Hekate

Evidence-based practice would be my answer to you! Your practice is your responsibility and your patient's safety and well being should be your priority. Therefore, a N-years old manual is NOT a reference. No one has time in our profession! Yet we still have to keep up with the latest literature and best practice.It is up to you to read and keep up with the latest trends and best practices. HOB at 30 degrees is the standard of care in most places. Holding the feeds when the patient doesn't tolerate it is both a safe practice and common sense- Knowing where your feeding tube is (pre or post-pyloric sphincter) is of importance as well (they are not managed the same way)-Your supervisor is not the primary nurse, therefore, he or she does not have a say beyond advice. If another nurse does something that you think is wrong, that is also your responsibility to call her up on it (and check your references). There is so much more to cover, but if I have to sum it up, I'll say it again: Evidence-based practice H~

I would tend to agree with ParkerBeanCurd (what's that by the way?) At the same time, I do understand the points made in the other posts....So my question to you is: Are you going to spend time volunteering? If yes, then I don't see what the issue is. You are still providing a helpful service for free, and if it benefits you too, there is nothing wrong with that. It will indeed give you a good feel for the place and if you get hired as a RN, you will already know the inner work of the place, which would definitely be a plus! Try to work the desk if you can, this way you get a chance to familiarize yourself with the paper work/computer system, protocols, etc.... I think it should be a win-win situation ! But my advice: Try to keep a low profile from now on, and let people warm up to you before you share your goal with them. I hope it all works out in the end! Good luck H~

As an ACNP, your scope of practice is Acute or Chronic complex conditions. What it means is that you are primarily trained to take care of patients with complex health issues, and most practice in the ED and ICUs. The outpatient, clinic type of work is possible for the ACNP, however, it would have to be in a specialty clinic, i.e: cardiology, surgery/trauma follow-up etc... The ACNP's education only lightly touches to primary care topics and concerns. If you are set on only doing outpatient work, then ANP or FNP would probably be more adequate. The other question you should ask yourself is, what is the type of patient you would like to take care of- what I mean by that, is that if you are very interested in kids, pregnant women etc...then you should consider FNP who cover the whole life spectrum and could take care of kids, as well as adults, and follow pregnancies etc.... Not to fret though, because once you are an NP, you can always come back to do an addition specialty- for example, if you were a ANP and realized that you truly enjoy more complex health issues, you can do a cert to have your ACNP on top of your ANP (and they are often available online, but do have clinical requirements). I hope my post made sense and might help you a little..... Good luck, H~

Well, I wouldn't recomand Shoal Creek! One of my friends use to work there and it was VERY unsafe! The rest of Seton seem oriented toward quality of care and put a big emphasis on shared governance and education- If you are still considering applying to one of the Seton hospitals, don't hesitate to shoot me an email if you have questions! (and a few ICUs are willing to train med-surg nurses if you are still thinking about it). Cheers! H~

Ever thought about starting a "SMART management course/center" with your former boss? we need more managers like you! "1. Never ask anyone to do anything you have not done yourself first. (This includes working off-shifts, holidays and weekends. Every manager should work at least 1 non-day shift per pay period, if not more. 2. Never mess with people's schedule. See rule #1. Work for them if needed, to accomodate their reasonable requests for time off. 3. Never mess with people's pay. If an error occurs and it is your fault, fix it yesterday. If an error occurs and it is the employee's fault, fix it tomorrow. Never expect an honest employee to wait until the next pay period to receive their money. These rules served me well as a manger. I hae n idea if my former boss reads this board, but if she does, I hope Cathy R. of SC recognizes herself :)"

Hi There! I use to want to do the CRNA training as well....that is, until I shadowed one of the CRNA I use to work with. As he said it so well, the job of the CRNA is 95% boredom and 5% pure panic! I think it all boils down to your character and what you are looking for. If spending hours behind the drapes of an OR doesn't bore you to death, then it might be the right path for you.This is a simplistic approach on my part, because CRNAs are very knowledgeable professionals and their role is crucial. But the daily reality of the job is something you might want to look at up close. In my case, one day with a CRNA was enough to convince me that I wouldn't be happy in that role because I can't stand being bored, nor having to deal with prima dona surgeons. I truly admire CRNAs as I have worked closely with many, and they regularly saved the situation (and the patient)in the post-op Open heart settings. But I think that the assessment of the CRNA I shadowed was dead on: You do get the critical situations 5% of the time where your skills and knowledge will or not save the day. But for the 95% of the time left, their role is very repetitive and a lot of "rushing then waiting" for hours on end. I went for the Acute Care NP master because it offered a similar level of knowledge base practice while having a lot of hands-on and complex procedures. In my eyes, the added bonus is to continue to have busy and rich work days interacting with patients and colleagues. On the salary level however, an ACNP doesn't make nearly as much money as the CRNAs. It is a question of personal priorities....In my eyes, no amount of money could make up for boredom (but I am an adrenaline junky, so no reference by any means!) I hope this helps a little... Good luck! H~

very well. you are entitled to your opinion, but since you call my posts "disrespectful rants" and accuse me of playing the victim card, i'll ask you if you have actually read my posts in their context? i am merely reacting to posts that i find very disrespectful and ignorant. i don't appreciate being constantly bashed because i am a foreigner and many of you "believe" that foreigners "take" your jobs. so i am sharing the nice reality of a foreign nurse coming to the us. stating the xenophobic practices i have experienced in this country hardly counts as a "victim act". i find quite interesting how little compassion and understanding one can have. does that mean that if you were to witness someone being discriminated against you would not do or even feel anything? i guess it is a sacro-saint crime to criticize even the most evil practices in the country!? do you agree with everything happening around you? beside being treated like a piece of crap by immigration people and a few citizens, i consider to have it easy as far as life style is concerned. but in case my message didn't get across, what makes me sick is to see how much injustice, poverty and violence exists in this country despite it being portrayed as the land of all opportunities. coming from another country, i did and still do find shocking to see the disparities in a country that projects an image of such opulence. contrary to what you think, my disgust is caused by the lack of tolerance and generosity i see around me. i am floored to see how many people struggle with the bare minimum to get by day in and day out. where i come from is no paradise, but i can say that everyone is given an equal chance to education, health care and social support. i wish i could say the same thing about this country, but unfortunately, it isn't so.... do you disagree with that too? i would have expected to find a more socially oriented crowd amongst nurses! i guess i was wrong on this count as well.... one last thing: when you say something like "i can hardly take you seriously as a person", at least do us both the favor of giving some king of rational for your "opinion". otherwise, i could not take your criticism seriously either.

i believe you have truncated the part of my message explaining my reaction. it is quite typical to manipulate words by taking them out of their context! know that my husband is a us citizen. know that my knowledge of history is not limited to the history of the usa, but covers most of the world (that is 12 years of history classes....all year long, year after year.) i weigh my words before writing them and if you believe that the poverty in this country is caused by your generosity to foreigners, you are only showing the depth of your ignorance. in my practice as in my life, i make no difference in the way i treat people regardless of their origins. tomorrow i am spending my day volunteering for less fortunate than me, and these people happen to be americans. as far as pretending to know what other immigrants/foreigners really think, i will tell you this: most of them will never tell a non-immigrant what they really think because they know how their frank opinion would be received: like you received my opinion. with intolerance... ask yourself why the usa is "hated" by most of the rest of the world. certainly not because you are peace makers! you only intervene in conflicts where there is something to gain, and if you know your history that well, then you must know that the us has put people in power to then demote (and execute them) when they gained too much autonomy. please do prove me wrong and give me one single example of us intervention where genocides are taking place, but no oil or geopolitics positions are motivating the intervention. "to read that you are very discontent with out country concerns me with you being in the medical field." do please explain this remark. as is, it does not make any sens to me. once again, let me reiterate the fact that you have taken the end of my post out of context. i don't believe it to be a very honest process. if you lack the humility and the curiosity to wonder if there could be some truth in my opinion (which is based on experience, not on a preconceived notion) then you are just exemplifying the narrow mindedness i come across so often. to disregard all the other things i have written about my experience as a foreigner in this country worries me as far as your abilities to have compassion for a fellow human being.

at least we don't get called "sister" like in the uk! that would definitely be a difficult title for a male to wear! unless there is a male equivalent? brother ? just kiddin!

yes! many other professionals trained in other countries are indeed hired in the us. furthemore, many of these professionals are recruited by american hospitals, universities and companies in their own countries to come work for them on american soil! you know why? because they can't find the same level of trained professionals , researchers, doctors etc... in the us! i think that you are very much "biased" and i truly wonder under what rock you live. unless you are 100% indian, you too are from immigrant decent. fyi: i will likely always be hired over an american new grad because i have more experience! (and worldly experience at that!) if you think that coming to work in the us as a rn is an easy process, think again. it took me over a year of exams, tests, screenings and exorbitant fees (out of my pocket) in order to be allowed to work in the us. which didn't mean that i had a work visa. in order to have a work visa, i had to be offered a job , and for my future employer to prove that i was qualified and would receive such salary and such benefits. only then could i apply for my tn visa. each time i left the country, my work visa was ripped off from my passport and i had to re-apply upon returning on us ground (it doesn't matter whether it was for a week-end in canada or a month in timbuktu !) every single time, i would be searched, my luggage would be searched, and i would have to wait hours on end at the airport, often missing my corresponding flight, in order to be re-issued my tn visa. every single time, i was questioned and treated like a criminal. i haven't returned to my country for 2 years because of skewed immigration laws (and mistakes). which means that i haven't seen my family for all this time either. even if i travel within the us, i end up being the one chosen for a full search. a 100% of the time! i was even accused of bringing in forbidden food after i forgot to remove a clementine from my hand bag given to me on a us airline flight. this was a national flight and the clementine had a nice big sticker saying "florida" on it! none the less, i was treated like a terrorist! trust me, nothing is worth all the humiliation and aggravation i have (like many other foreigners) gone through in this country. nothing, beside maybe the love i have for my husband. and get this: although i am paying the same amount of taxes as any american, i am not eligible for any grant, loans etc....if i were to be unemployed, i wouldn't be eligible for unemployment. considering that 30% of my pay check goes to uncle sam, i think that you should actually be happy that foreign professionals work in your country! it means free money for you! it is so disappointing to come across people like you with so little heart and many preconceived notions...

i'll take the bait. would you please explain why it "is so wrong" for foreign nurses to have a work visa, a green card, or to become american citizens? i was so tempted to report your comment as inappropriate, but my curiosity wins over my disgust. so do please explain your position/ opinion or rational.

there are 2 possible answers to your question (i'll assume it is a question...) : 1) the foreign nurses hired over the american new grad had more experience, and is therefore less costly for the hospital to train. 2) the foreign nurse was sponsored by that particular hospital to obtain her work visa/green card and therefore owes that hospital between 2 and 5 years . as a result, the hospital gains an employee that they know will not quit at least until the end of their contract. lastly, it may be a combination of the above 2 answers....when an employer sponsors a foreign professional, they have to prove without a doubt that the foreigner they are about to hire and sponsor is better qualified than an american professional applying for the same job; or that no american professional has applied for the said job for x months.

i have heard this theory of yours many times before, and quite honestly, it makes me sick! an officer at the border gave me attitude when i went to renew my tn visa and basically said something like what you wrote above. my then fiance begged me to keep my mouth shut, but i just couldn't. so i will tell you the same thing i told this officer: i came to the us because my then fiance is a us citizen and it was the only way for us to be together. i didn't come for the salary, because i made more in my country. i didn't come for the social/health insurance "benefits" because i had better coverage and much lower costs in my country. i didn't come because the life style in the us is better since i think that social conscience and life style just suck in the us! i came from a country that is rated in the first 3 best health care systems, and where quality of life is as good as it can get. we work hard, but we value our personal time/family time just as much. we start off with 7 weeks of paid vacation per year. our education is paid by our taxes (which isn't higher than the us taxes, before you ask). univeristy cost me 200$ out of pocket per year. should i continue? despite being the land of all hopes, i find that the us is very much backward in so many areas that i feel sick to my stomach on a daily basis to witness the injustice, racism, narrow mindedness and greed going on here in the us of a! there are many immigrants who come to the us because the image this country projects outside is one of ease, affluence and freedom. but, to this day, i have yet to meet an immigrant who thinks that the image projected is anything like what they have experienced since coming here ! wake up my dear, your country is certainly not a god send, and many many americans live below the poverty level. the violence is unheard of in any other industrialized countries! this is not a land of opportunities as far as i am concerned. there is much segregation going on. much censure as well. education is the least of all priorities and that is because it is much easier for governments to manipulate a nation of ignorant people. there is much hatred and i am ashamed to ever be associated with the pettiness and narrow mindedness of so many people in this country! the only real "americans" were the indians living on these territories before the colons came and killed most of them, then parked the survivors in reservations. nothing to be proud of!!! people like you seem to forget where you came from. do your homework, learn your history, and stop spitting mean comments to create more hatred.

if finding a micu position is difficult because they only want experienced icu rns, you may be able to befriend the icu nurses/manager if you ask to shadow there (for free). it would allow you to get some experience (very little though) but more importantly, it may allow you to put a foot in the door. once you get to know the team and their manager, you can try asking for a position (or even to take prn icu shifts) directly to the icu manager~ this way you know that you have that manager's support before putting your request in to be transferred. the downfall of that theory is mostly time.... it would likely require for you to invest unpaid time in order to gain the network that will support you in your future request. maybe worth a try all the same? good luck to you and keep us posted! h~

hi, time has come to start my first 2 clinical rotations. issue: i am relocating to austin (tx) and don't (yet) know anyone there. i am in the acute care np track, and both clinicals need to be done within a hospital system. that being said, one rotation focuses on the assessment skills (head to toe, and specialized by system i.e : ear, nose and throat ~ cardiovascular etc...) and the second (simultaneous) focuses on prevention and maintaining health. i would have gladly contacted a pcp/family doc, but my program director thinks doc's approach isn't holistic enough and i would "catch" bad habits i would appreciate any link, direction, contact info (or whatever you can think of) to get me started in my search of a mentor for these upcoming clinical rotations. all suggestions welcome! many thanks, h~

congratulations on the job offer, it sounds very interesting and challenging (in a good way!). i guess your quest should mainly be to find out if there are limitations in your scope of practice as a fnp. as for the role itself, if it interests you, i believe that your knowledge and skills will be honed by the experience and the training and guidance provided by the md/do or other nps you will be working with. one of my friends and ex-colleague is a fnp who now works for a group of neuro-surgeons in a level i trauma center. her job goes from assisting the neuro-surgeon in the or to rounding on all their patients and taking in-hospital calls for the group. as a result, she does the neuro-trauma consults in the ed, covers the neuro-trauma icu, reads ct scan, mri, mra, and even execute burr holes when needed. she seems to be doing great and truly enjoys her position. although she was doubtful about having the required skills for the job when she started, she was relieved to find mentors in her employers and gained the required knowledge by working alongside those surgeons. i "shadowed" her in the or and saw first hand how patient and great teachers these neuro-surgeons were. if you can find the same level of kindness and mentorship with the group offering you the job, it shall be an awsome opportunity! very little information i'm afraid, but i hope it helps... a little.... if i were in your shoes, i would go for it (but it all depends on what you are looking for). best of luck in your decision making process! h~

You can make a comment directly on the web-site above. Here is what I wrote... I have taken care of many patients post-op mastectomy in the PACU (post Anesthesia Care Unit) and the SICU (Surgical Intensive Care Unit). This procedure is extremely invasive and traumatic to the patient, physically and emotionally. Not only is a part of the breast, a whole breast or both breasts removed, but the surgeons have to track down and cut were the margins of the cancerous tissues are in order to prevent the cancer to spread further. It usually means that all the "ganglion" draining the area must be scraped and analyzed, often going all the way up under the woman's arm.Most often nerves,muscles and the lymphatic system are irreversibly damaged during the process, causing a lot of pain and limiting the range of motion of the arm affected (If bilateral mastectomy (on both sides) = both arms are affected). Risks of infections are high, even more so for the patients who have already started chemo and/or radiation therapy (if it kills the cancerous cells, it also kills the healthy cells, including the ones responsible to naturally fight infection). Because the lymphatic system is often scrapped off during the procedure, the "drainage system" is severally affected or even totally removed. The sequels following such surgery are usually extensive and the patient is in no position to take care of herself. It means that the burden falls back onto the shoulders of their family, whether they are or not able to provide adequate assistance and knowledgeable care. Indirectly, and beyond the risks it exposes the patient to, it can totally paralyze the earning power of their "caregivers" and affects the whole family. The husband or companion must stay at home to take care of their loved one despite the fact that most companies do not offer the option of taking time off (and retaining either their income or even their position). Additionally, General Anesthesia can literally be considered like a poisoning of the whole body.Most patients coming out of anesthesia are in atrocious pain despite being half unconscious. Several hours after awaking from the anesthesia, patients are nauseated and weak in the best of case, but most are downright sick like dogs, throwing up and unable to keep fluids or pain medication in their stomachs long enough to benefit their body. If these patients were allowed to remain in the hospital at least 48 hours post-op, they would be able to receive Intravenous re-hydration, anti-vomiting medication IV, pain killers IV, and all the assistance of nursing care, from washing and using the bathroom to changing the dressing, caring for the drains appropriately and monitoring any signs and symptoms of infection. It has been my experience that status post-mastectomy patients were too sick to be sent home by the end of the day after their surgery. Because the insurance would not allow to keep them, We have often had to officially discharge the patients,only to send them directly to the Emergency Department so their nausea, vomiting and pain could be relieved (which could have been done post-operatively on a surgical unit or even an observation unit). Conclusion: It is a very short sighted "solution" to send these patients home the same day. They often are re-admitted via the emergency room to manage their symptoms, which costs more to the insurance in the end. It also increases the incidence of post-op infections, sometime being serious enough for the patient to be admitted and treated in an ICU (most expensive hospital stay of all!), and beyond the costs these complications generate, they surely decrease the chances of recovery for the patient (and therefore their survival). If you can't find it in your heart to treat these women with the minimal human compassion, crunching numbers of the complications associated costs should convince the insurance companies that a longer post-op in-hospital stay is the way to go; medically, humanly and financially!

no offense, but i think that this is the most stupid excuse your facility served you! are you telling me that when you are on brake no one is covering for you? i regularly answer call lights for patients that aren't mine, including when their nurse isn't on brake. i have a strong feeling that your facility gave you those (most likely fake) sentinel events to explain their policy, but it doesn't fly one bit! seriously, have you ever encountered a family or a patient that nicely stays put when they are in pain or having difficulty breathing until someone asks them what is wrong??!!! i maintain that such policy is a license to mistreat the nurse. i bet you that management and administrators think it gives a great image of their customer service! i can see the billboards from here: "in our hospital we value your wants and needs so much so that our nurses never need to pee or eat, they only breath for the pleasure of serving you!" pluuease!!!

this has gone so far, it's unbelievable, scary and sickening! i feel so angry for you!!! so the advisers are not the payers, however here is what i would do if i were in your shoes: -ask your "current" employer (i mean the one that just terminated you) to see the policy they "quote" for your dismissal. if it even exist, i would be surprised if it actually addressed your particular situation i.e "no restrictions". - in my book, that would be one more company to sue! reason for the law suit :" wrongful termination and discrimination." they should not get away with it! - since you have more time on your hands now, try to use your anger as energy fuel to put together a law suit from hell for the 3 entities that wronged you: the bon, your previous employer, and this last employer. (and remember to be angry, not depressed! as a poster wrote, this speaks volume about them! it does not define you! and please do not believe one second that you are "damaged goods"!!!) - please do not let this situation make you doubt yourself! you did nothing wrong, and you should be commanded for your courage in the face of adversity, and your insight and maturity for seeking professional help. this is surreal! i still can't believe you got treated that way! i am not knowledgeable in laws and regulations, but i would bet my head on the fact that the actions taken against you would not (and should not) be condoned by the laws of this country (or your state). what state is that again? i just want to look into the online resources i can find about your particular state,bon, and even the different hospitals treating you in this shameful way. if you don't feel comfortable posting this information publicly, please feel free to send me an email. i don't pretend being able to help you much, but i would like to try anyway. -what does your lawyer says about it all? do you trust that he/she is really doing everything that could be done? i totally understand how run down you must feel, however i am begging you not to let it defeat you. once again, you haven't done any thing wrong. i hope to read from you soon and will pray for you meanwhile (and search the web on every free moment i get!) hang in there gotta girl! :redpinkhe h~

i can't believe what i just read! are you guys going along with such insulting, inhuman directives? i would throw a fit!:angryfire why wouldn't it be known that nurses take a lunch break? are we robots? do we not qualify for the most basic human needs?! this is just wrong in so many ways! i very rarely take my breaks and it isn't normal- but to actually advertise to patients a culture of slavery for the nursing staff is intentionally belittling and encouraging abuse! that really made me sick!

wait! it can get much worse! i know of an hospital where they provide .*.*.*:wshgrt:.*.*.*.(clue: it's pink) (the :devil:funniest:angryfire part is how i've learned about it) ~the patient asks her nurse: "when will i be served breakfast?" ... and i am thinking for myself "hellooo..hospital! not hostel!". the nurse turns around and with a big smile and a sweet voice says: "but my dear, you have to call room service to order first ". thinking that she is being sarcastic, i start laughing uncontrollably ....until i notice that the nurse is indeed handing the patient a menu, while both are :angryfire glaring at me. i almost fell off my chair! the patient is on the phone passing her order for poached eggs, but when she hangs up she looks like someone has just farted under her nose. i can't help myself but ask why she seem so....heu...upset (???) god! i should have kept it shut! for the following 2 hours she went on and on like a broken record, repeating again and again : "can you believe this!? they don't have poached eggs!! ! that is incredible!!! it is just unbelievable!! no poached eggs!!!!" as it turns out, that hospital has hired a well renown hilton (or some other posh hotel) ceo to be the head of the hostelpital!! i have been having anxiety attacks ever since....:anbd:

to get you started, i think you should first learn and understand the pathophysiology of shock + sepsis/septic shock: def of shock: complex clinical syndrome of decreased blood flow to body tissues resulting in cellular dysfunction and eventual organ failure. clinical picture of shock: * tachycardia *cold, clammy skin * hypotension * oliguria * decreased mentation compensatroy mechanisms to correct shock * catecholamines * leads to sns activation via baroreceptors * a (alpha)= peripheral vasoconstriciton *b1 (beta 1)= increase sa node firing, conduction through av node, and force of contraction, and coronary artery dilation *b2= bronchiolar dilatation * arterial constriction * venous constriction * dopaminergic * increased respiratory rate ~chemoreceptor reflex * interstitial fluid shifts * increase release of renin and aldosterone * increase release of adh * thirst * cns ischemic response septic shock is a subclass of "distributive shock" : etiology * severe overwhelming infection~ shock refers specifically to decreased tissue perfusion resulting in end-organ dysfunction * component of sirs (systemic inflammatory response syndrome) * causes: the process of infection by bacteria or fungi can result in systemic signs and symptoms that are variously described. approximately 70% of septic shock cases are due to gram-negative bacilli that produce endotoxins. the condition develops as a response to certain microbial molecules which trigger the production and release of cellular mediators, such as tumor necrosis factors (tnf); these act to stimulate immune response. besides tnfα, other cytokines involved in the development of septic shock include interleukin-1β, interleukin-6 and interleukin-8. pathophysiology of septic shock * host response mediated by complex hormonal and chemical substances* * decreased myocardial function * decreased force of contraction, reduced preload (due to massive vasodilation),decreased ef, increased edv and pressure * alterations in peripheral circulation * massive vasodilation * maldistribution * increased capillary permeability cytokines tnfα, il-1β, il-6 released in a large scale inflammatory response results in massive vasodilation, increased capillary permeability, decreased systemic vascular resistance, and hypotension. hypotension reduces tissue perfusion pressure and thus tissue hypoxia ensues. finally, in an attempt to offset decreased blood pressure, ventricular dilatation and myocardial dysfunction will occur. septic shock: clinical manifestations * low arterial bp ( systolic blood pressure mmhg, or a map * low svr * altered o2 extraction * tachypnea (rr > 20 or paco2 less than 32 mmhg) * tachycardia * reduced myocardial contractility * wbc count 12000 cells/mm³ * temperature instability (witch means elevated or below normal) * other organs will start shutting down virtually all other organs are going to be affected =>respiratory failure is common in the first 72 hours after the original insult. in the gi, the blood flow to the gi mucosa is going to be altered resulting in decreased mucosa, hepatic failure often follows,clotting abnormalities, and gastrointestinal bleeding. for the kidneys, we are going to see oliguria (abnormally small production of urine) then renal failure... decreased loc or changes in mentation and increased respiratory rate as it often develops into ards ... treatment of septic shock: * antibiotics * remove source of infection * fluid resuscitation * vasoactive meds * experimental tx: high dose steroids, naloxone, mediator inhibitors, monoclonal antibodies. recombinant activated protein c has been shown in large randomized clinical trials to be associated with reduced mortality in patients with multi-organ failure. it is also being reviewed for treatment of ards (which has a large incidence of pulmonary coagulopathy) with positive results. continuum of septic shock: * infection * sepsis * severe sepsis * septic shock * multiple organ dysfunction/failure * death => it begins with an infection or invasion of microorganisms => stimulates the systemic inflammatory response => we can say that sepsis is present when this systemic inflammatory response syndrome (sirs) is activated in response to an infection => sepsis progresses to severe sepsis when that inflammatory response (because of the release of endo-toxins and secondary mediators) has become harmful resulting in => organ dysfunction, hypo-perfusion and hypotension. it then progresses to multiple organ dysfunction ( multiple organ dysfunction syndrome or mods) and eventually death. multiple organ dysfunction syndrome is well established as the final stage of a continuum systemic inflammatory response syndrome -> sepsis ->severe sepsis ->multiple organ dysfunction syndrome.(from wikipedia) i hope this helps....since i don't know the purpose of your question, i focused my answer on the mechanism of shock and septic shock, as well as its syptoms and a few treatment options. you will see however that the practice changes depending on the hospital and the intensivist in charge of the icu. for example, the use of recombinant activated protein c is often used as a last ditched effort, which is often fruitless. some hospitals that cater to a "higher" socio economic population start using activated protein c as soon as spesis is spotted with a much better outcome... ps: all the underlined words in dark are interactive links to the corresponding wikipedia page with definitions and explanation so you can look up the terms you don't understand. good luck! h~

i think that what you have encountered with this ob head of dept is something we all experience regardless of the health system in place (unfortunately) . i have worked with the head of trauma for 2 years and this surgeon was known for making the most horrible mistakes! when patients have asked me if he was good, i tried to make tons of compliments about another surgeon that i knew was good without bashing the head of trauma in the hope to steer patients away from his incompetent hands. i often wondered why he was still in place~ not only was he a bad surgeon~ but he also had the worse character and working with him meant being regularly insulted, yelled at, not to mention trying to tie the loose ends after him. i was told that the reason he remained in his job was because a) no one else wanted to be the head of trauma (too much trouble, paper work, calls etc) and b) because he was on every possible board (general surgery, trauma, ems, political boards, hospital boards etc..) and therefore was so embedded in the social and professional network that nobody felt safe to point out his short comings. to my knowledge, several law suits were made against him, but again, his position within the political, medical and social network of this community protected and defended him to ever be judged guilty! and this is happening in our us sue-happy system.....:barf01::lol_hitti

there are many possibilities. first, is your patient a type i or ii diabetic? secondly, what do you know about his stroke? what part of his brain was injured? was it an ischemic stroke or an hemorrhagic stroke? does he have residual deficiencies resulting from his stroke? the association of hyperglycemia with congestive heart failure & brain injury (whether ischemic or hemorrhagic) may reflect a secondary stress response resulting from these complications (you said he has cad, does he also have chf?) hyperglycemia in the setting of acute neurological injury is felt to be attributed, in part, to a catecholamine surge and generalized stress response.this increase in circulating catecholamines is, subsequently, associated with a rise in serum blood glucose.elevated levels of glucose may lead to continued anaerobic metabolism and the production of elevated lactate levels, which in turn can aggravate ischemic insult, increase neuronal injury, and worsen the neurologic outcome... in ischemic stroke, hyperglycemia occurs in 20% to 40% of patients and is associated with infarct expansion, worse functional outcome, and an increased risk of death. in other words, his resistant hyperglycemia may be neurogenic. how high is his bg? you have already mentioned that the patient wasn't on steroids- does he show any sign and symptoms of an infection? you mentioned that he was barely eating...is this a new finding post stroke? is he drinking enough water? my next guess would be hhs: hyperosmolar, hyperglycemic syndrome (hhs). the keys to answer this question are that the patient is a type ii diabetic, the blood glucose is very high (1200 mg/dl), and the patient has been ill for several days resulting in dehydration. there are two ways that your patient can end up with high blood glucose: 1) too much glucose, and 2) too little water. think about making a glass of lemonade; you can make it sweeter by adding more sugar or by adding less water. diabetic ketoacidosis (dka) results from a lack of insulin (adding more sugar); hhs results from a loss of water to dilute the glucose (adding less water). the keys to distinguishing these problems are: dka develops within hours, in type i diabetics, with glucose levels ranging from 250-800 mg/dl; hhs develops over a period of days, in type ii diabetics, and has higher glucose levels, usually greater than 600 mg/dl. the treatment priority for dka is to replace the insulin because dka is caused by an absolute insulin lack. due to an osmotic dieresis from the high glucose level the patient with dka will also need fluids, but the mainstay of treatment is insulin. the treatment priority for hhs is to administer fluids because hhs is caused by fluid volume deficit. the patient in hhs may also need insulin to decrease the blood glucose and reduce osmotic dieresis, but the mainstay of therapy is fluid resuscitation. sources: ed4nurses & pubmed i hope this helps....keep us posted on your meeting and what comes out of it. i think it is important to find out what the cause of his hyperglycemia is, as it is likely a symptom, but whatever the cause is, it is equally important to treat his hyperglycemia to prevent further complications. h

i beg to differ! have you ever worked closely with a surgeon? or any us doctor? because i can assure you that the choices they make, their practice, is highly impacted by the different insurance policies, hospital incentives etc... i'll give you a very basic example: a young man undergoing cervical discectomy & fusion as an out patient because his insurance would pay 3000 $ more to the surgeon if the patient was not admitted! this is not something i heard off, it is something the surgeon told me directly! is it not a crazy and unsafe practice? the surgeon eventually accepted to keep the patient as a 23 hours stay because i checked with the insurance that it didn't qualify as an admit, this way the surgeon got his bonus, and we kept the patient until the next day to make sure nothing happened to him... i rest my case :angryfire