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clinical area day in and day out. What’
s more, it should be discussed,
debated
and rewritten by the nurses in that
area, before being reintroduced to
committee.  Missing this step is lethal.  
Recently, I interviewed a nurse, who
with over 23 years of service to a local
hospital, had never served on a
committee.  With over 51,400 hours of
training and experience, she had
never been asked, never learned what
it took to contribute to the resolution of
a system problem.  As nurses, we are
responsible for the state of our
practices.  Your voice at the table is
important, no, VITAL to the facility you
call home.  Speak to your supervisor,
see what committee opportunities exist
where you could make a difference.  If
you are a supervisor, make it your
business to staff up on days when a
nurse has a committee obligation.  
Your contribution makes an incredible
difference, ask any patient.
Making A Difference
Standing on the scales, Maria was
displeased with her weight.  This
pregnancy had not gone as smoothly
as the last.  Twice she had been put
back on bed rest, protein was spilling
in her urine which started about the
same time all this swelling became
bad.  Now, to stave off even more
problems, she was being admitted to
have her little girl early.  She had done
her reading as well as taken the
classes.  She was prepared for this.  
What she had not prepared for was
what came next.  Her IV pump looked
new but it kept beeping.  Nothing her
nurse did would satisfy the pump’s
constant complaining beep.  With an
apology for the noise, the still beeping
pump was pushed down the hall for
replacement.  At first, Maria felt flushed
as the 40 grams of Magnesium Sulfate
ran quickly into her vein; then so weak,
nauseated, horrible nausea.  Then she
couldn’t breathe.
Maria’s code was called 40 minutes
later.  Like 7 others in the AWOHNN
paper, she did not make it, nor did her
baby.  Simpson and Knox, MCN  
May/June 2004  
As a nurse, you have seen numerous
IV drips get away and run in faster
than expected.  The patient shifts and
the catheter moves in the vein. No
longer obstructed, the fluid is free to
flow.  The tubing came out of the
machine when the patient moved, etc.  
We know this. And yet, every day in
hospitals all across the country,
medications come from the pharmacy,
that if given faster than recommended,
will kill the patient.  Never hang a lethal
dose of medication over your patient.  
It is a Damocles Sword set to take the
life of your patient, destroy your career
and haunt your sleep forever.  
Under representation of nurses in the
hospital policy process takes more
lives than anyone can imagine.  Having
one nurse at the table when a policy is
written is a start.  But it darn well
should be a nurse that works in that
Antimicrobial Wipes-NOT!
According to researchers at Welsh
School of Pharmacy at Cardiff
University, the wipes actually trapped
bacteria and transferred them to other
surfaces.


Tendon Rupture
The FDA has mandated that a class of
antibiotics, fluoqinolones (i.e. Cipro)  
have a black box warning attached to
them.  The alert is to warn of the
increased risk of tendonitis and risk of
tendon rupture with their use.  In some
cases, the patients Achilles tendon
rupture occurred months after
treatment.  Patients taking a
fluorquinolone should stop immediately
for any sign of tendon pain.
French Better at Trauma Codes
French trauma protocols take into account that asystole in a trauma victim can be caused by hypoxia or hypovolemia.  Aggressive protocols using epinephrine result in a 30% survival rate to admission.
The take home lesson: asystole in a trauma victim? Switch to an ACLS Code, not a toe tag.
http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200710000-00002.htm;jsessionid=LvJLjGPKBMJl2DMpT2vGz11sF1jqvTMhGbfR3Sn58lCBSDBlYmyV!-1052912739!181195629!8091!-1
CRITICAL DIFFERENCE INC.
PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
12/29/08   Issue LVII  850-477-1234   Toll Free 866-CDI-NURS
CRITICAL DIFFERENCE INC.
PROFESIONAL FREEDOM THROUGH INDEPENDENCE
03/9/09   Issue LVIII  850-477-1234
Making a Difference
Madoff’s crew did it, Price Waterhouse did it,
and so many do it every day: give lip service
to setting standards. Every day, all around
us, in every walk of life, basic standards are
being breached.  The impact of this erosion
is evident everywhere: in how our loved ones
are cared for in the hospital to how many
years we will have to work to make up for
losses in the retirement account. There is a
way this can be turned around.  
Unfortunately it begins with each and every
one of us.  We have to establish and become
responsible for a set of minimum standards.  
You know the minimum standards of patient
care.  When they are breached you feel it in
every fiber of your being. Stop it there.  If you
are not convinced your patient understands
his discharge instructions, even when the
rest of the place is falling apart, stop that
patient from getting discharged.  It is far
better to hold up the process than to put
even one patient in a hundred at risk.  You
know this.  Stop for just a moment and think
of areas in your practice that you know are
not as they should be.  Plant your feet solidly
on the ground and promise yourself that you
are not going to let that happen again. It
takes just one person to bring standards
back to a procedure, problem or work area.
Work quality is set by each one of us.  We
are always looking at our colleagues to see
how they handle a situation, what technical
information they use or just how each
prioritizes.  Drucker's research on
management found that just by changing one
person's quality of work, the entire group
improved.  You are that person.  Set
personal standards of care and keep them.   
The world and each of us will be  
better for it.
47,000
The number of lives that could be saved per year, with
a change of approach in treating Diabetes.  By
controlling glucose levels early (starting with
prediabetic levels) as well as using drugs to reduce
high cholesterol, triglycerides, and blood pressure, the
study showed we can still the hand of the grim reaper
by 13% of the estimated 243,000 that will die of
Diabetes this year.  Dr. Weiss of NYU’s Tisch Hospital
says the time to treat the disease is before the hammer
of the full disease hits because a lot of damage is
already done.
http://www.msnbc.msn.com/id/28392976/?
pg=7#Health_PVN_Breakthrough2008

More Volume, More Nodes
Surgeons, who do higher volumes of
gastric and pancreatic cancer surgery
at comprehensive cancer centers,
check more nodes than at other
hospitals.  
K. Bilmoria, Archives of Surgery
The more you know about cancer, the
more you appreciate the value of
caution.
CRITICAL DIFFERENCE INC.
PROFESIONAL FREEDOM THROUGH INDEPENDENCE
06/29/09   Issue LVIII  850-477-1234
CRITICAL DIFFERENCE INC.
PROFESIONAL FREEDOM THROUGH INDEPENDENCE
03/9/09   Issue LVIII  850-477-1234
CRITICAL DIFFERENCE INC.
PROFESIONAL FREEDOM THROUGH INDEPENDENCE
03/9/09   Issue LVIII  850-477-1234
Making a Difference
The report reviews the “detainees”
comments: “I had blinders on; I was blind to
all outside input.”  “After a short time I was
emotionally, spiritually and physically
exhausted.”  “Immediately, I was made fearful,
anxious, and totally intimidated.” “The
nightmares continued for months,” “I couldn’t
stop shaking,”
“I was in a self preservation state.”  Were
these interviews done at Abu Ghraib,
possibly another report by Amnesty
International?  No.  They are comments made
by smart young nurses who had graduated
from 4 year nursing programs talking about
the hell they went through in their first 5
months on the job. JONA Vol. 31, No. 9
The class now graduating numbers over 200
locally.  The anxiety they will collectively feel
would power Pixar’s Monster Inc. power grid
for years.  The studies revealed almost the
same pattern worldwide.  First, the grads go
through what is universally described as a
self absorption phase.  They are totally
clueless, task oriented, panic ridden, and feel
exiled for 2 months… “I just wanted to get
through the shift without killing anyone.”  
Slowly this would progress to a period when
they felt more like nurses than students.  In
this phase, the grads related they were
spent, still feared all physicians, and had
grown weary of yet another example of what
is done vs. what they had been taught.  They
are coming to terms with the realities of the
role.  They accept their inadequacies and
imperfections.  At 5 months, they start the
incredibly important step of critical thinking.  
Up to this point they would enter a situation
and not necessarily know what they were
dealing with.  Now able to appraise a
situation, they can tackle the correct problem
first.  Clinical judgment starts to gel and they
are less likely to compromise patient care to
maintain the unit’s status quo.
What can you do?
First, understand just how little they
know about the job, the hospital and
what their role is.  Then do what you
can to let them know you are there to
help.  Check on them often and
remember to encourage them to
breathe.  In a commencement speech
recently Michelle Obama said that we
need to reach back and pull someone
less fortunate up with us.  This has
been done for each of us  and we will
remember those nurses forever.  It’s
payback time.
 Make a difference.
30%
The percent of nurses that quit their
first job within the first year. Bowles,
Cheryl et al Survey of Nurses’
Perceptions, 2005 Lippinoctt Williams
and Wilkins, Inc.

$40,000
Cost to the hospital for hiring and
orientation expenses for a nurse with
less
than 1 year tenure. Beecroft,
Kunzman, &Kroek 2001.
57%
The percent of nurses that quit their
first job within the second year.
Bowles, Cheryl et al Survey of Nurses’
Perceptions, 2005 Lippinoctt Williams
and Wilkins, Inc.

Swine Flu Info.
http://www.cdc.gov/h1n1flu/update.htm
CYP3A Does What?
A study in the New England
Journal of Medicine links
patients concurrent use of
erythromycin and other drugs
that inhibit the enzyme CYP3A,
such as calcium channel
blockers, Nizoral, Tagamet, and
grapefruit juice, as 5 times more
likely to experience sudden
death then patients not on a
CYP3A inhibitor.  The reason
appears to be that erythromycin
taken orally causes prolonged
cardiac repolarization.  It needs  
CYP3A for its metabolization.  
Medications that block the
enzyme further increases the
level of   erythromycin in the
system.
Newsletters from 6/29/09, 3/9/09,12/29/08,
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