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:
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.
And here’s another:
But this post is my favorite:
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.
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.
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.
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.
Social – this is how well you get along with others and your environment.
Physical – this is how physically fit you are by exercising and eating well.
Emotional – this is how well you’re able to express your feelings.
Spiritual – this is understanding the purpose of life, being self aware and open.
Intellectual – this is the desire for lifelong learning.
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
I eat at least one hot, balanced meal a day
I get 7 to 8 hours of sleep at least 4 nights a week
I have at least 1 person who lives nearby from whom I can ask a favour
I exercise to the point of perspiration at least twice a week
I do not smoke
I drink fewer than five alcoholic drinks a week
I am the appropriate weight for my height
I drink fewer than two cups of coffee (or tea or cola) a day
I have a network of friends, family and acquaintances on whom I can rely
I confide with at least one person in my network about personal matters
I am generally in good health
I am able to speak openly about my feelings when angry, stressed or worried
I do something for fun at least once a week
I recognise stress symptoms
I take quiet time for myself during the day
I have an income adequate to meet my basic expenses
I spend less than an hour each day traveling to and from work
I am calm when I am kept waiting/stuck in traffic/late for an appointment?
I have regular calm conversations with the people I live with about domestic problems, e.g., chores, money and daily living issues
I never try to do everything myself
I never race through a day
I never complain about time wasted and the past
I feel organized and in control
I am able to organize my time effectively
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.
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.
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.
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.
In the article, the evidence shows the following will help prevent delirium:
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?
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:
Is patient receiving a sedative infusion for active seizures?
Is patient receiving a sedative infusion for alcohol withdrawal?
Is patient receiving a paralytic agent (neuromuscular blockade)?
Is patient’s score on the Richmond Agitation Sedation Scale (RASS) >2?
Is there documentation of myocardial ischemia in the past 24 hours?
Is patient’s intracranial pressure (ICP) >20 mm Hg?
Is patient receiving sedative medications in an attempt to control intracranial pressure?
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.
RASS score >2 for 5 minutes or longer
Pulse oximetry reading <88% for 5 minutes or longer
Respirations >35/min for 5 minutes or longer
New acute cardiac arrhythmia
ICP >20 mm Hgb
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
Spontaneous Breathing Trials (SBT) are up next. The respiratory therapist will assess for safety.
Is patient a long-term/ventilator-dependent patient?
Is patient’s pulse oximetry reading <88%?
Is patient’s fraction of inspired oxygen (FIO2) >50%?
Is patient’s set positive end-expiratory pressure (PEEP) >7 cm H2O?
Is there documentation of myocardial ischemia in the past 24 hours?
Is patient’s ICP >20 mm Hg?
Is patient receiving mechanical ventilation in an attempt to control ICP?
Is the patient currently taking vasopressor medications?
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.
Respiratory rate >35 breaths per minute for 5 minutes or longer
Respiratory rate <8/min
Pulse oximetry reading of <88% for 5 minutes or longer
ICP >20 mm Hg
2 or more of the following symptoms of respiratory distress
Use of accessory muscles
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.
My remote stopped unlocking the 2009 Prius. The remote light lit up red every time I pushed it but the car didn’t respond.
I went on Google to try to figure it out. I hadn’t driven my car in 5 days. I found out there are 2 batteries in a Prius– one in the front hood to start the engine and the other in back for the hybrid use portion. I was pretty sure the front one was the one with a problem. I looked up how to jumpstart a Prius because I’ve never jumpstarted any car before.
Thank goodness for YouTube videos. And I parked in a garage. I asked one of the attendants to help me although once he heard it was a Prius, he became skeptical since in the past, he was unable to help another patron.
First I couldn’t open the door, so I found out that there’s actually a key inside of the remote. After I took it out, I read that it may be difficult to insert the key to open the door on the driver’s side. Thankfully it was easy.
Next, the attendant drove over a van, left the van on, popped open the hood, and attached the red positive jumper cable to the red, and black negative to the battery.
Using the other end, he connected the red cable to my Prius (under the fuse V12 battery box on the drivers side, flip the red little box), and connected the black on the hood’s metal latch (it sparked!). We tried turning it on several times by placing my foot the brake and pushing the on button. It didn’t work.
We sat a little longer– and took the black one on and off the metal connection several times before I saw my car lights go on, and then start emergency honking. The car turned on!
From the Prius? We took the jumper cables off — black then red. Then from the van, black then red.
Of course, concerned about the health of the battery, we searched up how to check. It was fine.