Michigan vs MSU

All this week, there’s been so much hype about the Michigan vs MSU. With Coach Jim Harbargh at Michigan, Michigan football is doing better than ever. Usually, I don’t really follow but my fiancé is a huge fan (he listens to podcasts and even submits questions via Twitter, haha) and now I’m a student!!

Anyways, Michigan has been dominating the last 4 games although MSU has won all five games undefeated thus far.

Apparently people all over the country are driving or flying in, staying in the cheapest hotel almost 30 minutes area at $250, with the cheapest tickets going at $175 this year (unless you’re a student who got season tickets).

Guy Fiori is going to be at Meijers this morning. “Game Day” is happening at the Diag. Somehow my friend talked me into going so I woke up early to get some studying done before I take a morning break and start back up in the afternoon.

It’s gonna be a lot of fun.

Speaking of studying, there’s a lot of new material. There’s a final exam in physical assessment and a principles exam coming up on pediatrics, fluid and electrolytes, blood products, and part I of the anesthesia workstation (yes, I can draw the oxygen molecule from the hospital outside, through the entire machine, and to the patient circuit— wow!).

I definitely feel on edge at a much higher rate than ever before. I’m usually a pretty calm person but now more than ever, I can feel my heart racing and getting anxious. And that’s almost everyday. I try to calm my nerves by either studying more, or setting time aside to go for a walk or watch some funny TV. Taking care of myself is probably one of the most important things I can do to endure through the program.

I learned this week (amongst other things), that a “sugar high” isn’t really a sugar high. As a tasty candy bar, full of “simple sugars” or glucose or monosaccharides readily available for insulin to act on, glucose is too quickly shoved into cells, causing a hypoglycemic effect. The alpha cells in the pancreas senses the hypoglycemia and releases glucagon. Epinephrine is also released from nerve endings and adrenals. Both glucagon and epinephrine go to the liver, which then undergoes glycogenolysis, breaking down glucagon into glucose and releasing it back to the bloodstream.

However, image the little kid full of epinephrine, setting off the sympathetic nervous system, causing him to run around like crazy during recess or banging his head against the wall. So a “sugar high” is really caused by “hypoglycemia” that’s induced by our more primitive insulin that floods our bloodstream when sensing a huge amount of glucose. If instead the ingested glucose was complex such as a starch, then our insulin is a much better match, releasing the appropriate amount of insulin without going overboard.

I did a few spinals this week (how cool and amazing it is!!) but next week I will try to do more general cases. All right, enough updating. Until next time.


PS. I know the first round of interviews is coming up so I just want to say good luck to anyone who’s interviewing at UM.

PSS. The double rainbow outside my window on Thursday is the featured photo. Nature is beautiful.

Clinical starts 

The last day of simulation was on Friday (can you believe that it’s been a month since I started?) and clinical starts this week! I’m excited and nervous.

First week of exams are over. Now we just have 1 exam each week until the end of December. 

The things we learned this week:

  • Proteins
  • Pediatric overview
  • Second gas effects

What I learned in clinical:

  • Propofol can burn, especially when the IV is in the hand or forearm. Unless contraindicated, give the lidocaine!
  • Don’t tell them that it won’t burn. Because it just might. 
  • Make sure the IV is working pre-op.
  • Always be ready to change location on the fly and be prepared for general anesthesia when doing a monitored anesthesia care (MAC) case.
  • Have all the drugs looked up, patient history, and be able to discuss the plan with the CRNA. 
  • Follow through with what you say. 
  • Be confident with your preoperative  assessment. Hit all the major points. Make sure you know their anesthetic history. 

Ok, here it goes. 

Also, the super moon lunar eclipse was cool. Though I may only feel this way because I’m not working today. Usually on a full moon, it gets just a little crazier in the hospital. I’m not sure if it’s just a coincidence.  

Here’s the supermoon with the eclipse starting. 



At 10:15pm EST, the moon turns blood orange. So cool! What a beautiful night. 


This week was interesting. I remember first seeing this video 6 days ago with all this positivity about a Miss America contestant, Kelley Johnson, talking about her experience as a nurse. I thought that was such a different take on what it means to have a talent. It’s not the typical talent showcased on Miss America  so I was actually glad that nursing was explained as a talent.

Then, The View happened. Although I don’t think that Joy and Michelle, the talk show hosts, went out of their way to make fun of nurses, they were simply ignorant of what nurses do. Nonetheless, it was hurtful to hear that Miss Colorado was just “reading her emails”, wearing a nurses “costume” and was questioned why she was wearing a “doctor’s stethoscope,” which really is just a stethoscope.

However, I can see how the hosts could be misled. As a relatively healthy person who hasn’t muddled in the healthcare field, you may see the nurse get a set of vital signs, ask for a history, and maybe give shots. You may not really see the difference a nurse makes in that scenario. Instead, you’ll see physicians who will use their “doctor’s stethoscope” to listen to you.
It’s only once you’re sick in the hospital that you see the nurses work their magic. I know that was what got me hooked. The compassion, skill, listening abilities, tough love attitudes… I knew I had to be one.
Regardless, Facebook blew up with #nursesunite and the group “Show Me Your Stethoscope” grew over 600,000 members in a couple days. Memes popped up all over and everyone in the healthcare team supported nurses. It was an amazing outrage.
doctor's stethoscope and nurse's costome
And here’s another:
And another:
insult nurses
 But this post is my favorite:
nurses unite
On Wednesday, The View attempted to apologize, but it was a half apology where they blamed the nurses for not listening to the content. Except that nurses are actually really great listeners and know that is not how you apologize. You have you owe up to your mistake and not blame others. People were still not satisfied with the response.

During this time, Johnson and Johnson and England’s Best decided to pull their advertising from The View. Considering how much J&J supports nurses, I actually appreciate that effort.
On Thursday, The View and NYU decided to have an educational segment about the role of nurses. Rather than playing the blame game, it’s better to educate.
 socrates the secrete of change

On Friday, the segment focused where nurses are and have made a difference. The NYU Stimulation instructors explained more broadly about what nurses do and described the educational background required for a nurse but I wished it was a bit more personal where they describe a more complex story that involved a nurse who played various roles and how they lead care. This would open people’s eyes into what nurses do.

You don’t really know what nurses do until you’re under their care. You’ll see providers come and go, but your nurse will be there for you. They will explain to you what’s going on when things get scary, work to allay fears, give medications, help you do almost anything that you can’t do, push you to do better, teach you about your medications and how you may have to change your life, make sure you’re safe from any kind of errors, act as your PT, OT, RT, speech therapist, and so much more. But you won’t even know they do all those things until you need them.

nurses do a lot

Michelle and Joy genuinely seemed interested and did seem to feel remorse for what happened. Raven, however, looked really bored who did not talk. It would’ve been better if she had engaged with her body to at least seem interested.
Before the end of the segment, stethoscopes were given out. I thought that was unnecessary because, as Joy shortly demonstrated after receiving one, she and other lay people do not know how to use one. Stethoscopes are an important medical tool, not a gift given to those who don’t know how to use one.
At the end, NYU recruited some of their nurses and nursing students (because I recognized those purple scrubs) to come out and support the educational segment.
Even if this is done as a publicity stunt to bring back the primarily audience to watch the show, I’m glad The View did it. At least they addressed the source of concern and hopefully they realize that you cannot just say anything and expect that people will accept it.
Ignorance is not always bliss.
It was amazing to see this kind of outpour of support and willingness unite on this. I hope that, despite our need for instant gratification for a desired effect, that nurses can unite on other things just as strongly.

Week 3: First Official Week 

Flexibility. Even in the first week, not everything went according to plan. But it’s about the willingness to adapt and go with the flow. 

The things I learned this week:

  • The Larynx — the cartilages, ligaments, muscles, and how all of those things work together and affected by anesthesia. And what are likely problems that can occur and how to respond. 
  • OR — checking the anesthesia machine and table top set up. 

This coming week is the first full week of class so here it goes!

Week 2: Orientation is completed

The second and final week of orientation is finished. The most important aspect that I got out of it was the wellness talk. I believe that in our lives, we continually try to find wellness in all aspects of our lives without even really realizing it.

There are six pillars of wellness

  1. Social – this is how well you get along with others and your environment. 
  2. Physical – this is how physically fit you are by exercising and eating well. 
  3. Emotional – this is how well you’re able to express your feelings. 
  4. Spiritual – this is understanding the purpose of life, being self aware and open. 
  5. Intellectual – this is the desire for lifelong learning. 
  6. Occupational – this is applying yourself to something that’s meaningful and rewarding. 

We all try to obtain this delicate balance. When one aspect suffers, we either go all overindulge in one way or hide in our shell. One way to gauge vulnerability to stress is through this short test. What I learned was that these are ways to help me relieve stress for the upcoming years. 

Score 1 for Always True 

Score 5 for Never True

  1. I eat at least one hot, balanced meal a day    
  2. I get 7 to 8 hours of sleep at least 4 nights a week     
  3. I have at least 1 person who lives nearby from whom I can ask a favour   
  4. I exercise to the point of perspiration at least twice a week     
  5. I do not smoke   
  6. I drink fewer than five alcoholic drinks a week     
  7. I am the appropriate weight for my height     
  8. I drink fewer than two cups of coffee (or tea or cola) a day     
  9. I have a network of friends, family and acquaintances on whom I can rely    
  10. I confide with at least one person in my network about personal matters    
  11. I am generally in good health     
  12. I am able to speak openly about my feelings when angry, stressed or worried     
  13. I do something for fun at least once a week    
  14. I recognise stress symptoms     
  15. I take quiet time for myself during the day    
  16. I have an income adequate to meet my basic expenses    
  17. I spend less than an hour each day traveling to and from work     
  18. I am calm when I am kept waiting/stuck in traffic/late for an appointment?     
  19. I have regular calm conversations with the people I live with about domestic problems, e.g., chores, money and daily living issues     
  20. I never try to do everything myself   
  21. I never race through a day     
  22. I never complain about time wasted and the past     
  23. I feel organized and in control     
  24. I am able to organize my time effectively    
  25. I recognise when I am not coping well under pressure     

Anyways, I picked the quote about courage this week because we’re told over and over again about the difficulty of this program. But I feel that no matter how many times it has been emphasized, you won’t be completely ready for it. The only way is to do it. So here it goes. 


Stress level:


Week 1: The First Week of Orientation

The theme of the week: Anesthesia school is having your mouth wide open, turning on the firehose, and swallowing every last drop. 

Of course, I haven’t experienced this quite yet — this first week consisted of the following:

  • Meeting classmates, and those in the other 4 anesthesia programs in Michigan
  • Feeling that being a part of AANA and MANA is vital to the profession
  • Getting nervous/excited
  • Sitting in business casual clothing (as opposed to scrubs)
  • Getting acquainted with the program handbook, the hospital, etc
  • Buying program shirts/sweatshirts (yes, this is important)

And aside from school, I

I feel that I still need to establish the following:

  • Wellness — having a 80% healthy diet and a health routine that’s worked into our study / class / clinical / sleep schedule. My roommate introduced to me Yoga with Adriene. She’s down to earth and moves nice and slow, which is good for a beginner like me.

Anyways, it’s probably also good to know that our class is going to help each other out. I’ll try to update this blog once a week with at least one thing I learned that week. These next 24 months are going to fly.


Stress level:


August 1

There’s less than 3 weeks left before school starts. I finished my last day of work, handed in my garage key card, cancelled my gym membership, and transferred my address from NYC to Michigan this past week. I’ve met with several friends for the last time before I move. I folded all my clothes and placed them into the suitcases. When I looked up and saw a blank white space, my vision started to get blurry and I felt a stream run down my face. I knew this day would come and I’m more excited than anything. 

What I learned and experienced over the last 8 years in NYC is tremedous and something that I would’ve never expected. Sometimes it’s still hard to believe that I’m actually leaving this place now and who knows when I’ll come back. 

Probably the most important thing I found out recently was that I was able to receive in-state tuition, after a 3 month queue and submitting my and my parent’s tax plus more information. 

Anyways, that’s it for now. 

What is Delirium? The ABCDE Bundle

According to my fiancé (yes we got engaged! And yes, he’s not a healthcare guy. In fact, he’s scared of needles), when he hears the word delirium, he thinks of someone being delirious or confused. Unfortunately, this state happens a lot in the ICU and causes a lot of problems.

You can go from being a crazy beast, pulling everything to being super quiet, not making eye contact to someone’s voice. What are the potential causes of delirium and what interventions can be done? Use THINK.




The Gold Standard to determine’s someone state is called the RASS score, or the Richmond Agitation-Sedation Scale. It goes from +4 to -5, as listed below. In conjunction with this, utilizing the Confusion Assessment Method for the ICU (CAM-ICU) determines if delirium is present.


A lot of times we are using medications for agitation and sedation but studies are showing that using multiple non pharmaceutical methods decreased delirium by 15%.

In the article, the evidence shows the following will help prevent delirium:

  • Early mobilization.
  • Frequent reorientation.
  • Clinical status updates and schedules.
  • Discuss patient requiring memory recall.

To me, when I read that list, I think most of it is pretty easy. Except for early mobilization. From what I’ve heard, there are patients who are intubated sitting in a chair! In my current ICU, that does not happen. The biggest concern is the stability of the patient. So what can we do?

Implement the ABCDE Bundle,

which stands of Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility. It incorporates the best available evidence related to delirium, immobility, sedation/analgesia, and ventilator management in the ICU. For the ABC Bundle, the nurse and respiratory therapist will go through his or her checklist before the trial.

A stands for Awakening.

The first step is to see if the patient can undergo a Spontaneous Awakening Trial (SAT). The nurse assesses these qualities:

  1. Is patient receiving a sedative infusion for active seizures?
  2. Is patient receiving a sedative infusion for alcohol withdrawal?
  3. Is patient receiving a paralytic agent (neuromuscular blockade)?
  4. Is patient’s score on the Richmond Agitation Sedation Scale (RASS) >2?
  5. Is there documentation of myocardial ischemia in the past 24 hours?
  6. Is patient’s intracranial pressure (ICP) >20 mm Hg?
  7. Is patient receiving sedative medications in an attempt to control intracranial pressure?
  8. Is patient currently receiving extracorporeal membrane oxygenation (ECMO)?

If the answer is yes to any of the above, then there needs to be a discussion with the interdisciplinary team before performing a SAT. If the answer is no to all of the above, then proceed with performing the SAT. Stop the sedation. If the following occurs, you should put the patient back on sedation but try at 1/3 to 1/2 the rate the patient was on before.

  1. RASS score >2 for 5 minutes or longer
  2. Pulse oximetry reading <88% for 5 minutes or longer
  3. Respirations >35/min for 5 minutes or longer
  4. New acute cardiac arrhythmia
  5. ICP >20 mm Hgb
  6. 2 or more of the following symptoms of respiratory distress:
    • Heart rate increase 20 or more beats per minute
    • heart rate less than 55 beats per minute
    • use of accessory muscles, abdominal paradox, diaphoresis, dyspnea

If possible, changing the sedation from propofol to precedex will help patient be calm and it does not depress respiratory status (especially after 24 hours).

B stands for Breathing.

Spontaneous Breathing Trials (SBT) are up next. The respiratory therapist will assess for safety.

  1. Is patient a long-term/ventilator-dependent patient?
  2. Is patient’s pulse oximetry reading <88%?
  3. Is patient’s fraction of inspired oxygen (FIO2) >50%?
  4. Is patient’s set positive end-expiratory pressure (PEEP) >7 cm H2O?
  5. Is there documentation of myocardial ischemia in the past 24 hours?
  6. Is patient’s ICP >20 mm Hg?
  7. Is patient receiving mechanical ventilation in an attempt to control ICP?
  8. Is the patient currently taking vasopressor medications?
  9. Does the patient lack inspiratory effort?

If the answer is yes to any of the above, then it may not be safe to perform the SBT. If the answer is no to all of the above, then the SBT is performed. However, if any of the below occurs indicating signs of failure, then stop.

  1. Respiratory rate >35 breaths per minute for 5 minutes or longer
  2. Respiratory rate <8/min
  3. Pulse oximetry reading of <88% for 5 minutes or longer
  4. ICP >20 mm Hg
  5. 2 or more of the following symptoms of respiratory distress
    • Use of accessory muscles
    • Abdominal paradox
    • Diaphoresis
    • Dyspnea
    • Abrupt changes in mental status
    • Acute cardiac arrhythmia

And of course, who is watching for these symptoms? The registered nurses.


C stands for Coordination.

This refers to the coordination mostly between the respiratory therapist and the nurse, although the discussion during the interdisciplinary team will also play a part.


D stands for Delirium.

THINK about the causes, use the RASS score every 4 hours and the CAM-ICU score every shift.


E stands for Early Mobility.

What I’m interested in is the minimum criteria for early mobility protocol.



However, if there’s any patient distress, then it’s time to stop. Below are the criteria for stopping early mobility.


 It’s hard to start something new as an individual as it requires a cultural change and the healthcare team to be behind it. 

But maybe the next time you take care of a ventilated patient, you’ll think of the ABCDE bundle and implement it as a part of your care.