A midnight breakdown

Rarely does anything bother me enough that I find myself writing at 0116 in the morning. There was a time that staying up this late was normal and there still are occasions where I stay up late meet a deadline. But, recently I read, heard, and felt a struggle from a friend I don’t talk to enough and haven’t seen in several years. My analytical mind kicked in at 0116 enough to get me out of bed in my underwear and come down stairs and begin typing.

A few days ago a friend from a past lifetime voiced a question. It was just a question, could have been rhetorical, but my no fear and honest attitude I responded. Something happened, my friend responded and something happened to me. I have a lot of friends but few close friends, but there was a time that I had many close friends, not that I don’t now, but friends I could count on, friends that checked in, friends that knew my name, where to find me, my goals and aspirations, my nightmares, and could make me laugh.

I understand people move on, it is inevitable, people change jobs, have families, aspire to new educational heights, and get new friends. But, were your old friends really that bad that you had to get new ones, not by choice, just by circumstance?
I spoke to one of my favorite people of my entire career today. Do we speak often, no not really, this friend has a new exciting life somewhere else and who am I to barge in? My call was unwarranted and unplanned, we went through the pleasantries, discussed my schooling, my bad attitude which is always apparent to my friends and seems to define me, and then we got to the reason for my call and really the reason for this long winded assessment. I was looking for a mutual friend’s number; I had the number somewhere, I think, but didn’t want to go pull my office apart looking for it, when it may not work anyway. Instead I chose to call the friends that shared the friendship of the friend’s information I was seeking. They were my friends too and they don’t call so I would. I talked to three different machines, people are busy, but I did talk to one friend. The reply from my friend was that they had not talked to the friend I was seeking for years. I was really saddened by this, am I one of those friends that don’t speak, doesn’t call, doesn’t e-mail? I hope not.

I often think the best and worst times of my life were confined to a 12 bed unit in Salt Lake City, for 4 years with five to six of the best people I have ever known, on the nights I worked. I miss those people, don’t get me wrong, as many of those people that will read this know, there were a few idiots that I worked with that made the ride a little more rocky, but one of those idiots could have very well been me. But, those people made the ride a little more fun when you could poke fun of a few co-workers that just didn’t have it together. But, I wanted to share a few of those people that made me laugh, I made them laugh, I got really pissed at and we bonded over poo bags, sex talks at 0400, relationship issues, code blues, practical jokes, and eating donuts off of the most dirtiest counters I have yet to again work on.

Here we go… I had a knack for being in the worst mood possible when at work, I kind of thrived on it in a sick sort of way, and still am a little unsure of why I was like that. But, I remember Krahn and Darling wrestling with the train of four, and watching Krahn’s eyes pulsate out of his head, Todd chewing gum talking to an old man, while calmly peeling the gel patches and placing them on this guy’s chest and then zapping him out of v-tach without even blinking an eye. That guy was pissed, but still alive. I remember hosing Todd with a pressure bag while he was talking to family on the phone and him whining to me like a kid because it was unprofessional. I remember Michelle teaching Tracie how different nationalities had different sizes of penises and Latin Americans were the smallest. Krahn playing a really bad joke on Natalie about her car being stolen, Krahn scaring Darling about some patient’s fake abnormal vaginal lab values and Markowitz picking up on it. I remember Cody wearing his pants backwards as if he needed another pocket and every conversation was turned to what Cody wanted to talk about. I remember Katy and McKenzie rolling on the floor because I told a complaining patient they couldn’t have any food because they had pills for dinner. I remember McKenzie’s first sick travel and telling her to memorize the code blue number if she needed us and seeing the fear in her eyes, and later becoming a great nurse with no fear. I remember Katy almost decking for telling her to get her shit together after sticking herself with a dirty needle after getting in a difficult IV on a confused patient. I remember Nelson being more ticklish than most of the girls and I loved to punch him just to hear him squeal. I remember Ed giving us the, “I don’t think you guys should do that,” when we pumped in two 16 gauges and a 14 gauge in some drunk with great veins and his Dorky flashlight. I remember how dashing and charming Dr. Simpson was with his accent to all the girls. I remember Tracie with shit on her teeth and Jake placing poo bags and doing push-ups in the hall. I remember Jill and her undying enthusiasm to do everyone’s work with a smile, and deal with all my questions, half of which I didn’t know the answer to, but knew she would find out for the both of us. I remember going to the bar with girls and having them all drink beer and me with my umbrella drink. I remember loving to annoy Lisa until she would say !@#$ you Monte and then I knew I needed to go bother someone else. I remember being scared to death of Randall because of his size, and finding out he is one of the nicest guys in the world. Randall's stories about stealing potatoes in Germany with the refugees. I remember the red embarrassed face of April Gunderson before she got used to the outlandish behavior of the group, Lisa Gro’s and I’s A-K-A-S-H-A (Akusha), when really it was Akasha was exactly how it sounds, and FUNNY Monte. I remember tormenting the animal lovers with my kill all animal stories of my youth. I remember Tari always smiling, and always making a joke, smoking cigarettes with Michelle and Lisa on bad nights. I remember Terri, her dogs and always having bigger guns than most of the guys, and Jake and her comparing. I remember Erika being trained by Pam, what the hell was that, talk about the blind leading the blind. There are many more of you that I haven’t named, like Angelica, Jeanette, Janice, Colonel or captain, or whatever Jake called Carolyn Mayfield, Brady, Micah, that girl that moved to California that lived in emigration canyon that never showered. Sarah would always ask me the creatnine level of all my patients in report and until nearly I got fired, I never knew what it meant, Tiffany, Melissa, Pearl, Angie and lasering off all her hair for her future husband, Liz, not ever knowing exactly what she was saying, Bryant’s self damning “Man Hands,” comment. If there are people I missed, I didn’t realize when I started writing this how many good friends I really had, although I don’t talk to all of you, most of you I think about all the time, and would like to talk to more of you on a more regular occasion. And, now that it is 0230, I am kind of burnt out of my original soap box, there are too many friends to remember, but I can remember all of you, if I wasn’t falling asleep typing and haven’t lost the umph of the my original issue. I know we are busy, but pick up the phone, or e-mail, or something. We are way too good of friends to not talk to each other anymore.

Module 6 Question 3

I would not make this an online course, but if this was not an option, I would incorporate more enjoyable and thought provoking activities that promote the interesting points of informatics and innovative technologies. Because this is a nursing class, the new simulation labs, and other technology that promote critical thinking without endangering the patient. Understanding how these systems work is fascinating, but not really covered as part of this course. Understanding the reasoning for the systems used by hospitals for HIPPA, and success in accuracy are important, but I felt all of this was mere information, without any interactive design to keep me interested in developing new ideas making weak areas stronger.

Providing the students with a complete syllabus at the beginning of the semester was great. Students could work on assignments at the student’s own pace with a deadline that is easily attainable. However feedback on assignments was minimal and was inconsistent between the different instructors, this course could easily be taught by one professor not three different ones.

This course did not meet my expectations for feedback or providing me with a clearer picture of informatics. However I believe that I understand systems management better when related to informatics, but felt course work reflected the known information and did not dive into new technologies or new evidence based practice surrounding new and upcoming practices, revolutionizing nursing and the medical profession.

Module 6 Question 2

I enjoyed Modules three and four, module three’s Multiple Intelligences Test provided me with the insight to understanding and becoming a more effective teacher. Secondly, understanding my own personality further assists me to understand how others, especially students interact with me and why. I was surprised that I enjoyed researching data about decision support mechanisms, but was thoroughly surprised of how helpful individuals were about obtaining pertinent information about company products. (Although, they saw me as a potential buyer and had interest in making money off of their referrals and information given) But, the research was interesting in learning how different decision support mechanisms worked, were evaluated, and how successful they were in other institutions. I have used numerous charting systems, some good and some bad, but have never evaluated how the same system works in other institutions or under other pretenses, the results were interesting and highly diversified. But, if asked, my favorite topics are always testing who I am, what makes me tic, or how to define my teaching style around current research or evidence based practice. So the Multiple Intelligence’s Test was right up my alley.

Module 6 Question 1

Taking an online course takes some motivation, but is incredibly flexible for self scheduling tasks or assignments. Assignments and other homework can be completed at the convenience of the student instead of the convenience of the college or professor. I enjoyed the format of the course because there were no meaningless discussions week after week, all information was provided, feedback was given promptly when questions were asked, and due dates were posted at the beginning of the semester and could be referenced easily allowing me to work leisurely through the course at my own pace.

The challenges in taking an online course are obtaining adequate feedback. Feedback is not instantaneous or easily graded or evaluated in an online course for the student. Unless the student seeks specific feedback the professor may not know there is an issue to be resolved and the student may resent constantly explaining the same issue or being a number instead of a person. The physical tangibility of a professor is desired and not really ever achieved in an online course; I don’t feel this is a great course for the online environment. When I think of innovative technologies or informatics, I think of tangibility, interaction, and strong communication. Not that these attributes cannot be accomplished in an online setting, but, in my opinion, these important attributes are limited and sometimes non-existent in an online course.

Module 5 Question 1

All medicine is being created and evaluated by the all might dollar (Which is a lot mightier than years past). As I was looking at the Health Care Research and Quality site I couldn't help, but think of DSRG's. Some diagnoses pay more than others based on medicare and medicaid, creating systems to maximize the revenue produced by each consumer is imperative to the hospital or health care's success.

The second issue comes from the other side of the table. Prevention, is the new wave of medicine and innovative design. However, the health care profession does not make any money on prevention. The more sick a person is in that health care organization, given the consumer has some type of insurance, the more revenue the patient brings to the organization.

Third issue, consumers or patients of health care are unaware and do not knowingly determine the reimbursement received by health care organizations. Part of the innovative design needs to incorporate patient's understanding of how the system works, what will they get billed for and why.

The site gives pros and cons promoting the idea to consumers that health care organizations are compliant with accreditation, regulatory commissions, and are seeking ways to improve health care for the organization, and ultimately, for the community population served. The use of electronic medical records, automated pharmaceutical dispensers and scanners, advanced or smart intravenous pumps are just a few ways health care is proving to the consumer, health care is providing the most up to date care, safely, effectively, and ensuring anonymity of their clientele. Lastly, because of these up to date changes, consumers see the jump in health care, because the consumers demand high technological care, low cost, and privacy. In order to continue keep health care affordable, health care will need to continue to create systems that protect the agency and protect the patient.

Module 4 Question 2

This is a difficult question, so, I am going to give two different spins off of how I perceive this question. One, several years back I worked for an intensive care unit that introduced an insulin drip protocol. This protocol was very aggressive and many of the nurse clinicians, including myself, struggled with compliance with the insulin protocol. The aggressive protocol continued to treat glucose levels with a continuous drip when glucose levels fell into the 60-70’s. As an experience clinician, I was highly critical of the suggested instruction by the protocol to continue the insulin drip, because of, “Redundant input variables,” from previous experience. I had a high probability of being right, knowing that before the next glucose check, my glucose would drop into the 40’s and 50’s, instigating the hypoglycemic protocol. I sought to thwart this negative experience of shutting off the insulin drip, pushing Dextrose 50, and starting a new cycle. This protocol data was evidence based, but lacked the consistency of providing accurate and intuitive guidelines to increase patient outcome. I found that by using the protocol I felt more at risk for negative outcomes than if I used the statistically wrong self probability scale based on past experience and current knowledge base. In this case, although there was intense ongoing research, the nursing data did not support accurate and consistent clinical decision support.

Second spin, computer based charting, medication administration, and information retrieval have greatly decreased medication error given to wrong patient, caught medication allergies to current or newly prescribed medications, provided an ongoing database for past medical history, and promoted consistency in care. These nursing or medical systems decrease the need for practitioners to have information overload, increase likelihood of prescribing the right medicine, treatment, performing the best intervention, and preparing for the best outcomes. However, each institution, clinic, unit, etc. need to evaluate and research how the intended nursing data will improve or relate to the decision made in that specialty. Not all data is universal, understanding the drawbacks, constraints, and ability to override guidelines are imperative to increasing the success, compliance, and attitude toward using informational technologies to guide decisions. The quality of the product has to be shown by the results, compliance, and success of the users, using the data.

Module 4 Question 1 Part 2

In answer to the second question, evidence based practice must be a priority in our practice when activating interventions based on past experience and/or positive probability of success. Most experienced nurses in specialized fields use a detailed instrument or guide to assist in their decision making process. Secondly, I am familiar with insulin protocols, blood pressure protocols, and emergency protocols that supplement the nursing practice. Using these protocols, interventions with evidence based practice and multiple research congruencies to increase validity, improve statistical data, and ultimately, improve patient care are imperative to increasing use by clinical practitioners. The nurse still relies on critical thinking to follow the guideline or make a clinical decision based on current patient situation, but the guideline or protocol is set in place to assist the nurse based on research, not just opinion, confidence, probability, or intuition. The introduction of new protocols can help reconcile poor human judgment heuristics, but may also undermine the autonomy and critical thinking of the nurse. However, teaching the nurse to base decisions after bouncing the idea through the guideline will greatly decrease the bias associated with poor predictions and increase the confidence level and trust level of the nurse using the guideline. Lastly, using an evidence based instrument correctly decreases and nearly eliminates the personal accountability placed on the nurse in case of patient/protocol issues.