For every nurse who had to go through the student lab multiple times until you learned how to open a sterile package without contaminating it, you'll appreciate this description  of a program to teach residents how to do procedures, What is innovative in academic medicine has been a standard of nursing education for almost ever, If you're not familiar, the Web M&M  site is great - it's Morbidity and Mortality Rounds on the Web - where professionals share mistakes to teach others. You can sign up for a regular e-mail that will let you know when the cases are updated. I've used this site for staff education - it covers all practice areas and I have learned a lot there.

From the same Web site, here is a great case study in which the physician is reprimanded for unprofessional behavior toward a nurse calling with a concern about an opioid overdose, Let's hope the physicians are reading this, too. What's your worst experience with a physician where you had to go to bat for your patient? How does your organization rate in holding physicians accountable for unacceptable behavior? One of my proudest moments was when I physically blocked a physician from getting close enough to a woman to intubate her. She said she never wanted to be on a ventilator again, her daughters agreed, and she had the original copy of her living will and durable power of attorney, naming one of the daughters. The attending agreed to her wishes, having known her forever. The per diem ED doc made all kinds of threats about "reporting" me - and I told him to go ahead, which made him even more angry. The patient held my hand tightly during all this and whispered, "Bless you," in the middle of this fight. That's when I knew I owed her everything I had to prevent the intubation she didn't want. She died peacefully, without pain, with her family by her side three hours later. Fortunately, we never saw that doc in the department again.

Here's a blog  from a woman practicing as a hospitalist. She's sharing her weight loss journey, and her post from April 27  could have been written by 10 nurses I know. It's a great place to get ideas for your own stories in the comments! I think I would love to work with her. What do you think?

And if you need something to perk up your days, check out Best Inspiration. Here, you'll find quotes, resources, books and all sorts of other inspiring things - and the opportunity to sign up for a daily quote to start your day off right.

Till next time ~

So, what does Nurses' Week mean to you? Depending on where you are in your nursing career and your current job, it can be a time of celebration or the marker of another frustrating year. If it's the latter, remember you have the power to change that - one of the beauties of being a nurse. You're never really stuck in a dead-end job.

I will be "speaking" at the American Association of Critical-Care Nurses National Teaching Institute  this week, live via Webcast. The convention is in Chicago, and I will be at Atrium Medical Corporation's headquarters in New Hampshire, connected to their booth in the exhibit hall. I'll be doing presentations on Tuesday the 6^th and Wednesday the 7^th, so if you're going to or are at the meeting, stop by and say hello. After the meeting, I'll post a link here to the presentations for you.

I've been a nurse for more than 25 years, and I am now in a place where I am not making the most money I could, but I do have a level of satisfaction that I haven't experienced in a while. Here's part of what I wrote in December in the print Advance for Nurses - you can read the whole piece here.

I am blessed to work in a home care agency in which patients actually do come first - the quality of our care is more important than the number of visits each day. We could all make more money working elsewhere, but we stay because our core values are supported every day and we have come to realize, each in our own time, that those nursing values are not for sale to the highest bidder. It's not easy with the cost of energy set to hit record highs and inflation nipping at everything we need to buy. But we are a staff with riches greater than gold. That's what makes us tick. I wish you all, my nursing colleagues, the peace and satisfaction that comes with such prosperity in the coming year.

But, I haven't always felt so positive - here's part of an article I wrote for the International Journal of Trauma Nursing 8 years ago:

[Why] are nurses so cruel to one another? Haven't we walked in one another's shoes over and over again? Isn't there an automatic empathy there? I was hoping so when I recently wrote a post to a nursing e-mail list after I came home from a [bad] night... I was taking care of a man who... developed multiple dysrhythmias while in the ED. I barely left his bedside and felt exhilarated that I had gotten him through his crisis and stabilized ... I took him to the ICU. As I was giving the update to the ICU nurse, I was chastised. I hadn't taken off his pants. I hadn't put the proper time tape on his IV, and I didn't put dates on the IV tubing. I wanted to scream, "I'm sorry, I was trying to save this man's life. Next time, I'll ignore his dysrhythmias in order to attend to these critical details." Instead of feeling exhilarated, I was crushed. I profusely apologized and left with my head down and, figuratively speaking, with my tail between my legs, appropriately contrite...

When I got home, I posted to the e-mail list for support. I thought only another nurse would know what I had gone through. My husband is very supportive, but he simply hasn't walked in my shoes. Was I shocked by the responses I got! The two that disturbed me the most were the ones who derisively stated there was only one excuse for my anguish - that I was a "newbie"...  I thought feeling overwhelmed and upset was actually a healthy sign. If I ever turn my emotions to stone as a result of years of experience, then I don't want to be a nurse anymore. But, the day I received those malicious e-mails, combined with the miserable night I'd had in the ER, I was ashamed to be a nurse.

For a long time...  there have been debates... about why nurses eat their young and attack each other. Is it because we have no mirror in which to see ourselves at our best? Is it because we are a predominately female profession? Is it because we fear our own vulnerability? Is it because we think new nurses need to go through some sort of hazing to prove their worthiness to walk in our experienced midst? I don't know. But, perhaps if we saw nurses the way real people see us, we might feel better about ourselves and, in turn, reach out generously to each other and our next generation.  [Carroll, P. (2000) To be a nurse. International Journal of Trauma Nursing, 6(1):35-36.]

If your nursing career isn't everything you want it to be, you have the power to change it. I know. I've done it. Happy Nurses' Week!

Til next time ~

Living with and caring for people with chronic illness can be extraordinarily frustrating. I know, I've lived with very symptomatic fibromyalgia since a bout of Lyme disease in 1991. There are some great resources online for both you -  if you have health challenges -- and for your patients when they need help.

But You Don't Look Sick is designed by Christine Miserandino, a patient advocate in New York who is living with lupus. She started the site to support people with "invisible illnesses" in which there are no obvious physical deformities, but persons are managing symptoms just the same. She has written an essay, The Spoon Theory  which is the best description of living with chronic illness I've read. I shared it with the nurses I work with, and it gave them insight into how many of their patients experience the uncertainty of how each day might go with unpredictable symptoms and fatigue that wax and wane. I hope you find it a valuable resource for professional colleagues and patients alike.

Here's a thoughtful post about chronic pain and pain management from a nurse anesthetist who blogs at Counting Sheep. It includes links to posts from people with chronic pain and to health care providers who write about the frustrations of not being able to adequately treat their patients' pain and perspectives in between .

Chronic Babe  is a site created by Jenni Prokopy, who has fibromyalgia and got frustrated with people who told her, "You're way too young to feel that way!" She provides all kinds of tips and hints and product reviews along with a regular e-newsletter. Here  she provides summaries and links to blogs that all relate to health care in different ways, from chronic illnesses to the healthcare system, to making life changes. This has been highlighted on Medscape for medical students, which is a great way to educate the next generation of doctors about chronic illnesses from the patient's point of view.  These folks would never call themselves "victims" of chronic illness - rather, they are actively living with their challenges and looking for ways to modify aspects of their lives in order to live as fully as they can.

Finally, think about the words you use when working with folks with chronic illness. Which would you say to a woman, "Are you diabetic?" or "Do you have diabetes?" There's a big difference. By calling someone "a diabetic" you are defining her identity by her disease as if it is an overarching, unchangeable part of who she is. On the other hand, if you ask if she "has diabetes," you are referring to her illness as just one part of who she is - just like if she has blue eyes or curly hair. It's much less overwhelming and catastrophic to think of a chronic illness as one aspect of your life rather than letting it define your life.  That can be the first step to effective coping.

Till next time~

I have missed writing for the blog - first, I was very sick and then I had a serious illness in the family. Hopefully, things are back to relative normal now and I can post regularly again. I had the pleasure to speaking at the ADVANCE Job Fair last month - about the Internet. I had a number of requests to post the links from my presentation, so here they are.

The Internet Society  is an independent, international, nonprofit organization founded 16 years ago to provide leadership in Internet related policies and standards throughout the world. This allows us to load and read Web sites from many different countries because they all publish to a common standard.

It can be hard to know whether information you get in e-mail or online is credible. If you've gotten a helpful story forwarded from a friend to your Inbox, before you pass it on, check here to see if it is real or a hoax. If you want to be sure the health information you search is reliable, search through the Health on the Net Foundation. This international organization has stringent requirements for sites it approves (I know, I got one of my Web sites approved through them) and you can search from this site. The search results will provide only the approved health sites. This is particularly helpful for students who don't yet have the experience to distinguish between credible sites and those designed just to sell something to an unsuspecting person or sites published by quacks.

Are your programs up-to-date with security patches? A typical computer has many programs, some of which run in the background that you may not recognize by name. It is virtually impossible to keep up with the regular updates for everything. I use Secunia Software Inspector. Click on the "scan now" button. If you need an update in order to run the scan, the site will provide a link so you can download it. The scan can take a few minutes to run. When it's done, the results tell you which programs on your computer are the latest version and which programs have security updates available. The report provides the link directly to the update so you don't have to hunt around and risk downloading something that might bring a virus to your machine. This site links only to the software manufacturers' original sites. I try to run a scan once a week.

For general computer information, I often check out Kim Komando. She has a radio program, writes newspaper columns, books and a few e-mail newsletters. Here is a link to her list of free security software available for download. Be careful, though and only follow links from her site. She has reported cases in which unscrupulous software companies have used her name to get links from search engines. Go to her site and use the search box there to find what you're looking for. You can also sign up for newsletters - I get the Cool Site of the Day and Tip of the Day.

It can be dicey negotiating the World Wide Web, particularly if you're not naturally geeky. While ADVACE nor I can guarantee other sites, these are the ones I use and find helpful in my everyday computing life. Remember that you need protection - always have a firewall, antivirus software and a spyware detector on your computer and up and running - always - and be sure to configure your antivirus program to scan all incoming e-mail so a virus won't be downloaded through your e-mail without your knowledge. It's not hard - I had a professional set up my first couple of computers, and in 12 years, I have never lost anything to a virus.

Till next time ~

Hello, friends!

We are still looking for your feedback on how your organization handles restraint policies - specifically, do you have a "tube and dressing" policy that differentiates from other reasons for restraints? This is to help out a colleague, so I'd appreciate any info we can pass on to her.

Do you like the ANA endorsement of Hillary?

Last week, the American Nurses Association endorsed Hillary Clinton for president. What do you think about that? The ANA calls itself the "unified voice for American nurses" - do they speak for you? I don't see other nursing organizations endorsing presidential candidates - particularly during primary season. Do you like the idea of the organization that the general public sees as representing all of us getting involved in political endorsements? I think it's ridiculous; isn't there enough fracturing the profession into interest groups already? Why jump into the political arena when other nursing organizations don't go there? I'd just as soon they focus on workplace and practice issues and stay out of politics, thank you.

CDC News Updates

The CDC has been busy this week with news that hasn't seemed to make it to the general media I read and watch, so I wanted to let you know what they're talking about. First is an influenza alert. Surveillance is showing an uptick in the number of influenza cases, and CDC points out that it is not too late to get a flu vaccine, or to recommend to patients since viruses can circulate as late as May. This has been a generally late year for flu cases. Next, CDC recommends use of oseltamivir or zanamivir as antiviral agents, administered within 48 hours of symptoms, and finally, they reinforce the importance of respiratory hygiene and cough etiquette and ongoing education for patients and families. The CDC's flu center has great resource materials I am using in my home care agency for patient and family information.

Another alert was published about a progressive neurological condition discovered in people who worked in a pork processing plant in Minnesota. Here's the request for information: 

The Minnesota Department of Health and CDC continue to investigate 12 cases of progressive inflammatory neuropathy among workers at a swine slaughterhouse. Symptoms have ranged from acute paralysis to gradually progressive symmetric weakness over periods ranging from 8 to 213 days. All 12 patients either worked at or had regular contact with an area where swine heads were processed and might have been exposed to aerosolized pig brain material. CDC is actively looking for any similar reports in other swine slaughterhouses.

Here's more from the American Academy of Neurology

Kids With Flu

Another warning is to check kids with influenza to see if they have a co-existing bacterial infection, particularly with MRSA. 

Although the number of pediatric influenza-associated deaths only increased moderately from the number reported during the 2 previous surveillance years, the number of deaths in which pneumonia or bacteremia resulting from infection by S. aureus increased 5-fold, and many cases (15 of 22) were caused by strains of MRSA similar to those associated with U.S. outbreaks of MRSA skin infection.

IV Heparin Recall

And here's one last item, notification from CDC about allergic reactions associated with IV heparin

CDC is investigating acute allergic-type reactions among patients who have undergone hemodialysis or cardiac procedures since Nov. 19, 2007. To date, CDC has identified 65 confirmed or probable cases among 53 hemodialysis patients at 19 dialysis facilities in 12 states. Although the cause remains under investigation, 61 of the 65 reactions occurred in patients who received intravenous heparin produced by Baxter Healthcare Corporation; the company has voluntarily recalled nine lots of heparin multidose vials.

That brings you up to date for this week - we'll bring you more useful info and links next week.

How has your week been? Things are a little less hectic in my home care world, but I know from networking with other agencies that not everyone is faring as well. I'm trying to remember that there are things I just can't control and that I have to just do the best I can - as nurses, that's generally hard for us to do, and it has been quite a learning experience!

I've gotten a question I need your help with. An acute care nurse is looking for information regarding restraint protocols for acute care hospital critical care or med-surg situations in which patients are restrained with soft wrist restraints to protect lines, dressings, and tubes. She explained there is a debate at her hospital whether there can be a separate policy and procedure designed for patient safety to protect lines and tubes that is different from using postural tools such as vests and geri chair tables that is different from a restraint protocol for behavioral control. No one disagrees about very strict guidelines for behavioral control restraints, but she says her previous employer had a nurse-initiated protocol for soft restraints that restrict the patient access to pull out lines or tubes that did not require documentation every 15 minutes, and could be followed up with a written order within 24 hours.

What are you doing in your facility? If your state requires reporting any patient who died while in restraints, do you include these "tube and line" restraints in your reporting procedure? I'd really appreciate your help with this one.

Are you concerned about the influence of pharmaceutical companies on medication prescribing practices and educational programs? PharmedOut  provides a wealth of information for health care providers that is funded by the Attorney General Consumer and Prescriber Education Grant Program a program that came about as a settlement with Pfizer regarding improper off-label drug marketing. At PharmedOut, you can access a wealth of continuing education activities relating to drugs and therapy, teaching tools, articles, and other resources where you can learn about proper medication use. Their Web links are particularly useful.

Harvard Medical School, in conjunction with the Pennsylvania Department on Aging has set up an independent drug information service. The goal of the project is to provide evidence-based, non-commercial information about drug therapy. Current topics include NSAIDs and cox 2 inhibitors, H2 blockers and proton pump inhibitors, antiplatelet therapy, lipid-lowering therapy, antihypertensive therapy, and type 2 diabetes management.

Effective Health Care  is a collection of research centers working in conjunction with the Agency for Healthcare Research and Quality. The beauty of this site is that it pulls information together in one place for existing evidence, tools that generate new evidence, and making the research user-friendly for ease of translation into practice.

Let me know what you're doing with restraint policies, and I'll share it here next week.

Until next time...

Here I am trying to dig out in the New Year! How about you? Just days ago, the forecasters all predicted a huge snowstorm for us here in New England. Pfffft. It didn't happen; we just got a little bit of snow. Wouldn't you like to be able to be that wrong and have no real consequences? I'm dealing with that frustration right now, since Medicare changed the way home health agencies are paid as of Jan 1, 2008. I am the quality management coordinator for a medium-sized home health agency, and I feel as if I have been digging out from about 5 feet of snow since then!

This is such a nursing story. In order for our agency to get paid, all these things must go right:

1. our software had to be revised and accurate according to the new Medicare rules
2. our software has to transmit our information to the state
3. the state must transmit to the organization contracted to process the billing for Medicare
4. Medicare must receive the information and internally process it according to the new rules
5. Medicare has to pay the agency

Now, what are the chances that each of those steps will be absolutely correct right away on January 2? We're not even close here on January 17. As the agency nurses, we are the ones troubleshooting every step of the process to find out why claims are being rejected - in a situation where we are doing everything the way we are supposed to! Sound familiar? I'm on an e-mail list with other home health nurses, and we can commiserate - most agencies are having huge problems at some step in this process.

So, if you are feeling like you wanted to start fresh in 2008 and can't believe the month is half over already and you don't know where it went, you are not alone! One of my New Year resolutions is to check in here at least weekly with new information for you, and as always, if you have any clinical questions or are looking for information or support for a prickly situation or patient you're dealing with, drop a note in the comments, and we'll do what we can to point you in the right direction. We have an amazing community here - take advantage!

Here are some interesting things that have come across my keyboard recently....

Key Signs of Critically Ill Infants

I was an ER nurse for a long time before I went into home care, and before that, I worked in pedi/neonatal critical care. I was always comfortable with really sick kids because when they are in trouble, I always thought they looked as if they were in trouble. But, most of my fellow nurses in the ER without pedi experience were afraid they would miss something. A great resource from the World Health Organization is summarized in this article and the original article was published in the Lancet.

The research looked at severely ill infants in the first two months of life whose parents sought care from facilities in very poor areas without sophisticated diagnostic tools. Researchers identified 12 key signs and symptoms that correlated to severe illness; these are assessments any nurse could accomplish within the first five minutes of caring for a sick infant.

Women's Heart Attack and Stroke Risk Calculator

February is Heart Health Month and here is a new risk calculation tool designed just for women. To complete this Reynolds Risk Score, enter 6 different items related to medical history and blood test results, and a 10-year risk for heart attack or stroke will be calculated for you. The page also provides links to great information about heart disease and stroke risks in women and how to reduce risk. Go for yourself, send women you care about, and your patients, too.

Updated Immunization Schedules for Kids and Adults

The CDC has updated its immunization guidelines for young people to age 18; the immunization center is here. This link takes you to a site that provides you with the recommendations, new updates, and schedules you can print and share in both English and Spanish. For adults' guidelines, click here 

Till next week ...

It's nice to hear from you in the comments - feel free to add to the discussion, and provide your point of view. This week, Inga wrote about her experience going back to the bedside after taking a refresher course. She tells us:

"The people who take care of hospital patients today, "certified technicians" barely speak English - but that is not a problem because they are only trained to do the mechanical things. There are a lot of good new things in the hospital world - but does it not come down to good hand washing and to let the patient die without pain and with dignity?"

"I was not impressed with 50% patient population over 80 years old on the hospital unit I worked on. I was shocked. I had to beg a doctor to let a patient die because it was her time to go and to stop all unnecessary expensive tests."

Have we become so caught up in the technology we have at our disposal that we have forgotten the person in the bed underneath all that equipment? Who is advocating for the patient's wishes? As nurses, we know with our sixth nursing sense what it means to "prolong death" instead of prolonging life. But who should decide what constitutes a meaningful recovery?

Inga, who made the determination for that patient that it was "her time to go?" Had she told you she didn't want any more tests or treatments? Had her family said she had expressed those wishes to them if she was unable to make her own decisions? Or, did you just "know" as nurses know things?

My father had been critically ill, but begged me not to allow them to intubate and ventilate him. He had bad COPD and probably wouldn't have been able to breathe on his own - ever - and I agreed wholeheartedly with him. He was comfortable with rolling the dice and foregoing mechanical support. He made it through the pneumonia. But, when he got home after a rehab stay, he required a cane to walk and could only go a few yards before he had to stop and catch his breath. (He had played a round of golf the day before he went into the hospital.)

I was thrilled to see him at home sitting in the yard, seeing the sun on his face as he watched the golfers tee off on the sixth hole behind his house. But, he was miserable. It was not an acceptable quality of life for him. I learned in a much more personal way that "quality of life" is an intensely individual determination, and even with a close family member, it wasn't my call - I had to have his specific guidance.

I often wonder if that quality of life issue, and not "knowing" our patients anymore is at the heart of the frustration we old timers feel when we care for patients today, compared to 20 or 30 years ago when we started out. As Inga notes, technicians are now performing patient care tasks that were part of a holistic approach to total nursing care - I learned more about people and did the most comprehensive assessments when I gave baths - I was very reluctant to delegate that important, intimate time with my patients for I knew it was far more than a simple task of washing. What do you think? What is at the heart of the frustration you feel today? Let's explore this in the comments and see if we can come up with some strategies for feeling more satisfied at the end of the day.

Until next time ~

It is important we remember our nurse colleagues who wear that proud title of "Veteran" - it's not just for those brandishing traditional weapons. Nurse veterans have fought and continue to fight a different kind of war: one against death and disfigurement, suffering and loss.  "Vietnam Nurses With Dana Delaney"  aired over the weekend. Supported by Sigma Theta Tau and the Johnson & Johnson Campaign for Nursing's Future, this documentary is based on the book The Fine Art of Nursing Care: Lessons in Healing from War and Art, by Margaret Carson, RN, PhD and Linda Finke, RN, PhD.

In this 25^th anniversary year of "The Wall," you can visit the home of the Vietnam Women's Memorial Foundation  A quote from a story on the women's memorial dedication in 1993 captures the role of nurses in wartime, "these women were the last people those guys saw or talked to before they died." Today in the deserts of Iraq, the mountains of Afghanistan and the hospitals of Germany, our brothers and sisters-military nurses-still serve that critical mission - one carried out since nurses first put on the uniform in service to this country.

You may not be aware that there is a nurses memorial at Arlington National Cemetery and that hundreds of nurses are buried in "section 21"  also known as the "Nurses Section." It is just north of the Memorial Amphitheater. Section 60 is where men and women lost in Operation Iraqi Freedom are buried.

Finally, I recommend you visit the Veteran's History Project at the Library of Congress online. Here  is a search I did using the keyword "nurse" and the results are breathtaking. There are listings by name and unit for nurses that served, but you're in for a special treat when you see the tag "view digital collection." That links to additional materials ranging from photographs to audio interviews to transcripts in which military nurses describe their service. Soldiers also recall their special experiences with military nurses. I was particularly taken by a handwritten diary from Kathryn B. Ernstes Bailey of the Army Nurse Corps (December 18, 1943-October 16, 1945). You can read each page written in her own carefully penned script from World War II.

Till next time ~

As usual, nurses are doing amazing work. This story, just published online at ADVANCE describes the work San Diego nurses are doing -- many of whom were evacuated themselves and still don't know whether their own homes survived the flames.

Want to volunteer? Here's the application form for the California Nurses Association RN Response Network -- they have already sent a contigent to SoCal. The Medical Reserve Corps, sponsored by the Office of the Surgeon General has also sent volunteers; find your local chapter through the link above. Nurses who are volunteers with the American Red Cross are being deployed from all over the United States. My local news in Connecticut profiled a CT nurse whose flight for SoCal leaves in the morning. I'm sure you are all sending your thoughts and prayers to California for what we all know will be rough times ahead, once the national news media has lost interest and moved on to something else.

Nurse-to-Patient Ratios

Last time, reader Laura Dixon left a comment asking about nurse-to-patient ratios in intensive care. Laura, here are some resources I hope you find helpful in your quest to provide safe care. The California Nurses Association had led the way on mandating nurse to patient ratios, and they have compiled a Web page of resources. An article from the American College of Physicians Online from 2001 showed, "Having fewer ICU nurses per patient is associated with increased risk for respiratory-related complications after abdominal aortic surgery." I did a search at pubmed.gov -- hopefully, you will be able to access the results at this link. If that link gives you trouble, go to the National Library of Medicine and type these words in the search box: nurse patient ratio intensive care.  There's more ... an article this summer in the NY Times.com In discussing an article from the journal Critical Care, the Times notes:

            "After controlling for age, gender, disease and other variables, the researchers found that incidence of pneumonia was associated with an average of .78 nurses per patient two to four days before early onset V.A.P. and .42 nurses per patient two to four days before late-onset V.A.P. The low nurse-to-patient ratio was a significant risk factor for ventilator-associated pneumonia."

I hope that helps you out, Laura!

Snoopy About Clooney

Since my last entry, poor George Clooney and his girlfriend had a minor motorcycle accident and were taken to Palisades Medical Center in New Jersey. How interesting that a few weeks later, seven people had been suspended for a month without pay  after more than 40 people not involved in his care viewed Clooney's chart.  What do you think about that? Have you ever cared for a celebrity? How hard was it to keep things private? I can tell you that when Mike Tyson had a similar minor motorcycle accident here in CT where he had a home, the medical community was all a-buzz about what happened to him and his response to care in the ER. 

Or, have you ever been hospitalized and tried to keep it quiet? Good luck. I worked in a hospital in which the unit secretaries would peruse the next day surgical schedule to see if they knew anyone on the list. Knowing how bad it was, when I had exploratory surgery a number of years ago, my surgeon set up an alias for me to maintain a little privacy until I was out the door. It was great until the resident wrote for my discharge pain meds in my fake name! My dear husband had to stop at the surgeon's office to get the prescriptions re-written in my real name so I could have them filled. Let us know what your experiences have been.

And, as Laura did, let me know if you are looking for some info I can help you with, or one of our readers could offer a suggestion or solution for a clinical challenge you're having.

Until next time ...

I don't know about you, but this has been one of those weeks for me, and the weekend couldn't come at a better time.

Isn't it something that there is now an uproar about wearing Crocs in the hospital? This article from BBC sets out concerns sets out concerns. What do you think? Are they an infection control risk? I think of my shoes in my ER days and can't imagine wearing shoes with openings in them, no matter how comfortable. And even now in home care, we have to worry about cockroaches in some patients' homes. Crocs, Inc. responded by announcing that they are putting new shoes in production - for healthcare - without their well-known holes. Do you wear Crocs at work? Have you been concerned about the openings on the top of your feet? Will you buy the new model?

And while we're talking about restrictions placed on what healthcare workers can wear, do you work in a hospital or other organization that prohibits artificial fingernails?  I can see requiring short nails, but I can tell you from personal experience that my well-maintained, short, coated fingernails are a lot better than my ragged, sharp natural nails. Would you work for a hospital that prohibited anything artificial on your nails? How do you feel about this type of regulation that affects your life outside of work - beyond your working hours?

This week, I was looking for some good patient teaching information for a patient newly diagnosed with diabetes, and found the National Diabetes Education Program. Not only does this site provide a wide variety of materials, but they are also in a number of languages - from Cambodian to Samoan, Chinese, Tagalog and Thai - education tools that may be difficult to find. All materials are available for immediate download in PDF format - easily read with and printed from Adobe Reader.    

Are you looking for something to help your practice? Have a great resource to share? Drop a note in the comments, and if you need something, I'll try to find it and put it in my next post.

And to have some peace going into the end of the workweek (whenever your workweek ends), here is a Web site where you can always find the peaceful calm of a sunset: Eternal Sunset has collected Web cameras from all over the world that are aimed toward the Western sky, so any time of the day or night you can visit and see a sunset from somewhere. I've watched sunsets from Iceland, Haifa, the Sinai, Syria, Germany, and various places in the U.S. There's also a map you can use to track where the sun is setting at any given time.

Until next time.

I've been reviewing the latest clinical practice guidelines for managing COPD, and as a respiratory therapist (and RN), I am delighted to see that now the recommendations are universal - everyone should use a spacer or holding chamber with a metered-dose inhaler. After years of hotly debating the "ideal" technique, I am glad to see reality stepping in after the realization that it doesn't really matter what the experts say is "right" - nobody can do it anyway. So get your COPD patients a holding chamber or spacer and teach them how to use it. They'll absorb inhaled meds better that way.

Take a moment to remember the first nurse killed in combat in Iraq. Army Capt. Maria Ines Ortiz died in July when a mortar hit the Green Zone, where she was working. 

How are you doing with the Joint Commission requirement that patients be discharged from accredited facilities with a complete list of medications? We're not seeing a whole lot of updated lists in our home care admissions. Do you have a process in place? Whose responsibility is it in your facility?

What nursing Web resources do you regularly rely on? I'd love to start a links page here with sites you find helpful. I use the free Epocrates nearly every day to run interaction checks for my home health patients -  it's much more current than our electronic medical record system. You'll need to register -  it's free -  and as a member, you can e-mail questions and a human will respond! They also have downloads for PDAs there.

Let me know what you think! You can also use the comments here to ask your own clinical questions and seek input from the vast resources that ADVANCE readers bring. I'm looking forward to building a strong supportive community here, but I can only do it with your help.

Till next time.