tag:blogger.com,1999:blog-6833607.post7758716909054693471..comments2023-06-14T03:36:55.988-07:00Comments on Head Nurse: Speaking of Learning Experiences....Johttp://www.blogger.com/profile/16520599099436383317noreply@blogger.comBlogger1125tag:blogger.com,1999:blog-6833607.post-58014403818474278032009-05-27T21:07:07.335-07:002009-05-27T21:07:07.335-07:00Thanks for the object lesson. It always pays to b...Thanks for the object lesson. It always pays to be honest, upfront, humble and accepting of the butt-whupping when it comes (if deserved). <br /><br />It also always pays to give yourself a break and learn from your lessons when they happen, to pass them along, and find a way to ensure they never happen again.<br /><br />My personal learning experience for all to learn from (granted, it doesn't have the potential consequences your scary story has, but it's mortifying and has really stuck with me): <br /><br />Needed a central line to push blood for an explosive GI bleeder (Hgb ~4.5) at the proverbial 4am. So, my senior resident and I choose to use a triple lumen inside a cordis for his IJ, so we would have plenty of access, even while the blood was running (dude was sick). <br /><br />Both of us had plenty of experience with trip lumens, but had never put in a cordis. Thought, "hey, they're the same insertion process, right?" and marched ahead (patient awake through this whole time - we were really wishing for an altered mental status by the time we were done). <br /><br />Gloved and blue-covered everything and everybody. Tried repeatedly to put in the cordis - hmmmm, it's not going in x 30+minutes (jab, jab, make a bigger hole... jab, jab, make a bigger hole). Patient kept squirming and asking what was going on - hard to explain you're f*ing up when you're still f*ing up, with sharp instruments poking in his neck.... <br /><br />Thankfully, we'd brought the trip lumen in with us too, and just opened that up and stuck it in the already-made/still bleeding gaping hole in his neck.<br /><br />Turns out that the triple lumen and cordis have very different insertion techniques and we got pretty beaten up by staff when we tried to explain ourselves on rounds - it's never a good sign when 2 staff members are *silent* for a few minutes. <br /><br />I could have just said, "no harm, no foul" as there was no real consequences to the patient, but I still get red in the face just thinking about it. So, I chose to take it to heart and learn from it:<br /><br />MORAL to the story, and learning point: review your procedures if it's new - DON'T assume it's the same as something else you've done. Fess up and admit your mistakes. Learn and move on.08armydochttps://www.blogger.com/profile/08822263660673470153noreply@blogger.com