#100Intubations

Anesthesia school is a 2-year marathon.

When you feel tired and beat up, you just have to keep going. Just keep going to clinical.

Anyways, I just wanted to announce a couple of things.

First, I’m done with my second semester and I’m onto my third semester. I took a week off for a family vacation in between the semester. It was definitely much needed. This semester is supposedly better in some ways. For example, there are less OR jitters compared to the 1st semester. But going to a new clinical site presents its own challenges (a new anesthesia machine, new charting system, different drug dispensing, different protocols, different equipment, different labels, different drug vials and doses, new names and faces, not knowing where anything is, new surgeons, new procedures, different patient population, etc). Now we’re going strong by going to clinical 4 days a week and 1 day of class (and my, that day is 10 hours long!!). When I look back at what I knew in October versus now, it is a huge difference. It’s incredible.

This semester there’s a couple of focuses: research, emergency management, regional anesthesia. I’m pretty pumped. I’ve come far but there’s still much more to go. Resiliency has never been more important than now.

Second, as of yesterday, I’ve done 100 successful intubations. It’s a great feeling.

Third, thanks to everyone who’s been writing me positive messages about the blog, supporting me through the flashcard purchases, and anyone who’s enjoyed reading my blog. I see that each month there are more visitors and visits than the next, despite me not updating it as frequently as I used to.

Fourth, happy nurses week again.

Fifth, congrats to those who got into the UM-Flint nurse anesthesia program. It was nice meeting some of you and I’m sure we’ll meet again soon enough!

I have to go now. Until next time,

Jessica

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.

Jessica

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. 

#NursesUnite

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:
nursesunite
And another:
insult nurses
 But this post is my favorite:
nursesunite
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.
raven
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!

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.

 

IMG_0978.PNG

 

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.

IMG_0976.PNG

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%.

IMG_0977.PNG
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.

IMG_0979.PNG

 

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

IMG_0980.PNG

 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. 

 

NYU Accelerated Nursing Program FAQ’s Part II

I recently received an email from a prospective nursing student and thought that it was worth posting my answers.

Hi Jessica,
I came across to your blog while searching for NYU’s accelerated nursing program.  Reading your blog has been very helpful. Congrats on becoming a nurse. Currently I have my undergrad in a business discipline and I am really considering a nursing career instead. I just have some questions regarding nursing, it would be great to get your feedback. Thanks so much if you have the time to answer any of these questions!

1.       Does it matter whether you take your pre-reqs at a community college or 4-yr college when applying to NYU? Do pre-req grades matter? Will there be a higher chance if acceptance if pre-reqs are taken in NYU?

You can take your pre-reqs at a community college or a 4 year college. Pre-req grades matter a lot. Definitely do well on these. I don’t believe there’s a higher chance of acceptance of the pre-reqs are taken at NYU. Majority of students take pre-reqs at a community college or a 4 year college.


2.        What were your credentials when you applied to NYU (eg. GPA, experience)? And did you find NYU to be worth it after working in the field? Is there any other nursing programs you would recommend in NY?

My GPA was 3.84. As for experience, I volunteered at a hospital when I was applying. It’s important to highlight your feelings towards nursing especially after speaking to them and seeing what they do.
NYU is a great school and I’m glad I attended the school. The professors are top-notch and the students are helpful. There’s an interdisciplinary program so med students and nursing students learn about working together and each other’s roles. It is one of the top research institutions as well especially in elder care (NICHE Program http://www.nicheprogram.org). However, it is a really expensive program so I don’t recommend it to everyone.
The other nursing schools in New York / Long Island that I hear good things from include Hunter, Columbia, Stony Brook, Adelphi, Molloy and Pace.

3.       Difficulty finding a job? Did you work part-time while studying in the program?

After I passed the NCLEX, it took about 6 months to find a nursing position. A couple of problems I ran into included not knowing how to interview (because this is a skill you need to practice). I didn’t start my search until after I passed. Some students connected with nurse managers during clinical and were able to secure a position shortly after graduation.

I did work once a week as a swim instructor during school to help supplement the costs. Some students didn’t work at all while others worked 36 hours a week (a full-time job!!). The first and second semester are the toughest so give more time devoted to school before deciding to work.

4.       Do grades matter a lot to employers? Do I need to get straight A’s or can I afford to have a few B’s or even a C?

Some employers require a minimum GPA (3.4, 3.5) before they even look at your application. Some don’t. It’s how you present yourself and your mannerism that matter and whether you retained information from school and can apply it.


5.       What is the starting salary like and is it worth being a nurse practitioner? What kind of nurse do you think is best to become/specialize in if any?

Starting salary differs from location to location, ranging from $40-80k. In NYC, it starts around $70-80k if you’re working at a private hospital.

Becoming a NP is dependent on the person. While I’ve heard that becoming an NP is the greatest thing in the world (I hear a lot of positive feedback), there are still a few who are discontent with the position, as there is more responsibility that comes with the position. Some people don’t want to deal with the higher stress and responsibility but wanted to go back to school and ended up hating being an NP. This requires a lot of self-reflection. What do you think would suit you and are you ready for it?
Personally, I’ve explored many advanced nursing professions. Not only should you look at your duties but also the lifestyle. Where would you want to work, what would you do, when would you want to work, what income would you make, what mobility is there? The best advanced nursing profession depends on the individual and what they want out of life. I picked Certified Registered Nurse Anesthetist. I like the one-on-one direct patient care aspect requiring a high level of critical thinking and autonomy and teamwork.

6.       What’s life as a nurse? What are the difficulties and good parts of being a nurse? Expectations in the work force?

Life as a nurse differs between the environment that you work in. I work at the hospital where there’s 12 hour shifts (7-7:30am and pm), 3 days a week (for full time) and you can choose your schedule (with some limitations such as having to choose at least 3 weekend days, 2 Fridays, etc). Some people choose to do 3 in a row each week and have 4 days off. Other hospitals have it so you work 3 12-hour shifts plus 1 additional day every 4 weeks. Some units, especially in CTICU, PACU and ER, have other shifts from 11am to 11pm or 2pm to 2am.

It’s great having 4 days off because you definitely need it to recuperate and you’ll have time to do something else if you’d like.
Some places have day (7a -3p), evening (3p-11p), and night shift (11p-7a), especially in rehab and nursing homes, and require you work 5 days a week.
At work, you often need to have handoff communication about the patients. Then you assess the patient and pass out medications. You make nursing diagnoses about each patient and use critical thinking. You think to yourself: What’s the goal for the patient today? And then make it happen. You’ll speak to various disciplines to coordinate the care.
There’s a couple of tough parts about being a nurse.
1) Families – Some follow the unit policies and others do whatever they want. Communication is sometimes hard but trying to understand where they are coming from helps.
2) Physicians, MLP – your input is often crucial to the patient’s outcome but sometimes the provider will disagree with you.
3) Patients – some are nice and others are crazy, confused and not so nice.
4) Self- being able to let go everyday of the outcome is tough. At the end of the time, you have to set 1 small goal for the patient and as long as they meet that, you have to be satisfied with the care you provided. Nurses tend to be overachievers and want to always give more but with the number of things that must be done, it’s impossible to do everything you had in mind. You have to remember that nursing is a 24/7 job.
The good parts about being a nurse is knowing that you’ve made a difference is someone’s life. You get to think about an active problem and you get to take yourself and solve that problem. You get to hold someone’s hand and reassure them. It’s an amazing privilege to have to save a life, to have a better life, or to let someone die with dignity.
As for expectations in the workforce, there are several different angles you can discuss but I’ll discuss about your own expectations. There’s a nursing theorist named Patricia Benner who stated that the nursing career is based on the nursing model-
You really do start not knowing a lot, just the basics. You focus a lot on technical skills because it’s something you have to work on. Then as you progress, you build more confidence. Soon you’ll start to see areas in nursing where care can be streamlined or have protocols to standardize care. You’ll be in charge, take on harder assignments, be a preceptor, etc.

7.       Any general suggestions on what I should focus on or do to become a nurse/get into NYU program?

Do well on your pre-reqs, volunteer or work in healthcare, and get to know a few professors who will write a letter of recommendation for you. And write a killer personal statement answering every question asked.

I hoped that helped! Read my first post for more information on NYU’s Accelerated Nursing Program, find out if NYU Nursing is worth it, how to pick a good nursing school, and find out if you can afford an accelerated program. Or if you have any further questions, email me.

Jessica

The Second Career Nurse [Infographic]

While there’s a lot of people who say that nursing was all they ever wanted to do, there’s also a lot of people who doubled back and thought otherwise (including myself!). There are many barriers to commit nursing as a number one career choice. One of the biggest hurdles is our conformity to society. What do our parents, family, friends, and society think about our career choice?

I know personally that I had pressure. I know many male nurses receive a certain pressure too. I know that many immigrants who may look down on nursing get that pressure. Even patients will ask, why nursing?

People get an image in their head and continue to apply that to everyone. A female should be a nurse, a male should be a doctor, some immigrants may think nursing is not a noble profession but rather a dirty one (mostly because of how the nursing profession is portrayed in other countries). We have to break free of these stereotypes and see nursing for what it really is.

Nursing is one of those fields where you get to make a difference in someone’s life everyday– where you combine the science and the art. You will make sure that someone will receive the best possible care, and in the safest way. And when that doesn’t happen, you will start an investigation questioning why that is and what can be done differently.

When we start to have a diverse group of nurses, different ideas abound, different strengths surface, and as a whole, nursing gets stronger.

You can jump over these hurdles by thinking about what is nursing, and how nursing is such an amazing and vast field. There are so many choices and different ways you can contribute, touch another and be touched. You can in one direction and go up as high as you want, or expand horizontally and try out different fields of nursing. You can choose to be by the bedside, or an administration, in research, in an insurance company, etc. Wherever you decide to grow, just go for it. Say it out loud and proud and you will gain social support.

I got in touch with the author of the Top RN to BSN website, who suggested that I include this infographic below on the Second Career Nurse. She did her research and learned more about the characteristics of the Second Career Nurse. I thought it was informative so here it is! If you look at the graph below, you will see that in 2012, 1 in 3 nursing grads are from accelerated nursing degrees.

Now, I have some questions for you as the reader. What made you change your career and how did you get your support for switching into nursing? Comment below to start a discussion. I look forward to chatting with you.

Jess

 

Second career nurses are solving the nursing crisis.

Source: The Second Career Nurse