injection showed improvement.
95%
The volume of blood reduced off a  
sharp object passed through a
double glove.  According to AORN, the
safety afforded by double gloving is
well worth the effort.
89%
The percentage of intubated patients
that had gastric enzyme pepsin
positive
aspiration during their ICU stay.  The
article in
Crit Care Med
2006:34(4):1007-15 dispels any
notion that an ET cuff protects your
patient from aspiration during tube
feeding.  In the study, half of the
patients had pneumonia after their
fourth day in the ICU.  When your
patient is getting tube feedings, if at
all possible, get their head of the bed
up 30 degrees.  Check for residual
volumes q 4 hours, and if appreciable,
check with the doctor about a
prokinetic agent to aid in gastric
emptying.
                  CRITICAL DIFFERENCE INC.
     PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
  6/24/07   Issue LI  850-477-1234   Toll Free 866-CDI-NURSE
Making A Difference
In a microsecond, you regret what you
just said.  In fact, what was said just
made things go downhill fast.  There is
not a nurse alive that hasn’t at one
time or another been racing to get to
their next patient and been confronted
by a patient’s family member,
physician, or co-worker and said
something they regret.  How is it we
can hone our skills to respond to a
code perfectly, but can’t say the right
thing in a pinch?  Given a moment, we
would have been able to come up with
the perfect answer or response.  
Somehow, though, those words are
nowhere around when you need
them.  What to do?  First, buy yourself
some time.  Use your considerable
skills to get a feel for what is going on
and then make a response.  If a
patient or patient’s family member is
upset, you might apologize that there
is a problem and go to the patient’s
room to evaluate the situation.  Most
of the time, pausing before addressing
the complaint will better prepare your
response.  Politicians are frequently
cornered by pointed questions.    
Reporters asking questions in a way
that no matter what their response
will cost him his job, or worse.  
Politicians simply answer with a
practiced, prepared response.  
Knowing it would be needed
eventuality, it is neatly packaged,
memorized and can be given slowly,
buying them a moment to organize
their thoughts.  
They know the questioner will any
second
rephrase the question and come at
them again.   So, next time someone is
bowed up in front of you about a
problem, even if it is one you are
familiar with, buy yourself some time.
Let him know you are concerned as
well and will find out what is going on
and get back with him immediately.  
The bottom line is no other profession
trusts themselves to say the perfect
thing immediately.  We shouldn’t
either.  Review situations you are
likely to confront on a daily basis.  
Memorize something that will be your
response in the face of a flash
question, something that shows you
care and aren’t blowing them off.  It
can be as simple as asking them to go
with you to find the answer. Or ask
them something about what they just
stated.  Remember, it is not just what
you say, but what your body says.  
Smiling inappropriately, rolling your
eyes, etc. will negate even the most
well thought out response.  We work
in a very tense environment. Our
patient’s are totally out of their
element, physically un-comfortable and
have unmet
expectations for staffing and services.
Over 80% of them enter the hospital
feeling that you do care about them.  
One careless comment, no matter how
innocent, can destroy all the work
nursing has done for this patient to
date.  Practice your prepared
responses.  Purposely buy yourself a
moment of time for a real considered
response.  Knowing how to respond
correctly will make your life easier, and
make a difference to those around you
in the process.
40%
The percentage of times physicians
failed to review the number of tablets
and the timing of the doses when
giving out prescriptions to a patient.  
Arch Intern Med, 166(17),1855
The Pill vs Patch
Folks need to be made aware that
those on the patch may be at twice
the risk of deep vein thrombosis than
those on oral contraceptives.
AWOHHN
Lifeline
, 10(3), 250

13%
The percentage increase for infection
for each unit of blood infused.
Crit Care Med 2006;34(6):1602-7
Protein In Your Urine?
Sorry to hear it.  Besides having to
worry about neprhosis, you can add
stroke and coronary heart disease to
the list. According to researchers in
Honolulu, protienurea is independently
predictive of stroke and CHD.  
Arch
Intern Med
2006; 166(8):884-9

114,380
The number of deaths between 1990
and 2001 that listed pressure ulcers
as one of the causes of death.  
Skin
Wound Care
2001;14(4):208-15.  It
took 2 hours for irreversible damage
to tissues to begin when subjected to
continuous pressure.  
RN Vol.70,No 2.  
So if your patient is at risk, a change in
position every 2 hours just changes
what tissue will start dying next.  
Think q 1 hour position changes if you
are really serious about your patient’s
care.
Incretin Effect
Diabetics have dramatically decreased
plasma levels of one of the gut
hormones due to none other than
DPP4, which inactivates the incretin
hormones.  Enter Januvia which
inhibits DPP4, (approved in 2006 by
FDA for Type 2 diabetics), restoring
one of the body’s few mechanisms of
glucose control.
                               CRITICAL DIFFERENCE INC.
       PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
  10/1/07   Issue LII  850-477-1234   Toll Free 866-CDI-NURSE
Making A Difference
History is filled with people who have
survived terrible reversals, torture,
and privation.  When asked how they
had survived, they related why they
had to live.  The search for that why is
the meaning of life.  In nursing, we
see people that have hung on to life
by a thread until a loved one arrived,
and then slipped the bonds of this
life.  These people had a reason to
hang on, something had meaning for
them.  Equally, we have seen
someone retire, and very shortly
thereafter, die.  Freud felt life was the
pursuit of pleasure, Adler felt it was
power, Frankl argued it was meaning.  
He believed the two deepest sources
of meaning were from love and work.   
Looking around, one can find little
rhyme or reason for who people fell in
love with (really, what were they
thinking?).  Let us look at work.  In
nursing, we see life’s entire
continuum.  We are there when the
infant takes his first breath and his
grandparent takes their last.  We are
there to guide folks through some of
the worst moments of their lives.  
Nurses, by their very nature, are the
observers of  life.  We know when the
heart rhythm takes a wrong turn or a
wound is not healing right.  We notice
when someone is moving further into
depression, or when an infant’s nares
start to flare. These skills are not
easily obtained and do make a
difference.
There are few professions that mix art
and science as does nursing.  It is as
rich a source of meaning as one can
find.  How is it, then, that so many
nurses are suffering in their jobs?  
Humans designed as hunter gatherers
were able to meet their caloric and
shelter needs in about 4 hours a day.  
We have somehow gotten the notion
that 12.5 hours a day is an acceptable
work day.  We have to give it up.  I
don’t mean to say that we go to 4
hour shifts (though the French did talk
about it).  After all, Neanderthals
never had to pay for a plasma screen
TV.
When you hear the grass is greener
on the other side of the fence,
remember, the most common reason
the grass is greener is that someone
on that
side of the fence is working her fingers
to the bone to make sure it’s
watered.  If you find yourself in a work
area that doesn’t sustain your
willingness to serve, it may be time to
move on.  All of nursing is not made
the same, and we are not made for all
the profession has to offer.  Before
leaving nursing, jump some fences,
see what’s out there.  Finding
meaning in your life is heavily based
on finding meaning in your work.   It’s
just too important to ignore.  You are
too important to nursing
4,000 Dead and Counting
Researchers feel that roughly 4,000 of
the recorded 5,000 asthma related
deaths were from long-acting β-
agonists (Serevent). Salpeter SR et. Al.
Ann Intern Med 2006;144(12):904-12.
Instead of pulling the med from the
market, they have issued a black box
warning,  “To use as a last recourse
only.”  Result, nothing.  Prescriptions
are still being written at the same
speed.  Look for another 4,000 to die
this year.  Know someone with asthma
on a β-agonist?  Let them know it’s
time to switch meds or get better life
insurance.
Are You Sick and Tired?
Well it may be Hepatitis B.  If so, the
FDA just approved Tyzeka. This is a
new antiviral using a new molecular
entity to suppress the virus and it’s
inflammation of the liver.  www.fda.gov
Increase Patient Satisfaction…
reduce the number of missed call
lights, and cut the number of patient
falls. Easy according to C. Meade with
the Alliance for Health Care Research.  
Do nursing rounds.  The bottom line “A
patient’s perception of the quality of
nursing care largely depends on the
nurse’s ability to meet the patient’s
needs.” Giving your nurses enough
time to do hourly nursing rounds
allows them to catch patient needs
before they become patient issues.  
Percentage of excellent ratings before
the study 38.2, after doing rounds
80.1.
Reduction of falls 60%.   You do make
a difference, but if you want to make a
bigger difference,
do rounds hourly.