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platon20

platon20

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platon20's Latest Activity

  1. platon20

    Can NPs write fertility drugs?

    The only NPs who should be writing scripts for fertility drugs are those who work with MDs who specialize in REI (reproductive/endocrine medicine) who have special training beyond the usual OB/GYN stuff. IN that context, yes, NPs can script for clomid. However, it is GROSSLY IRRESPONSIBLE AND BORDERLINE NEGLIGENCE for anybody other than somebody who works at an REI clinic to script these drugs, that goes for both MDs and NPs. I would NEVER allow a family practice NP to script these drugs, just as I would never allow a pediatrician MD to script them either. Its dangerous and foolish for those without special training to get involved.
  2. I dont think its fair to judge all doctors based on that one thread. I will say that Obama picked a poor example to highlight the importance of nurses. He basically said that the doctors were irrelevant and only the nurses provided anything useful which is total crap. A kid w/ bacterial meningitis who receives the best nursing care in the world will die without a doctor's intervention. My point is you need both doctors and nurses. I think Obama was simply catering to his audience. If it were a group of doctors there, he would have gone on and on about how the doctor did the LP, diagnosed meningitis, and saved his daughter's life. My point is that he's a typical sellout politician who will say whatever he thinks makes the audience happy.
  3. platon20

    Is The Doctor Missing It? Stepping on Doc's Toes

    No, this is inappropriate. Nurses cant/shouldnt be calling physician consults. The only exception would be for a crashing patient who needs an ICU doc to assess for possible transfer to the unit. Calling a endocrinology consult for a patient with poorly controlled diabetes is the doctors' job, not in the nursing autonomy/scope of practice. Your job is to document the pooorly controlled sugars and that the primary doc is not addressing the issue. Later you can try to talk to the program chief or head of staff; but calling a consult is out of the question. P.S. High blood sugars is RARELY cause for an urgent consult in the middle of the night. Most endocrinologists I know would be ****** off if they got paged at 4 AM because a known diabetic has a sugar of 500. They'd be happy to add on a sliding scale regimen or increase Lantus dosing in the morning.
  4. platon20

    Difficult Doctors...Vent

    No, this is inappropriate except in circumstances where a patient needs an ICU bed and the primary doctor wont call you back. Only in that circumstance is it OK to call another doctor (ICU doc). I agree with this; best way to go. NO, this is not acceptable. Nurses cant and shouldnt call for physician consults. A consult is specifically a physician to physician deal. First off, a specialist wont get paid for a consult thats called by a nurse. Secondly, most specialists would be rightly angry at a nurse calling a consult, ESPECIALLY in the middle of the night. Thirdly, consults generally require knowledge of pathophysiology that nurses dont have. If a nurse called a nephrologist in the middle of the night with a chief concern of "this patient is oligouric/anuric" thats not very helpful information in and of itself. Its incredibly rare that you need a nephrology consult in the middle of the night, even for a 100% anuric patient. Dialysis can usually wait till the AM, and nurses arent qualified to know when someone needs emergent dialysis or whether they just need conservative management until the primary doctor can talk to the specialist in the AM.
  5. platon20

    We may need fewer nurses in the hospital...

    Ummm, a midwife is not qualified to take care of babies outside of the immediate resuscitation window after birth.
  6. platon20

    We may need fewer nurses in the hospital...

    Umm, trust me you dont want that. Doctors already spend ungodly hours with paperwork for reimbursement. Do you really want to work your 8 hour or 12 hour shift and then go home and do paperwork all night long to "bill" for your services? Because thats what you would have to do. Medicare/Medicaid/insurance companies are built on denying reimbursmeents. That means they come up with ridiculous paperwork hoops you have to jump thru. So just charting that you "placed an IV on Mr Jones" wont get you reimbursed. You'll have to do ridiculous things like record the lot/part # of the IV tubing you used, document a medical code as to why you put the IV in, document which meds and doses were needed for the IV, etc. What you think is a 5 second scribble to get reimbursed just turned into a 15 minute pain in the ass paperwork procedure to get paid maybe $5 for doing an IV.
  7. platon20

    nurses intubating newborns

    I could see the occassional transport RN intubation, but transport RNs doing PICCs? Thats ridiculous. Do they do chest tubes too? The transport RN's job is to stabilize infants for TRANSPORT, not to screw around w/ PICC lines. If they are holding up the transport to the NICU so they can put in PICC lines then they are providing poor quality care. A PICC line is NEVER an emergent issue that has to be dealt with during transport. Our level III NICU has residents and fellows that do 99% of all intubations, PICCs, UVCs, UACs, chest tubes. Its rare that a transport RN does an intubation, but I've seen it happen once or twice when the baby somehow gets extubated during transport. But those situations are few and far between. Frankly someobdy that only does 1 intubation every few months is not qualified to do them. You need an experienced provider to do so.
  8. platon20

    What is so wrong with discussing end of life care?

    I see a lot of accusatory/angry posts on here about how its all doctors fault as to why people are kept alive for so long. I think you guys are way off base. The reason doctors keep people alive is not because they are trying to make as much money as possible or to give residents "extra" training. Its because the DEFAULT mode is to keep people alive as long as possible unless the family/patient says NO. However, in order to get patients/families to say NO to further care is a very long and involved process and its not easy to do. Most of the time in order to get families/patients to withdraw care, you have to give them absolutes. You have to tell them "you will not survive this, there is zero benefit to doing this procedure." Instead of saying that, most doctors will say something to the effect of "you may die, but we dont know for sure." When you say that, the DEFAULT position of patients/families is to say "well since you dont know for sure then lets just keep doing everything." Consider the possible case scenario. 80 y/o man with stage IV osteosarcoma comes in with a major heart attack, asystole for 10 mins before being shocked back to "life" now he's on a ventilator. Doctor #1: "There's no chance of survival. Nothing we do will change his outcome. We should withdraw care" Doctor #2: "He will probably not survive this but we dont know whats going to happen yet. We can do X, Y, and Z if you want but it may not help." I propose to you that Doctor #2 scenario is FAR more likely than doctor #1, because it is very uncomfortable to speak in absolutes. Would you nurses agree with the assessment of doctor #1 if it was your father? Or you would you think to yourself "hey I've seen guys in worse shape than this survive before, this doctor doesnt know what he's talking about." There are thousands of doctor #2 for every doctor #1 out there, because it is virtually impossible to speak in absolute terms about imminent death and survival odds. Given that, its easy to see why the "default" path is to just keep doing stuff for as long as possible. There's a lot of uncertainty in medicine, and that carries across into end of life discussions. Its not as easy to convince a family to give up life support as you guys think it is (that is unless you are willing to use absolutes)
  9. platon20

    Karmic Justice for Winkler County Nurse Doctor

    The reason doctors get away with malpractice is because they can afford dirty lawyers who will sue the medical board any time they get sanctioned. As a result, the medical boards only move against doctors if the evidence is absolutely overwhelming, and usually "simple" medical malpractice doesnt cut it. You've got to rape patients or kill them directly. There needs to be a change in law that gives state medical boards more protection from lawyers and you will start to see them hammer down more of these idiot docs. Texas is a big state -- I seriously doubt that the people running the medical board have any idea who this "cowboy" in rural Texas is or what he is up to.
  10. platon20

    Over riding a resident?

    I agree with #1, not with #2. There are 2 occassions where a nurse should question a doctor's orders: 1) when its unsafe; 2) when its an obvious oversight or duplicate order. The scenario described by the OP fits neither of those scenarios. Its not like the resident ordered a heparin drip for musculoskeletal chest pain. THAT is an unsafe order and needs to be questioned. Doing stat troponins, CXR, EKG DOES NOT HARM THE PATIENT AND IS A VALUABLE DIAGNOSTIC WORKUP, therefore it should have been done, as ordered. You are ABSOLUTELY wrong here, and it illustrates the trouble that nurses have when they think they can replace the thinking of doctors. While its true that chest pain should be evaluated in person by a doctor, there are studies showing that musculoskeletal chest pain vs ischemic chest pain in post-op patients cant be distinguished very well by most patients. Therefore they deserve a basic workup. As for troponins being "worthless" in OHS cases, again you are absolutely WRONG on this point. Of course they are going to have elevated troponins, but the TREND in troponin rise is critical. Lets say you have a pre-op heart patient with troponin of 200. Post-op, it rises to 500 due to myocardial injury from the procedure. Then, it will commonly start to drop off slowly, maybe 2 days post-op its down to 250. Then the patient c/o chest pain on POD #3 and the troponin level is back up to 400. Are you honestly going to sit there and ignore the troponin level because you say its "useless" in OHS cases? Thats absolutely wrong logic, if post-op troponins rise at hte same time the pt is c/o chest pain, then you have to assume that they are having an ischemic event post-op that needs to be managed. Again, to say that troponins serve no role in the post-op care of OHS patients is ridiculous. Thats something that DOCTORS, not NURSES, are trained to address and you are wrong for thinking you have the knowledge base to make that decision. Thats no justification for ignoring the order. If you are getting swamped by critically ill patients and cant keep up with them all, then its your responsibility to notify the charge nurse and have somebody else help you out. You cant in good conscience say "I'm too busy with my other patients to deal with this patient who could be having a life-changing ischemic event."
  11. platon20

    Deciding to call MD

    Easy for you to say. How many 36 hour shifts do the ARNPs in your unit work? Where I am, its only the residents who work those kind of hours, the ARNP are there for their 7-7 shifts and then they go home.
  12. platon20

    When doctors don't return calls.....

    You guys actually call the cops? Thats ridiculous. What the heck are they going to do? Arrest them for not answering pages? Absurd. Cops have a lot more important work to be doing rather than chasing down lazy docs who wont answer their phones. I'm surprised the police would actually agree to do that kind of work.
  13. platon20

    Tonight's Boston Med: nurses featured!

    Re: ER nurse amanda talking to the resident: It wasnt what she said, it was the WAY she said it.... with a lot of attitude and a superiority complex in her voice. Her body language and tone was atrocious. The proper way to address this would be as follows: Nurse: "Dr X, I noticed you ordered 1mg haldol for our patient. Can we give her a larger dose? It comes in 5mg/1mL and the standard dosing range for haldol for agitation is 2-10mg IV or PO. We usually use at least 2mg." Its totally nonconfrontational and a much better way to handle the situation. Now if the doc refuses or gets an attitude, then by all means go over his head or tell him that he's wrong or whatever. But that should be a SECONDARY response, not the primary one. There's no need to be rude when you dont have to. Rudeness should be saved for situations that are A) life threatening or pose a serious risk to the patient's health; B) after repeated attempts to be nice have failed. The situation shown on TV with the resident ordering 1mg of haldol instead of 2.5mg falls into neither of those categories.
  14. platon20

    Multidisciplinary rounds

    Oh I'm sure thats exactly how it happened. If you sent out a memo to all the surgeons about it, I'm sure they'd love the idea in theory as well.. Then, when the rubber hits the road and they realize that its going to delay them by even a little from getting to the OR in the AM ASAP, thats where it falls apart. Getting surgeons to agree in principle to group rounds and then actually getting them to utilize it in practice, when it makes them "late" in getting to the OR, are 2 entirely different animals. You structure the rounds in such a way so that they can get to the OR at the same time, and I'm sure they would all be glad to do it. But time is money and as long as they perceive these group rounds to be holding them away from their cash machine (i.e. OR time) they are NOT going to participate.
  15. platon20

    Multidisciplinary rounds

    Good luck getting any kind of surgical MDs to do multidisciplinary rounds. They are a lot diffferent than non-surgeons. Their "rounds" consist of a 3 minute peek at the patient and make sure they are still breathing. Then its off to the OR as quick as possible to get as many cases in the day as they can. Non-surgeon MDs will be more receptive to the idea, and thats ONLY because they dont have any OR time they are trying to schedule around. They have a lot more time to hang out and do rounds with everybody. Multidisciplinary rounds are a good idea, its helpful to get everybody on the same page. However coordinating all those people to come together at the same time is a logistical nightmare.
  16. platon20

    Are hospitals deadlier in July?

    Its not that clearcut. I've been called to patients with HRs in the 20s before, only to find out later that the monitor was malfunctioning. I wouldnt break out the pacer immediately, I'd wait for a double check on the equipment first before doing so. Now, if the MD knew for sure that the HR in the 20s was legit, then yes they should have done something about it. How far off is this from the patient's baseline? I've seen PCO2s in the 100s before in chronic retainers who we didnt do anything about. Did the MD just refuse to intubate and instead try BiPAP instead or some other resp support? I dont know that doing a stat intubation is the first thing that comes to mind with all patients with the blood gas you listed. Depends on the circumstances. Was this REALLY an NSTEMI or just suspected? Elevated troponins by themselves dont necessarily mean NSTEMI, they are somewhat vague in terms of diagnostic criteria. I've seen patients with troponins in the hundreds before with chest pain that we didnt treat all of them as NSTEMIs. I agree, the stipulations made above seem unreasonable to me. I agree, but I think this is not something that deserves a page at 0300 if this issue came up on the night shift. They can wait till the next morning when the attending comes around to change the diet order. I agree, with the caveat that if all the RNs suddenly changed on July 1st and you had a bunch of new grads on the same day that you would have very similar problems and the death rate would go way up.
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