I know the following story does not relate to telephone triage, but I do think there is something in it that anyone can learn from. Sometimes, in our hurried lives, we have to take time for the little things in life...
Time for Martha
I gathered my bag from the trunk of my car, took a deep breath, and headed for the door. I was new to Home Health, and Martha was one of the many patients assigned to my caseload. I was there to assess her, and draw labs, and was admittedly, a little nervous about meeting her for the first time. When you are a case manager, it is very important that you develop a bond with your patients, and I was not sure of how well our first meeting would go.
The one thing I was not aware of was, Martha had a HealthCare Power of Attorney, who was her friend and neighbor, and the Power of Attorney’s mother was her housekeeper. They too were waiting inside for me.
Martha appeared to be the picture of anybody’s grandmother, a typical petite, white haired, 80 something year old who was very cordial, but her POA was anything but nice. Jan almost immediately began laying out the rules of how things went in Martha’s house, and demanded to be included in her care. The mistake I made that day was focusing on Martha, and paying little attention to Jan. Martha, after all, was fully alert and oriented, and was capable of making her own decisions, and I wanted to be the good home health nurse and provide my patient the best care I could. I would learn later that Jan was very protective of her friend, and she felt it was her “duty” to take charge.
Martha took my hand, looked me in the eye, introduced herself to me, and welcomed me into her home. She was widowed, had no children, and had moved to our town approximately 20 years before to retire. She had been diagnosed with lymphoma less than 18 months earlier. Her prognosis was not good, and yet, what drew me to her was her liveliness. Instead of focusing on her condition, she immediately began asking me questions about my life. She was genuinely interested, and not just being respectful. I had a difficult time redirecting her back to the reason for my visit.
I finished my visit, and thought all had gone well, until I went back to the office and was called in to speak to my supervisor. Right after my visit, Jan had called my supervisor, angry that she was not allowed to “take charge”, and wanted me removed from the case. My supervisor had made the decision to call Martha and ask her thoughts on the matter before that decision was made. Martha being the honest, straight-forward person she was decided she wanted to give me a chance, and was not happy that Jan had called when she was unaware. Needless to say, the next few visits after that, I felt like I was walking on egg shells.
I scheduled Martha as one of my first visits of the day because she lived so close to the office, but I quickly learned that was not going to work. She was Jewish, and having tea or coffee with her visitors was very important to her. It was her way of welcoming you to her home and showing friendship. If you quickly completed your visit and left, she was insulted. So, I changed her visit time to the last one for the day, so there would be enough time for Martha. I would call her when I was on my way, and she would have the coffee and cookies ready by the time I arrived. Sometimes, Doris her housekeeper, would be there, but she never said a lot. She just listened. Over time, Jan began to appear less and less, and when she was there, she appeared more relaxed and friendly, much to my relief.
Martha and I developed a bond over the months that followed, and I for a while had a hard time believing her prognosis. She was so full of life. She loved to laugh, and tell stories about her days as one of the only female investment bankers in New York, how she met her husband, and how she learned her colorful vocabulary. Martha professed a strong faith in God, but would very quickly let the curse words fly if something made her mad. Only Martha could pull that off with class.
It was so hard to believe such a tiny person could have such a large heart. It did not take me very long to learn not to admire anything in her home, because if you did, Martha would give it to you. Value did not matter. What mattered to her was making her friends happy. During my time with Martha, I was pregnant with my third child, and she worried about me as if she was my grandmother. My friend and I went to lunch one day, and were involved in a minor car accident. I was not hurt, but asked the office secretary to call her and let her know that my visit with her that day was going to be delayed. By the time we arrived back at the office, the secretary approached me, and urgently advised me to call Martha and let her know that I was ok. Her words to me were, “Martha is ready to send flowers to your funeral”.
One day, I began to see a decline in Martha. She had less energy, and was having more pain. Suddenly, Martha was not as talkative as she used to be, but always smiled when I was there, and continued to ask me about my life and family. I think it created a diversion for her, even for a brief period, to help her forget about her pain. I approached Hospice with her, but she would hear nothing of it. “Hospice is about dying”, she would say, “And besides they cannot do anything for me that you cannot do”.
We continued to make adjustments in her pain medications, and try to make her as comfortable as possible, until one weekend, I received a frantic call from her housekeeper, Doris. She was very apologetic for calling me on my day off, but was distraught and said, “You are the only one she will listen to. Martha is very depressed, and saying she is going to take her entire bottle of pain medication”. I spent an hour on the phone with Martha and Doris that day, and hung up with Martha promising she would not do anything to hurt herself until I saw her again. She never threatened suicide anymore after that, but began to become more distant over time.
Not long after that, I learned Martha had been admitted to the hospital with acute leukemia. The next morning, I made plans to visit with her, but was stopped short by a telephone call from Doris. Martha had died that morning. As I sat there choking back the tears, Doris comforted me by telling me how much our visits had meant. She said, “You always made time for Martha, and that was so important to her”.
Thirteen years later, I still think about Martha from time to time, and laugh when I think about her spunk and charm, but most of all, I think about how she taught me that sometimes it is just the little things in life that matter most. ~
Friday, September 17, 2010
Monday, July 26, 2010
Taking Control of The Call
To be an effective telephone triage nurse, you must not only give accurate advice according to the protocols, but the call must also be completed in a timely manner. Most calls can be completed in 3 to 5 minutes. Some of the more complicated ones, such as those you have to page a physician for, can sometimes take as long as 15 min for more.
In order for the call to be completed in that 3 to 5 minute window, you must take control of the call from the first second the caller answers. Let's examine further how to accomplish that.
First things first. Get the housekeeping stuff out of the way. By that, I mean verifying spellings, dates of birth, etc.(Make sure the demographics are correct.) Nothing messes with a billing statement more than to have 1 patient with 4 different spellings of the name. Also, with varied accents, and telephone reception, many letters sound the same. So, when you have similar letters such as "d" and "b", it is always a good idea to verify using examples. For instance, you can say, "Do you spell Abby, A, b as in boy, b as in boy, y?". This decreases errors dramatically.
Next, in obtaining the medical history, it is not necessary to obtain all of it, just what is pertinent to the current situation. Medications and allergies should also be obtained and this could include any OTC medications that the pt is taking.
There are certain questions that you should never ask in order to keep the call under control, and quickly gather the assessment information that you need. You should always ask questions that require short, quick responses if possible. One question that should be removed from your vocabulary is, "Tell me what is going on tonight". That leaves the caller wide open to give you any information they want including information that may not obtain to the situation at hand. This leaves you taking longer time trying to decipher what information you need and what you don't.
Stick to the questions in the protocols. If you ask all of those that pertain, you will have a complete picture of what is really going on, and the information will be obtained in a lot less time. If the caller starts to wonder off in the conversation, you can redirect politely by saying, "Let's get back to that in a second.I need to ask you some questions first".
Make the call flow from beginning to end, just like your documentation. Gather all of your assessment information before giving advice. If you skip around, you may miss some valuable bit of information, plus it adds more time to your call. And, by continuously asking all the questions in the protocols, it does not leave time for the caller to think of unnecessary information to tell you.
Finally, smile and be reassuring! Explain to the caller why you are giving the advice that you are. This is the time to educate, but keep it in understandable, layman's terms. Reassure them that they are not alone, and instruct them when they need to call back and what to watch for. If you are reassuring and give them all the information they need to feel empowered, they are more likely to give a good report back to their physician and less likely to call back several times in the same night with more concerns or questions on the same issue.
In order for the call to be completed in that 3 to 5 minute window, you must take control of the call from the first second the caller answers. Let's examine further how to accomplish that.
First things first. Get the housekeeping stuff out of the way. By that, I mean verifying spellings, dates of birth, etc.(Make sure the demographics are correct.) Nothing messes with a billing statement more than to have 1 patient with 4 different spellings of the name. Also, with varied accents, and telephone reception, many letters sound the same. So, when you have similar letters such as "d" and "b", it is always a good idea to verify using examples. For instance, you can say, "Do you spell Abby, A, b as in boy, b as in boy, y?". This decreases errors dramatically.
Next, in obtaining the medical history, it is not necessary to obtain all of it, just what is pertinent to the current situation. Medications and allergies should also be obtained and this could include any OTC medications that the pt is taking.
There are certain questions that you should never ask in order to keep the call under control, and quickly gather the assessment information that you need. You should always ask questions that require short, quick responses if possible. One question that should be removed from your vocabulary is, "Tell me what is going on tonight". That leaves the caller wide open to give you any information they want including information that may not obtain to the situation at hand. This leaves you taking longer time trying to decipher what information you need and what you don't.
Stick to the questions in the protocols. If you ask all of those that pertain, you will have a complete picture of what is really going on, and the information will be obtained in a lot less time. If the caller starts to wonder off in the conversation, you can redirect politely by saying, "Let's get back to that in a second.I need to ask you some questions first".
Make the call flow from beginning to end, just like your documentation. Gather all of your assessment information before giving advice. If you skip around, you may miss some valuable bit of information, plus it adds more time to your call. And, by continuously asking all the questions in the protocols, it does not leave time for the caller to think of unnecessary information to tell you.
Finally, smile and be reassuring! Explain to the caller why you are giving the advice that you are. This is the time to educate, but keep it in understandable, layman's terms. Reassure them that they are not alone, and instruct them when they need to call back and what to watch for. If you are reassuring and give them all the information they need to feel empowered, they are more likely to give a good report back to their physician and less likely to call back several times in the same night with more concerns or questions on the same issue.
Saturday, July 17, 2010
I Am A Telephone Triage Nurse
I love it when I meet someone that asks me about my job. If you tell them you are an R.N., the first thing they think is that you work for a hospital somewhere. I love to see the expressions on their faces when I describe to them how I never have to worry about donning scrubs, bad weather, not seeing my family for 12-14 hours per day, or traffic congestion, (unless you count the dogs in the hallway outside my office). I can proudly say I am a Telephone Triage Nurse.
I know from what you have just read, you are thinking, how hard can that be? How can you be a nurse, and actually like your job, or even yet, LOVE it? Some days, after a long shift, I am more tired than when I worked 12 hours on a telemetry floor, but it is more rewarding and enjoyable than I could ever have imagined nursing to be. Sure, when I was a new graduate, I hit the Med-Surg floor with rose colored glasses ready to save the world. It did not take too long before I realized the only thing I was going to be able to save was my sanity.
Nursing has always been a demanding job, and in 2010, the statistics don’t look any better than they ever have for nurses. With the economy in poor shape, tighter restraints have been placed on hospital budgets. This has lead to hiring freezes, holds on raises, and lay-offs. Ultimately, the result is increased patient load for the nurse on the floor. Acuity levels are higher, and nurses are finding themselves filling multiple roles. At the end of the day, you are left saying, “Is this what I want to spend the rest of my career doing?”
After struggling for years in one specialty area or another, I begin to think that there had to be something else better out there. Something that was enjoyable, that allowed me to spend time at home, and yet, the pay was still comparable to what I was earning in a hospital. I earnestly began my search for a new me. Hey let’s face it, nursing is a big part of who we are as individuals! Thus, began my life as a Telephone Triage Nurse.
My work day typically begins about 5:00 in the evening, and ends about 12am. On the weekends and holidays, the hours vary. They can run from 3 to 12 hour shifts that begin with logging onto websites, checking in with the other nurses to see if any updates, checking emails for changes, and getting my headset and phone ready to go. I take a quick peek at the screen, and see only 4 calls in there that need to be returned. Not a bad way to start a July day. If it were January, it would not be unusual to see up to 20 or more calls that all need to be returned within 30 minutes.
Triage nursing is not about chatting on the phone. It is about following specialized protocols for the age specific population that you are dealing with. In addition to protocols, there are office specific requirements, paging physicians, advising over the counter medications when appropriate, correct documentation, and sometimes, true emergencies. (Being computer savvy has its advantages. You could never keep up without at least some basic computer skills.) When you call that patient or parent back, you never know what you are going to find waiting on the other end of that line.
There are times that the job can be so demanding that you wonder if you are going to make it to the end of your shift without either dying from a splitting headache, dehydration because you have not had time to get a drink of water, or a ruptured bladder because there is no time for a bathroom break, but nothing is more heartwarming than to hear the comfort in the first time mom’s voice when she understands that she is not alone at 3am with a newborn who has a temperature of 103, or the reassured elderly gentleman that realizes he is going to be ok, even though he mixed up his medications.
Each call can be so different from the last, and the outcomes are sometimes never known. I have often sent patients who appeared to be critically ill to the ED, and wondered if they lived, or if the advice I gave might have played a part in saving their life. Sometimes, even curiosity plays a role. You can sometimes hang up from a complicated call questioning what is really wrong with that patient.
The one thing that I think I enjoy the most is providing excellent customer service whenever possible. That’s right. The patients are our customers, so are they physicians and for that matter. The other nurses are too. You see, I can’t do this job alone. It requires team participation, and each member of the team is my customer. Excellent customer service means returning calls in a timely manner, attempting to give the most appropriate advice, being respectful to the patient and attempting to meet their momentary needs, respect for the physicians in calling them only when necessary, and supporting my team members because they are there on the front lines with me, side by side. That is the sum of job satisfaction!
I am a telephone triage nurse,….and I LOVE MY JOB!
I know from what you have just read, you are thinking, how hard can that be? How can you be a nurse, and actually like your job, or even yet, LOVE it? Some days, after a long shift, I am more tired than when I worked 12 hours on a telemetry floor, but it is more rewarding and enjoyable than I could ever have imagined nursing to be. Sure, when I was a new graduate, I hit the Med-Surg floor with rose colored glasses ready to save the world. It did not take too long before I realized the only thing I was going to be able to save was my sanity.
Nursing has always been a demanding job, and in 2010, the statistics don’t look any better than they ever have for nurses. With the economy in poor shape, tighter restraints have been placed on hospital budgets. This has lead to hiring freezes, holds on raises, and lay-offs. Ultimately, the result is increased patient load for the nurse on the floor. Acuity levels are higher, and nurses are finding themselves filling multiple roles. At the end of the day, you are left saying, “Is this what I want to spend the rest of my career doing?”
After struggling for years in one specialty area or another, I begin to think that there had to be something else better out there. Something that was enjoyable, that allowed me to spend time at home, and yet, the pay was still comparable to what I was earning in a hospital. I earnestly began my search for a new me. Hey let’s face it, nursing is a big part of who we are as individuals! Thus, began my life as a Telephone Triage Nurse.
My work day typically begins about 5:00 in the evening, and ends about 12am. On the weekends and holidays, the hours vary. They can run from 3 to 12 hour shifts that begin with logging onto websites, checking in with the other nurses to see if any updates, checking emails for changes, and getting my headset and phone ready to go. I take a quick peek at the screen, and see only 4 calls in there that need to be returned. Not a bad way to start a July day. If it were January, it would not be unusual to see up to 20 or more calls that all need to be returned within 30 minutes.
Triage nursing is not about chatting on the phone. It is about following specialized protocols for the age specific population that you are dealing with. In addition to protocols, there are office specific requirements, paging physicians, advising over the counter medications when appropriate, correct documentation, and sometimes, true emergencies. (Being computer savvy has its advantages. You could never keep up without at least some basic computer skills.) When you call that patient or parent back, you never know what you are going to find waiting on the other end of that line.
There are times that the job can be so demanding that you wonder if you are going to make it to the end of your shift without either dying from a splitting headache, dehydration because you have not had time to get a drink of water, or a ruptured bladder because there is no time for a bathroom break, but nothing is more heartwarming than to hear the comfort in the first time mom’s voice when she understands that she is not alone at 3am with a newborn who has a temperature of 103, or the reassured elderly gentleman that realizes he is going to be ok, even though he mixed up his medications.
Each call can be so different from the last, and the outcomes are sometimes never known. I have often sent patients who appeared to be critically ill to the ED, and wondered if they lived, or if the advice I gave might have played a part in saving their life. Sometimes, even curiosity plays a role. You can sometimes hang up from a complicated call questioning what is really wrong with that patient.
The one thing that I think I enjoy the most is providing excellent customer service whenever possible. That’s right. The patients are our customers, so are they physicians and for that matter. The other nurses are too. You see, I can’t do this job alone. It requires team participation, and each member of the team is my customer. Excellent customer service means returning calls in a timely manner, attempting to give the most appropriate advice, being respectful to the patient and attempting to meet their momentary needs, respect for the physicians in calling them only when necessary, and supporting my team members because they are there on the front lines with me, side by side. That is the sum of job satisfaction!
I am a telephone triage nurse,….and I LOVE MY JOB!
Friday, June 4, 2010
In Search of a Miracle 911
We have all been there. The frustrated parent on the other end of the line is searching for someone to make her child better now. Tomorrow is too late. As you attempt to calm this anxious mother, and gather the necessary information to give an accurate assessment and advice, she becomes angry, and questions why you are asking her "unnecessary questions" when she just wants some straight answers. Does this sound familiar?
Let's pause for a moment, and consider what this parent may be going through.Parents like to be in control of every aspect of their child's life, especially when they are small. Most parents take the charge that is given to them seriously,and therefore,they desire to meet that child's basic needs for food, clothing, shelter, and love, and they continue to want to meet that child's needs when they are sick. Consider for a moment though, illness is the one thing that parents have no control over. They can't just pick that child up, love them, read them a book,rock them to sleep, and make it all go away. If the child has a chronic illness, the parent may have to endure watching their child suffer through hours of pain, tests, and treatments, and that is all they can do is watch. They feel very helpless, and often become angry at themselves, at God, at the physicians, nurses or anyone else who just happens to be there at that moment. They are angry this is happening to them, and to their child, and there is nothing they can do to stop it.
How do you deal with it you ask? It is certainly not an easy task to be the nurse on the other end of that line. It is very easy to become frustrated with the difficult parent, and feel like they are just being belligerent and inconsiderate of the Golden Rule.The best technique is to stop, take a deep breath, and consider some effective communication skills for a more effective outcome.
Even though the non-verbal aspects of communication are minimized when performing a telephone assessment, one study suggests that 85 percent of the telephone interaction is based on "tone of voice" with the remaining 15 percent being the word content.
When we think of communication skills, we often think of speaking, but active listening comes first and is often overlooked.
Let's look at blockers that prevent active listening. Are there environmental distractions? If you are in a call center, is it busy? Is there alot of background noise? Is someone standing in front of you? Is you cell phone going off simultaneously?
Do you have Third Ear Syndrome? Two ears are listening to the patient, but the 3rd ear is listening to the siren outside or to the teenager having a tantrum just outside your room.
Be careful of jumping ahead. We can think at 500 words per minute, we can hear at 300 words per minute, and we speak at 125 to 150 words per minute. It is easy to jump ahead in attempts to be more time efficient.
Be careful of emotional filters. Is the caller the same demanding one that calls about the same issue all the time? Good listeners will avoid the emotional filter unfairly influencing the interaction.
Avoid mental side trips. You are on your fourth call of the day giving out diarrhea advice, and what you are really thinking about is what you want for lunch.
Sometimes, it is easy to deal inappropriately with emotional cues, and instead display blocking behaviors, such as: offering advice and reassurance before the main problem has been identified, explaining away distress as normal, attending to the physical aspects only, switching topics or "jollying" the patient along.
Some more common sense approaches are paying attention, assess the patient's level of knowledge, read between the lines, consider the patient's prospective with empathy, and consider hidden agendas/unspoken requests.
The following are seven speaking principles when triaging a call:
*Smile
*Use the caller's name.
*Reflect back important points
*Incorporate courteous remarks
*Display empathy
*Mirror the patient (using similar vocabulary, if appropriate)
Finally, don't use jargon or abbreviations when speaking, don't mumble, and don't use negative language(eg. "I am sorry the doctor will not go back to the office to see you" versus "The quickest way to be seen would be if you are able to make it to an Urgent Care".
Remember the angry caller? One rule of thumb to always keep in mind is "They don't care what you know, until they know you care".
Let's pause for a moment, and consider what this parent may be going through.Parents like to be in control of every aspect of their child's life, especially when they are small. Most parents take the charge that is given to them seriously,and therefore,they desire to meet that child's basic needs for food, clothing, shelter, and love, and they continue to want to meet that child's needs when they are sick. Consider for a moment though, illness is the one thing that parents have no control over. They can't just pick that child up, love them, read them a book,rock them to sleep, and make it all go away. If the child has a chronic illness, the parent may have to endure watching their child suffer through hours of pain, tests, and treatments, and that is all they can do is watch. They feel very helpless, and often become angry at themselves, at God, at the physicians, nurses or anyone else who just happens to be there at that moment. They are angry this is happening to them, and to their child, and there is nothing they can do to stop it.
How do you deal with it you ask? It is certainly not an easy task to be the nurse on the other end of that line. It is very easy to become frustrated with the difficult parent, and feel like they are just being belligerent and inconsiderate of the Golden Rule.The best technique is to stop, take a deep breath, and consider some effective communication skills for a more effective outcome.
Even though the non-verbal aspects of communication are minimized when performing a telephone assessment, one study suggests that 85 percent of the telephone interaction is based on "tone of voice" with the remaining 15 percent being the word content.
When we think of communication skills, we often think of speaking, but active listening comes first and is often overlooked.
Let's look at blockers that prevent active listening. Are there environmental distractions? If you are in a call center, is it busy? Is there alot of background noise? Is someone standing in front of you? Is you cell phone going off simultaneously?
Do you have Third Ear Syndrome? Two ears are listening to the patient, but the 3rd ear is listening to the siren outside or to the teenager having a tantrum just outside your room.
Be careful of jumping ahead. We can think at 500 words per minute, we can hear at 300 words per minute, and we speak at 125 to 150 words per minute. It is easy to jump ahead in attempts to be more time efficient.
Be careful of emotional filters. Is the caller the same demanding one that calls about the same issue all the time? Good listeners will avoid the emotional filter unfairly influencing the interaction.
Avoid mental side trips. You are on your fourth call of the day giving out diarrhea advice, and what you are really thinking about is what you want for lunch.
Sometimes, it is easy to deal inappropriately with emotional cues, and instead display blocking behaviors, such as: offering advice and reassurance before the main problem has been identified, explaining away distress as normal, attending to the physical aspects only, switching topics or "jollying" the patient along.
Some more common sense approaches are paying attention, assess the patient's level of knowledge, read between the lines, consider the patient's prospective with empathy, and consider hidden agendas/unspoken requests.
The following are seven speaking principles when triaging a call:
*Smile
*Use the caller's name.
*Reflect back important points
*Incorporate courteous remarks
*Display empathy
*Mirror the patient (using similar vocabulary, if appropriate)
Finally, don't use jargon or abbreviations when speaking, don't mumble, and don't use negative language(eg. "I am sorry the doctor will not go back to the office to see you" versus "The quickest way to be seen would be if you are able to make it to an Urgent Care".
Remember the angry caller? One rule of thumb to always keep in mind is "They don't care what you know, until they know you care".
Monday, May 17, 2010
How To Safely and Effectively Remove A Tick
Through its bite, a tick can transmit the spirochete, virus, rickettsiae, bacteria, and protozoa that cause a wide array of infectious diseases in children, including Lyme disease, Q-fever, ehrlichiosis, babesiosis, Rocky Mountain spotted fever, and tularemia.Some ticks secrete a neurotoxin that produces tick paralysis, with neurologic manifestations and ascending paralysis.
Not all species of tick attach to humans and, of those that do, the likelihood that one will transmit a pathogen depends on its developmental stage and prevalence of infectious pathogens in a particular geographic area. Estimates are that the prevalence of the spirochete responsible for Lyme disease, Borrelia burgdorferi, in the nymphal stage of Ixodes scapularis, the deer tick, in endemic areas of the Northeast and Midwest, is 15% to 30%. (The responsible vector in the western states is I pacificus, a deer and cattle tick.) The likelihood of disease transmission from the bite of an infected tick is only 1% to 3%.A patient who develops a tick-borne disease is unlikely to recall a tick bite—generally because a tick drops off its host after feeding.
Whether any pathogen is transmitted by the bite of a tick is determined by the location of that organism in the tick's gut and the duration of the tick's attachment to its host. A pathogen residing in the salivary glands of the tick will pass to its host more quickly and efficiently than one in the tick's lower gastrointestinal tract. The principal determinant of disease transmission, however, is the duration of the tick's attachment: The longer a tick is attached, the greater the likelihood that the pathogen will transmit to host.
Each pathogen requires a different duration of attachment.3 Transmission of B burgdorferi from an infected deer tick is unlikely with less than 24 hours of attachment, more likely after 48 hours than after 24, and highly likely after 72. Shorter periods of attachment may suffice for an infected tick to transmit Ehrlichia chaffeensis and E ewingii, the pathogens responsible for ehrlichiosis.This research confirming the relationship between duration of attachment and the spread of infectious agents underscores the importance of timely tick removal.
The tick employs several appendages to achieve its tenacious grip on your patient host. On each side of the hypostome—a rod-shaped structure through which the tick sucks blood from the host—are cheliceral digits that painlessly penetrate the host epithelium (see figure). Hundreds of barbs on the outer surface of the hypostome grip the skin like fishhooks as it enters the break in the epithelium. To strengthen its hold, the tick secretes a ring of cement around the cavity, fixing itself in place for a feast. It is while the tick feeds—a meal that can last several days or a week—that pathogens may be transferred to the host. Meal complete, the tick detaches from the patient's epidermis, leaving the cement behind. (Depth of attachment varies by tick; dog ticks, for example, attach superficially, whereas lone star ticks and Ixodes species attach more deeply within the epidermis.
Petroleum jelly? Gasoline? How about angled forceps?
The definitive treatise of tick removal has yet to be published, despite the abundance of anecdotal suggestions in the medical literature.The few randomized trials that have compared removal techniques have significant limitations; most studies used animal models, and others were underpowered.
The primary goal of tick removal is to remove the tick's body, head, mouth and mouth parts, and the cement—anything left in the skin can cause infection and local irritation or lead to a granuloma. The best technique is one that allows you to:
* remove the tick as soon as possible to minimize or interrupt the transfer of infectious material
* prevent the tick from regurgitating infectious material into the patient
* minimize damage or pain to the patient undergoing the procedure.
Techniques to remove an embedded tick employ either mechanical force to pull it out or application of agents such as viscous lidocaine, petroleum jelly, nail polish, isopropyl alcohol, or gasoline that irritate or suffocate the tick and cause it to spontaneously detach. Because a tick breathes at a rate of three to 15 breaths an hour, suffocation methods are rarely effective. Animal studies have demonstrated that irritating the tick with a lighted match, heated nail, or pocketknife—which may burn the child or cause the tick to regurgitate its contents into the host—do not stimulate the tick to detach.Researchers who injected lidocaine and lidocaine with epinephrine below the site of attachment also failed to induce the tick to detach.
Nine steps and a steady hand—surest way to remove a tick
Although no technique will remove completely every tick, one that employs slow, steady traction applied at the point of attachment is more likely to remove the tick intact with the cement.One such method is described in "Nine steps and a steady hand—surest way to remove a tick." Success depends on the type of tick, its developmental stage, and depth of attachment. Note that nymphs that penetrate deeply are less likely to be removed intact by any method.
Experts recommend a blunt, medium-tipped, angled mosquito or splinter forceps. (Using your fingers to grasp the tick will force its contents into the host and is less likely to remove the mouth parts and cement.) Any retained mouthparts or cement should be removed promptly with forceps; alternatively, the area can be excised with an 18-gauge needle, as would be done for a splinter.
Commercial devices for tick removal demonstrate varying degrees of utility.One such tool has jaws that allow the operator to grasp the tick at its mouth and then pull it away from the skin. A second tool incorporates a V-shaped notch so that, as the operator slides the tool along the patient's skin, the tick is trapped at the apex and then pulled from the skin. Although these instruments may be as useful as tweezers or forceps for tick removal, they are not commonly found in most offices or hospital emergency departments.
Post-procedure considerations
It is unnecessary to preserve the tick's remains in alcohol because the predictive value of tick analysis has not been defined.Post-exposure prophylaxis with antibiotics also is not recommended, because of, first, the low risk of disease transmission after a tick bite and, second, the risk of adverse effects from doxycycline and the unproven efficacy of amoxicillin for prophylaxis.Consider prophylaxis, however, in a patient who has multiple tick bites or if a tick's attachment is known to have lasted at least 72 hours. Counsel parents to monitor the child for signs and symptoms of infection.
Parents and child may need to be reminded that avoiding tick bites is key to avoiding Lyme and other tick-borne diseases, and that avoidance can be achieved by simple measures:
* Wear long pants in areas where tick exposure is likely, and tuck pant legs into socks to ward off the immature ticks on the ground and on low growth.
* Inspect the skin, especially the armpit and groin areas, immediately after outdoor activities to detect and remove ticks before transmission can occur.
* If skin exposure is unavoidable, apply an appropriate insect repellent to skin or clothing to protect against tick bites.
Not all species of tick attach to humans and, of those that do, the likelihood that one will transmit a pathogen depends on its developmental stage and prevalence of infectious pathogens in a particular geographic area. Estimates are that the prevalence of the spirochete responsible for Lyme disease, Borrelia burgdorferi, in the nymphal stage of Ixodes scapularis, the deer tick, in endemic areas of the Northeast and Midwest, is 15% to 30%. (The responsible vector in the western states is I pacificus, a deer and cattle tick.) The likelihood of disease transmission from the bite of an infected tick is only 1% to 3%.A patient who develops a tick-borne disease is unlikely to recall a tick bite—generally because a tick drops off its host after feeding.
Whether any pathogen is transmitted by the bite of a tick is determined by the location of that organism in the tick's gut and the duration of the tick's attachment to its host. A pathogen residing in the salivary glands of the tick will pass to its host more quickly and efficiently than one in the tick's lower gastrointestinal tract. The principal determinant of disease transmission, however, is the duration of the tick's attachment: The longer a tick is attached, the greater the likelihood that the pathogen will transmit to host.
Each pathogen requires a different duration of attachment.3 Transmission of B burgdorferi from an infected deer tick is unlikely with less than 24 hours of attachment, more likely after 48 hours than after 24, and highly likely after 72. Shorter periods of attachment may suffice for an infected tick to transmit Ehrlichia chaffeensis and E ewingii, the pathogens responsible for ehrlichiosis.This research confirming the relationship between duration of attachment and the spread of infectious agents underscores the importance of timely tick removal.
The tick employs several appendages to achieve its tenacious grip on your patient host. On each side of the hypostome—a rod-shaped structure through which the tick sucks blood from the host—are cheliceral digits that painlessly penetrate the host epithelium (see figure). Hundreds of barbs on the outer surface of the hypostome grip the skin like fishhooks as it enters the break in the epithelium. To strengthen its hold, the tick secretes a ring of cement around the cavity, fixing itself in place for a feast. It is while the tick feeds—a meal that can last several days or a week—that pathogens may be transferred to the host. Meal complete, the tick detaches from the patient's epidermis, leaving the cement behind. (Depth of attachment varies by tick; dog ticks, for example, attach superficially, whereas lone star ticks and Ixodes species attach more deeply within the epidermis.
Petroleum jelly? Gasoline? How about angled forceps?
The definitive treatise of tick removal has yet to be published, despite the abundance of anecdotal suggestions in the medical literature.The few randomized trials that have compared removal techniques have significant limitations; most studies used animal models, and others were underpowered.
The primary goal of tick removal is to remove the tick's body, head, mouth and mouth parts, and the cement—anything left in the skin can cause infection and local irritation or lead to a granuloma. The best technique is one that allows you to:
* remove the tick as soon as possible to minimize or interrupt the transfer of infectious material
* prevent the tick from regurgitating infectious material into the patient
* minimize damage or pain to the patient undergoing the procedure.
Techniques to remove an embedded tick employ either mechanical force to pull it out or application of agents such as viscous lidocaine, petroleum jelly, nail polish, isopropyl alcohol, or gasoline that irritate or suffocate the tick and cause it to spontaneously detach. Because a tick breathes at a rate of three to 15 breaths an hour, suffocation methods are rarely effective. Animal studies have demonstrated that irritating the tick with a lighted match, heated nail, or pocketknife—which may burn the child or cause the tick to regurgitate its contents into the host—do not stimulate the tick to detach.Researchers who injected lidocaine and lidocaine with epinephrine below the site of attachment also failed to induce the tick to detach.
Nine steps and a steady hand—surest way to remove a tick
Although no technique will remove completely every tick, one that employs slow, steady traction applied at the point of attachment is more likely to remove the tick intact with the cement.One such method is described in "Nine steps and a steady hand—surest way to remove a tick." Success depends on the type of tick, its developmental stage, and depth of attachment. Note that nymphs that penetrate deeply are less likely to be removed intact by any method.
Experts recommend a blunt, medium-tipped, angled mosquito or splinter forceps. (Using your fingers to grasp the tick will force its contents into the host and is less likely to remove the mouth parts and cement.) Any retained mouthparts or cement should be removed promptly with forceps; alternatively, the area can be excised with an 18-gauge needle, as would be done for a splinter.
Commercial devices for tick removal demonstrate varying degrees of utility.One such tool has jaws that allow the operator to grasp the tick at its mouth and then pull it away from the skin. A second tool incorporates a V-shaped notch so that, as the operator slides the tool along the patient's skin, the tick is trapped at the apex and then pulled from the skin. Although these instruments may be as useful as tweezers or forceps for tick removal, they are not commonly found in most offices or hospital emergency departments.
Post-procedure considerations
It is unnecessary to preserve the tick's remains in alcohol because the predictive value of tick analysis has not been defined.Post-exposure prophylaxis with antibiotics also is not recommended, because of, first, the low risk of disease transmission after a tick bite and, second, the risk of adverse effects from doxycycline and the unproven efficacy of amoxicillin for prophylaxis.Consider prophylaxis, however, in a patient who has multiple tick bites or if a tick's attachment is known to have lasted at least 72 hours. Counsel parents to monitor the child for signs and symptoms of infection.
Parents and child may need to be reminded that avoiding tick bites is key to avoiding Lyme and other tick-borne diseases, and that avoidance can be achieved by simple measures:
* Wear long pants in areas where tick exposure is likely, and tuck pant legs into socks to ward off the immature ticks on the ground and on low growth.
* Inspect the skin, especially the armpit and groin areas, immediately after outdoor activities to detect and remove ticks before transmission can occur.
* If skin exposure is unavoidable, apply an appropriate insect repellent to skin or clothing to protect against tick bites.
Wednesday, April 21, 2010
We Appreciate Our Nurses 365 Days A Year
National Nurses Week is coming soon in May. Most facilities and corporations put something together during that week, or maybe just for one day to show their nurses their appreciation. It is obvious however, that nurses give far more to their employers than anything that they could be given in return, monetarily or in any other way.
There are two kinds of people in this world, givers and takers. We nurses surely fit into the giver category. We literally pour ourselves out for others, in caring. How do we do this? How do we give and give and care and care, over and over again? What do we contribute to our community? In my opinion, our greatest “giving” contribution to our community is our children. You might feel this is irrelevant, but consider that most of us are parents or future parents. We realize that loving, teaching, and preparing our next generation of productive citizens is the GREATEST gift we can give to our community. We prepare our children for the joys and struggles that lie ahead for them. The giving and caring starts in our homes where we make parenting a priority and tremendous sacrifices for the family. Let us never forget the mighty work that dedicated parenting is for the community.
Beyond our homes, our attention and energy expands out to our studies and our work. We chose to be givers in this world when we answered that calling into nursing which we hear initially. We endure our rigorous studies and finally achieve that hard-earned goal, our nursing license. When we enter the profession, we are enchanted and enamored by the excitement and challenges, but all too soon the disillusionment sets in. We realize that things aren’t quite like the textbooks explain, and that maybe not every patient always gets the right amount of attention and effort devoted to them that they each deserves.
We realize that time and resources are finite, so we figure out ways to do more with less, and get more mileage out of our day. We learn to multi-task better, to streamline our processes better. We start to skip lunches, forget to drink and hydrate ourselves, and hardly ever make it to the bathroom. We put ourselves aside for the sake of the patients.
Throughout our careers, we CONTINUE to show that we are givers by not only living out our higher calling, but by choosing to stay and remain in our work. Even though we have our fair share of legitimate reasons to abandon ship, ALL of us here haven’t done that. We have CHOSEN NOT to. It’s our decision. It’s our decision to stay. It’s our decision to still care. It’s our decision to continue to endure the sometimes harsh conditions and situations we find ourselves in. The list of ways we show this determination and dedication to our patients is endless.(Christina Feist-Heilmeier, RN, MSN)
Nurse Telephone Triage Service is proud of our nurses, and appreciate the care they give to the patients we serve on a daily basis. For that, we say THANK YOU for your dedication, your hard work, your positive attitude, and your commitment to make NTTS the successful corporation that it is!
There are two kinds of people in this world, givers and takers. We nurses surely fit into the giver category. We literally pour ourselves out for others, in caring. How do we do this? How do we give and give and care and care, over and over again? What do we contribute to our community? In my opinion, our greatest “giving” contribution to our community is our children. You might feel this is irrelevant, but consider that most of us are parents or future parents. We realize that loving, teaching, and preparing our next generation of productive citizens is the GREATEST gift we can give to our community. We prepare our children for the joys and struggles that lie ahead for them. The giving and caring starts in our homes where we make parenting a priority and tremendous sacrifices for the family. Let us never forget the mighty work that dedicated parenting is for the community.
Beyond our homes, our attention and energy expands out to our studies and our work. We chose to be givers in this world when we answered that calling into nursing which we hear initially. We endure our rigorous studies and finally achieve that hard-earned goal, our nursing license. When we enter the profession, we are enchanted and enamored by the excitement and challenges, but all too soon the disillusionment sets in. We realize that things aren’t quite like the textbooks explain, and that maybe not every patient always gets the right amount of attention and effort devoted to them that they each deserves.
We realize that time and resources are finite, so we figure out ways to do more with less, and get more mileage out of our day. We learn to multi-task better, to streamline our processes better. We start to skip lunches, forget to drink and hydrate ourselves, and hardly ever make it to the bathroom. We put ourselves aside for the sake of the patients.
Throughout our careers, we CONTINUE to show that we are givers by not only living out our higher calling, but by choosing to stay and remain in our work. Even though we have our fair share of legitimate reasons to abandon ship, ALL of us here haven’t done that. We have CHOSEN NOT to. It’s our decision. It’s our decision to stay. It’s our decision to still care. It’s our decision to continue to endure the sometimes harsh conditions and situations we find ourselves in. The list of ways we show this determination and dedication to our patients is endless.(Christina Feist-Heilmeier, RN, MSN)
Nurse Telephone Triage Service is proud of our nurses, and appreciate the care they give to the patients we serve on a daily basis. For that, we say THANK YOU for your dedication, your hard work, your positive attitude, and your commitment to make NTTS the successful corporation that it is!
Wednesday, April 14, 2010
Foreign Body Ingestion in Children
It is inevitable that children will put objects into their mouths from time to time, and sometimes they end up swallowing them. The age group most prone to swallowing foreign bodies is preschoolers. Most of the time, it is either coins or non metallic sharp objects. X-rays can detect 100 percent of metallic objects swallowed, and about 85 percent of glass objects, while detection of fish bones is only about 25 percent. Children who swallow foreign bodies are not always symptomatic. About 50 percent have no symptoms at all. Often, non metallic sharp objects that are swallowed are lodged in an area that can be successfully removed with direct laryngoscopy alone. About 40 percent of swallowed coins can be removed in this manner. Absence of symptoms should not preclude presence of a foreign body in children. Particular attention should be paid to mentally handicapped children with vague GI symptoms.
Most swallowed foreign bodies pass harmlessly through the GI tract. However, if it has a sharp edge, is greater than 1 inch in diameter, or batteries, the patient must be evaluated as soon as possible. Children with preexisting GI abnormalities (eg. tracheoesophageal fistula, stenosing lesions, previous GI surgery)are at increased risk of complications and are more likely to retain foreign bodies in the stomach.
Most complications of pediatric foreign body ingestion are due to esophageal impaction either at the thoracic inlet, cricopharyngeus sling or the mid esophagus. Once the foreign body reaches the stomach of a child with a normal GI tract, it is much less likely to lead to complications. Foreign bodies occasionally become lodged at the ileocecal valve. Foreign-body induced appendicitis has been reported. Besides sharp, pointed, toxic, or objects that are too long or wide, another important exception is the child who has swallowed more than one magnet. Reports exist of swallowed toy magnets attracting and adhering tightly to each other through the GI tract, leading to small bowel obstruction or necrosis of intervening tissues. Systemic reactions, such as a nickel allergy, are unusual but have been reported.
Retained foreign bodies may cause GI mucosal erosion, abrasion, local scarring or perforation. Foreign body migration may lead to peritonitis, mediastinitis, pneumothorax, pneumomediastinum, pneumonia or other respiratory disease. Migration into the aorta may produce an aortoenteric fistula, a horrific complication with a high mortality rate.
Esophageal foreign body symptoms may include dysphagia, food refusal or weight loss, drooling, emesis or hematemesis, foreign body sensation, chest pain, sore throat, stridor, cough, unexplained fever or altered mental status.
Stomach/lower GI tract foreign body symptoms may include abdominal distention/pain, vomiting, hematochezia, or unexplained fever.
Most children who have swallowed a foreign body do not need specialized care. Although a theoretical risk of spontaneously vomiting and then aspiration of a foreign body exists, this is unusual. Do not attempt to dislodge a foreign body from a spontaneously breathing patient by giving abdominal thrusts or syrup of ipecac.
If the child is not at increased risk, asymptomatic, and the object swallowed is not determined to be harmful, homecare advice can be given. Reassure the parent that most anything that can get to the stomach will pass through the intestines over the next 3-4 days without difficulty. Test the child's ability to swallow foods. If no symptoms are present and the object was small and smooth, ask the parent to give the child some water to drink. If the water is swallowed easily, the child should be able to eat some bread or other soft foods. Inform the parent that most foreign bodies are passed in a normal BM in 3-4 days, and there is nothing you can do to hurry the process. Have the parent call back if the foreign body was not passed in 3 days, abdominal pain, vomiting or bloody stools develop, or the child becomes worse.
Most swallowed foreign bodies pass harmlessly through the GI tract. However, if it has a sharp edge, is greater than 1 inch in diameter, or batteries, the patient must be evaluated as soon as possible. Children with preexisting GI abnormalities (eg. tracheoesophageal fistula, stenosing lesions, previous GI surgery)are at increased risk of complications and are more likely to retain foreign bodies in the stomach.
Most complications of pediatric foreign body ingestion are due to esophageal impaction either at the thoracic inlet, cricopharyngeus sling or the mid esophagus. Once the foreign body reaches the stomach of a child with a normal GI tract, it is much less likely to lead to complications. Foreign bodies occasionally become lodged at the ileocecal valve. Foreign-body induced appendicitis has been reported. Besides sharp, pointed, toxic, or objects that are too long or wide, another important exception is the child who has swallowed more than one magnet. Reports exist of swallowed toy magnets attracting and adhering tightly to each other through the GI tract, leading to small bowel obstruction or necrosis of intervening tissues. Systemic reactions, such as a nickel allergy, are unusual but have been reported.
Retained foreign bodies may cause GI mucosal erosion, abrasion, local scarring or perforation. Foreign body migration may lead to peritonitis, mediastinitis, pneumothorax, pneumomediastinum, pneumonia or other respiratory disease. Migration into the aorta may produce an aortoenteric fistula, a horrific complication with a high mortality rate.
Esophageal foreign body symptoms may include dysphagia, food refusal or weight loss, drooling, emesis or hematemesis, foreign body sensation, chest pain, sore throat, stridor, cough, unexplained fever or altered mental status.
Stomach/lower GI tract foreign body symptoms may include abdominal distention/pain, vomiting, hematochezia, or unexplained fever.
Most children who have swallowed a foreign body do not need specialized care. Although a theoretical risk of spontaneously vomiting and then aspiration of a foreign body exists, this is unusual. Do not attempt to dislodge a foreign body from a spontaneously breathing patient by giving abdominal thrusts or syrup of ipecac.
If the child is not at increased risk, asymptomatic, and the object swallowed is not determined to be harmful, homecare advice can be given. Reassure the parent that most anything that can get to the stomach will pass through the intestines over the next 3-4 days without difficulty. Test the child's ability to swallow foods. If no symptoms are present and the object was small and smooth, ask the parent to give the child some water to drink. If the water is swallowed easily, the child should be able to eat some bread or other soft foods. Inform the parent that most foreign bodies are passed in a normal BM in 3-4 days, and there is nothing you can do to hurry the process. Have the parent call back if the foreign body was not passed in 3 days, abdominal pain, vomiting or bloody stools develop, or the child becomes worse.
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