At The Front Lines

Nurses and doctors have died at the front lines. In a war against a dreadful disease. In Ebola-ravaged West Africa, about 60 healthcare workers accounted for 8% of about 1,000 fatalities since the outbreak of the viral hemorrhagic fever six months ago. Two American missionaries who were in the midst of the fight against Ebola in Liberia, a doctor, and a medical hygienist, contracted the disease and have been flown to an Atlanta hospital for treatment.

They are true healthcare heroes, part of those at the front lines who have to contend with poor healthcare infrastructure in Africa, countries further overwhelmed by the virulence of the epidemic.

Dr. Kent Brantly and Nancy Writebol are heroes who lived, thanks to an experimental drug. Dr. Samuel Brisbane, Dr. Sheikh Umar Khan, and Dr. Modupeh Cole, sadly, succumbed to the fight of their lives; they are heroes. Other nameless nurses and healthcare workers have also died as heroes.

Countless other workers carry on in the struggle to survive while working in extreme conditions, in hot protective suits and ill-equipped centers. They are also heroes.

And the brave men and women keep coming back. Monia Sayah, a nurse with Doctors Without Borders, spent 11 weeks in Guinea. Despite the challenges of working in sweltering heat amid a community distrustful of foreigners, she was still willing to return to West Africa.

This Friday, August 8, 2014, the World Health Organization (WHO), finally declared the Ebola outbreak an international healthcare emergency.

And yet, there are more healthcare specialists being deployed by Doctors Without Borders to West Africa. A renewed call to action to help out. This is reminiscent of the firefighters in the 9/11 tragedy who trooped up the World Trade buildings while the panicked masses stormed out.

Some people had blasted the US government for daring to bring the infected missionaries to our shores. Men and women who live in gilded towers shake in their pedicured toes as they questioned why Americans are being subjected to a possible epidemic in our midst. Phobic individuals who could actually afford a "bubble world" propagate fear to protest the transfer of American citizens to a hospital whose staff is well-trained in all matters infectious.

Susan Mitchell Grant, Chief Nursing Officer at Emory Hospital, wrote in her op-ed piece:

“Most importantly, we are caring for these patients because it is the right thing to do. These Americans generously went to Africa on a humanitarian mission to help eradicate a disease that is especially deadly in countries without our healthcare infrastructure. They deserve the same selflessness from us. To refuse to care for these professionals would raise enormous questions about the ethical foundation of our profession. They have a right to come home for their care when it can be done effectively and safely.

As human beings, we all hope that if we were in need of superior health care, our country and its top doctors would help us get better. We can either let our actions be guided by misunderstandings, fear, and self-interest, or we can lead by knowledge, science, and compassion. We can fear, or we can care.”
http://www.washingtonpost.com/posteverything/wp/2014/08/06/im-the-head-nurse-at-emory-this-is-why-we-wanted-to-bring-the-ebola-patients-to-the-u-s/?tid=pm_pop

As a nurse, I understand the moral and ethical responsibility and I take pride in doing the right thing. Even far away from West Africa, healthcare workers everywhere are faced with the unknown. Violent patients, mysterious diseases, uncertain diagnoses, unsafe times.

I have taught about Ebola, smallpox, and pneumonic plague in my Emergency Preparedness classes, so I know how frightening and how challenging these diseases are. As I chanted "Isolation, isolation, isolation", I hoped that the nurses take heed and isolate patients as the need comes up.

A triage nurse is at the front lines. All she can do is to be alert for the signs, to protect herself, the patient, and the community she serves. The nurses, doctors, and other healthcare workers are well-aware of the immense challenges they face, and yet they choose to stay. The courage and the dedication are awe-inspiring.

We are in the business of saving lives. This is what we’ve signed up for. We choose to care.




Addendum: More names were added to honor the sacrifice of those generous souls who passed away and to celebrate those who are still fighting for the people of West Africa.

I am a Nurse

I am a Nurse.

Whether I spend most of the time at the bedside or in front of students, I am still a nurse. Every day, my goal is to influence a nurse to do her very best, as others have done before. I am but one of the fortunate ones given the privilege to serve and make a difference.

Nursing is not for the faint-hearted. It is not for those who expect a calm and uncomplicated journey to retirement. This profession does not promise a day free of stress and challenges, nor full compensation and even appreciation for services rendered.

It is for those men and women who recognize the difference they make for those patients faced with the uncertain and sometimes the inevitable. Their hands are there to support the weak and to provide dignity even during the most unfortunate times.

Nurses have to cheer their patients up, to encourage and nurture them, but sometimes to hold their patients' hands when everything else had failed. They touch lives every time, every single day.

Nursing is for those who share a special place in their hearts for those struggling with pain, those who need a gentle touch, or those who need a willing listener to even the most mundane of complaints.

Nurses accept the call for compassion and grace. The rewards are emotional and spiritual, probably some extra points in heaven.

Nursing makes me a better person. That is why I am still a nurse.

Nursing, Thirty-one Years Ago…

Nursing, thirty-one years ago…

Like a cliché, it seems only like yesterday. But one only has to look at the hands wrinkled by countless handwashings, it orientates me to the fact that “Man, I have been a nurse for a very long time”.

I am a nurse educator, so I welcome new nurses to the fold. I do not get threatened by the generation gap because I am energized by new knowledge and technology. It is an exciting time for a nurse today with advanced medicine, electronic documentation, and nurse empowerment.

But I do feel protective of the special gift that senior /seasoned nurses bring to the table. The experience of thirty-one years has not only made me stronger clinically but has also given me a better perspective of the impact of these nurses on the patients who will only benefit from knowledge earned through hard work and determination.

I truly support the tremendous contribution that the seasoned nurses have given to the profession, and they will play an important role in guiding the new nurses today to realize their full potential. Sadly, there is a sense of "entitlement" on both sides. There should be a better way to bridge the gap between generations. Patients do not really care what the nurse's highest academic degree is as long as they get compassionate care from the nurse.

Having learned from my mistakes, I respect myself even more today. Unencumbered by false modesty, I can proudly and humbly say that I am a damn good nurse, not because of any advanced degree but because I learned patient-centered care long before it became a buzzword.

Thirty-one years ago, I stepped into Coler Memorial Hospital on a cold January morning. Our group of young Filipino nurses newly flown to New York was culture-shocked. I thought that our patients spoke with difficult accents, all slang yet full of grammatical errors. I was convinced that the doctors misspelled their orders and were insulted when we questioned duplicate medications.

Our nursing supervisors towered over us with doubt written on their faces. They probably were wondering how these naïve, young women could stand up to the bossy LPNs who used to rule the roost. We were usurpers to the throne. We didn’t know any better and how dare we come to this place expecting to find our way into their nursing world.

But dared we did. We held our own, learned the slang, and worked our way to earn the respect. Not only by our supervisors but mostly by our patients who delighted in our enthusiasm and compassion. My supervisor Ms. Covington used to challenge me to go beyond my comfort zone. Somehow the patients who were abandoned in our care became our own grandparents. We held their hands and listened to their nostalgic remembrances of lives spent caring for their loved ones. We dried their tears just as we dried our own tears of loneliness for families left behind in the Philippines.

“You’re my favorite, Cerrudo.”, one of the chronic dialysis patients rewarded me with this one day. I quickly bragged to my friends about how I finally won over the most difficult patient in the unit. My friends did not even give me time to relish my victory; Sessa told them the same thing last week. I was Sessa’s favorite at that time because I had given her an extra ice cream.

My first unit was the Medical ICU. One part was the chronic ventilator unit where patients remained attached to ventilators; we became experts with trache care, suctioning, and communicating with our patients the best way we could.

Mr. Alston used to clench his jaw and blink his eyes three times if he wanted things done. One bedridden patient could only give a lop-sided smile if we positioned him right. Mrs. Richards frowned if we didn’t tuck her bedsheets right and gave us thumbs up when we did. Young Alli smiled at everything we did for her, as we wiped the drool on her neck, cleaned her trache, and brushed the tangles on her hair. I massaged the contracted feet of my ALS patient who continued to have a vibrant mind while his body wasted away.

The patients were our family… and every time one passed away, we cried with the rest of the staff. Most of the time, the nurses were the only ones who grieved their passing because the families had long abandoned them.

Two years later, I was promoted to a head nurse position in a general med-surg unit with 40 patients. I took my share of duties as part of functional nursing. There was usually one medication nurse who started and finished the day by giving meds with printed medication cards; from the back to the front of the unit where meds were given through gastrostomy tubes. Another nurse and I worked with a group of two nurses’ aides as we fed, bathed, exercised, and walked the patients. At 3 p.m., we started our narrative charting, our notes the same every day except for the vital signs and whether patients had bowel movements or not.

Thankfully, the technology and staffing got much better. The suction EKG bulbs were horrendous and left their distinct marks on our patients’ frail chests, the yucky gel too difficult to clean off. The manual mercury sphygmomanometer is now a thing of the past, now it’s just a button to push on the automatic cardiac monitor and we get veritable data of riches: BP, HR, oxygen saturation, MAP, endtidal CO2.

Gone are the medication cards, those 2-by-2 index cards with hand-written transcription of medication orders, and the dosage times written in black, green, and red. Gone are the Kardexes with nursing diagnoses that never changed. Gone are the hand-written doctor’s orders that were meant to confuse.

Back then, I was new, nervous, and unsure of my place in this world. Thirty-one years after I first stepped on American soil, I am still convinced that Nursing has given me valuable lessons along the way. That the rewards of nursing far exceed the material blessings. The compassion I have shown my patients was the greatest gift I could have given them.

And now, as a clinical adjunct professor and a clinical nurse specialist, I try to impress my students and nurses to remember why they chose this profession. I celebrate their need to explore new boundaries and to push the envelope but I remind them, as well as the seasoned nurses, to embrace their similarities and learn from each other.

When the patient needs a hand, it doesn’t matter if the hand that is offered is that of a baby boomer or a millennial. At the end of the day, the patients will remember a nurse who gave them the respect that they deserve.

Through the nurses I teach, I wish that a compassionate nurse lives on.

"My Firsts... as a Nurse in the US"- http://jcerrudocreations.blogspot.com/2012/03/my-firsts-as-nurse-in-us.html

“You must be kidding!!!!"

“You must be kidding!!!!“

The ER is a very funny place. There are things here that defy explanations and stories that are just too crazy to be true. But if it happened in the ER, it must be true. We don't make these things up.


In a case worthy of “House”, some astute paramedics finally solved a baffling case of syncope.

For 3 consecutive nights at around 9pm, EMS had received a call from a wife that her husband had “fainted”. The husband was often hypotensive but quickly recovered in the ER after some IV fluids. All tests came out negative and the patient was discharged in the morning, only to come back the same night. The wife stated that her husband had no physical complaints all throughout the day, but then she would find him weak and faint at night time.

On the fourth call, the EMS crew noticed the patient’s bedside table. There were two tubes of medications side by side that the husband uses just before he goes to bed: one nitroglycerin ointment for the patch and one hemorrhoid ointment. One medication patch on his heart to make the heart blood vessels dilate, and one medication to relieve the pain and to reduce the swelling of the hemorrhoids.

It turns out that the patient mistakenly applies his nitro ointment to his hemorrhoids every night.

High-tech and TMI (Too Much Information) s0metimes provide an awkward scene at Triage. And the nurse gets uncomfortable being shown a "selfie" without any warning. On the other hand, it is better to look at an image than having to see it in real life.

Spell Check please….

I admit I’m a spelling snob; it’s a genetic mishap, a flaw in my character. Please forgive me, but it is too embarrassing to sit through a chart review with other departments having to defend sloppy documentation.

I’m not talking about common errors like lose and loose, your and you’re, break and brake, and there and their. Highly-educated people sometimes slip up with these mistakes. I can understand a typo here and there, but here are some egregious (and funny) spelling errors.

Reading some patient charts can be excruciating sometimes.

Deployed- “The airbag should have diploid.”
Phlegm- “The patient coughed up green flem”
Purulent – “The wound has a pussy discharge” (not an actual misspelling, but just sounds wrong)
Circumcised- “He was not circussized”.
Rapport- “The patient maintains good rappore with family.”
Bizarre- “Wife said that patient was acting bazaar.”
Intubated- “The patient was incubated by the ED team.”
Gout- “The patient complained of pains from her goat”

According to the Thesaurus, a typo is a mistake in printed matter resulting from mechanical failures of some kind. Typos are caused by fast and fat fingers. No, these are not typos. The last time I looked at the keyboard, “t” is two rows higher than “c” and “a” is way over on the left side of “u”.

EMS Narrative history text: (written in capital letters)
34 MALE AMBULATORY @ AMBULANCE. HE WAS @ HIS WORKPLACE HAVING DRINKS, BEERS, WHEN HIS HORSE BEGAN TO BREED PROFUSELY. IT STOPPED. HE IS INTOX. HIS GIRLFRIEND IS CONVINCING HIM TO GET EVALUATED @ HOSPITAL. HE DOESN’T WANT TO BECAUSE IT STOPPED. TXP BECAUSE HE IS INT. ON AND NOT IN A POSITION TO RMA. HE WAS@HOSPITAL LASTWEEK, AWAITING APPT. 14TH ENT.

The patient turned out to have a Nose Bleed. I wonder where the "Horse Breed" came from.



Thank you to Kirill, Tina and Janice for the material.

My Emergency Nurse Hero

My emergency nurse hero is Jennifer Whalen.

In the clinical setting, she was an ER nurse par excellence. Her intelligence and compassion shone through in her work. A self-confessed Type A personality, she quickly became the epitome of what an ER nurse should be: smart, focused, driven, determined, and with a kick-ass attitude with the goal of giving her patient the best care ever.

And then she became the patient. With the shocking news of her Stage 4 pancreatic cancer, Jennifer rallied her friends and her co-workers as her Hermione army; to support and to cheer her as she tried to apply that same determination in the fight of her life.

She was incredibly strong and amazingly positive. In my work as a nurse, I have seen extraordinary acts of courage and heroism around me. But I have never seen anyone as inspirational as Jennifer.

After the diagnosis of the Big C, she used her second chances. To mobilize her army of supporters. To reconnect with old friends. To mend broken fences. To share her incredible optimism. To find love again.

Here was a woman who bared her soul and selflessly shared her journey with the rest of us. She left her own legacy of strength and fortitude. And she taught us all valuable lessons in life. She was a master educator and her fight for her life was her lesson plan.

Jen passed away today, Dec, 21, 2013, finally pain-free, in her sleep surrounded by her loving family. In the hospice where she finally accepted the path she was to take. I wish that there was no doubt in her heart of how she had forever changed us, that she would know that she is much loved and admired. Not just by her own family and close friends, but even by those who had seen from afar how special she truly is. In her last moments, she was not alone.

We are forever changed. Jen had left her footprints in our hearts. She had been courageous more than I can ever hope to be. Among the hardworking nurses of Elmhurst ED, she had excelled.

Jennifer Whalen, RN, BSN, CEN, she was a gift to all she touched.

Happiness... to an ER Nurse

An ER nurse is of a special breed. Our sense of humor is off-beat and off-centric to most, especially to those not in the nursing profession. But even among other nurses, we have acquired an unfair reputation; we are branded as aggressive and rude, and most in-patient nurses regard as too cold and not as caring.

Hey missy, if you have to deal with the never-ending traffic and the constant stressors, you probably would have run far far away like Speedy Gonzalez. Just try to spend an hour in our shoes.

Maybe we are crazy, maybe we are just adrenaline-junkies, but we have learned to appreciate the little things that make life in the ER not just tolerable but have actually induced a chuckle or two. To survive, we found delight in the simple pleasures of ER life.

Tongue-in-cheek humor; anything to brighten the day and to lighten the load.

Happiness… to an ER nurse:

1. Being relieved on time because your relief found parking on time.

2. Having the right team with you, although you were short-staffed.

3. Receiving a thank you from that difficult patient who almost made you forget you’re a nurse.

4. Saving a life because you dared to question a wrong order.

5. Seeing the hallway filled with stretchers; that means the ED is empty.

6. Getting patients with great veins.

7. Finishing the shift without being cursed, hit at or hit on.

8. Getting a typed list of medications at triage instead of two bagful of medications that needed to be sorted out.

9. Changing the child’s pain scale from 10 to 0, and finally getting a reprieve from the demanding parents.

10. Connecting the dots on a puzzling case in the ED and coming up with the presumptive diagnosis before the doctor did.

11. Witnessing the facial droop disappear after the thrombolytic did its magic.

12. Catching a baby before it hits the floor, especially after the mother initially denied she’s pregnant.

http://filipinonurses.org/index.php/2013/09/19420/

Colorful World of Patients

It is a colorful world of patients out there. Maybe it is man’s attempt to provide some levity in an otherwise depressing state of being a patient.

Colorful disease names were used, partly to describe some of the symptoms in yellow fever, scarlet fever, and blackwater fever.

If you make the horrible mistake of running intravenous Vancomycin too fast, you might as well prepare yourself for the rush of red on your patient's face. Experience the "Red Man syndrome". Of course, you would be turning red too as you realize that you just made a major boo-boo.



“Calming fabric colors, patterns and textures create an ambiance much desired in health-care settings, from surgery waiting rooms to newborn intensive care to psych units. Ever since a 1985 study that showed that a specific color, Baker-Miller pink, reduced aggression among prison inmates and patients in mental-health institutions, designers have been seeking a look that soothes and subdues the stressed.”
http://fabricarchitecturemag.com/articles/0108_maside1_color.html




And that is why, we'll never ever find a hospital room painted in vivid, vibrant colors. Just think of how the color red enrages a bull. Ole!





"Chromhidrosis is an extremely rare condition that causes a person to excrete colored sweat. It can come from either of the two types of sweat glands, but the common thread is that the colored sweat is produced in the gland. Apocrine chromhidrosis results in only yellow, green, blue, black and brown sweat. "
http://health.howstuffworks.com/skin-care/problems/medical/chromhidrosis.htm

The nurse who sweated red in the above article was not particularly stressed out on the job, but the culprit was discovered to be a packaged food that contained tomato powder and paprika..



I never knew the color "amber" until I got into nursing school. Since then, I've seen a rainbow of urine colors.

Red or pink urine
• Blood- UTIs, enlarged prostate, cancerous and noncancerous tumors, kidney cysts, long-distance running, and kidney or bladder stones
• Foods: Beets, blackberries, and rhubarb
• Medications: Rifampine, Phenazopyridine (Pyridium), and laxatives containing senna
• Toxins- Chronic lead or mercury poisoning


Orange urine
• Medications: anti-inflammatory drug sulfasalazine (Azulfidine), Phenazopyridine (Pyridium), some laxatives, and certain chemo drugs
• Medical conditions: Liver or bile duct diseases, and dehydration

Dark-brown or tea-colored urine
• Foods: Fava beans, rhubarb, or aloe
• Medications: antimalarial drugs, chloroquine and primaquine, metronidazole, nitrofurantoin, laxatives containing cascara or senna, and methocarbamol
• Medical conditions: Liver and kidney disorders

Blue or green urine
• Dyes: Brightly colored food dyes, diagnostic dyes used for kidney and bladder function tests
• Medical conditions: Familial hypercalcemia, a rare inherited disorder, sometimes called blue diaper syndrome and urinary tract infections caused by pseudomonas bacteria.
http://www.mayoclinic.com/health/urine-color/DS01026/DSECTION=causes

“Another cause of blue-green urine is Methylene Blue which was till now known mainly as a dye but is now entering into the field of cardiac surgery and critical care as a very important therapeutic agent with diverse applications. The evidence for its use in methemoglobinemia is well established but that for its use in vasoplegia, septic shock, hepatopulmonary syndrome, malaria, ifosfamide neurotoxicity etc is limited but promising and commands more research.”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3087269/

“The procedure of intra-articular injection of methylene blue is an easy and safe way to identify disruption of the joint capsule and may facilitate early intervention. Intra-articular injection of methylene blue that demonstrates extravasation of dye from the wound site is highly suggestive for open joint injury.”
http://emedicine.medscape.com/article/114453-overview


Who says Nursing is not a colorful profession?