Tenesma

exposed gray matter and blood in the lungs does not make for a good donor (except for bone/cornea, and you don't have to keep them intubated for that). the force of impact to reveal gray matter is not compatible with life, and therefore you are just keeping a brainstem alive. etomidate is useless for many reasons your only choice is a cric... but what a waste of time in the field. I would just bag-valve mask and transport to the hospital and hopefully the pt would expire en-route...

if i see gray matter i would place an IV, hydrate them w/ some morphine and let the family say goodbye with a lot of bandage on that pts head/face...

While PA, CRNA, PH.D. students do take some courses with medical students - they often don't take the same amount of hours and don't take all the tests involved with that specific course. For example, CRNAs take some physiology classes w/ the med students for specific components but aren't present throughout the year for that class. If however somebody were to take the complete class, including all the hours and all the tests, then I would think it only fair to receive credit as well.

Your position is that CRNAs can do Chronic Pain and the interventional aspects of it - since you guys contend it falls under the practice of nursing - and since you have some superficial exposure to pain intra-operatively and post-operatively. Why don't CRNAs do Nephrology and Dialysis, or Pulmonology and Bronchoscopic Biopsies, or Intensive Care, or Pediatrics and vaccinations, or Cardiology and Interventional Caths w/ stent placement? You could argue that superficially you are exposed to renal management, bronchoscopies, vasopressor management, pediatric cases, intra-op MIs during your cases - so therefore those fields should become the practice of nursing... that argument is weak - I implant spinal cord stimulators on a regular basis, but it doesn't mean that I will start doing Motor Cortex Stimulation. The acquisition of knowledge is necessary and so is the appropriate training. A CRNA who is trained to do a physical exam is geared towards pre-op eval (ie: airway, cardiac, pulmonary, and checking if the pupils are dilated) - the finer findings of a non-crossing patellar reflex and positive ipsilateral babinski in a patient with loss of proprioception wouldn't mean much to you unless you had the fundamental knowledge of the proper functioning of the lateral corticospinal tracts with interruption of the lateral spinothalamic tracts - so that you could diagnose Brown-Sequard syndrome. Somebody who treats chronic pain really should be a physician, and have both the background anatomical/physiological/neurological understanding of how to diagnose, and how to treat based on mentored experience (ie: residency or fellowship). Can you teach somebody to do a fluoroguided injection? Sure, I can teach my mother how to do that - is it appropriate (other than she will make good money)? no... chronic pain is soo much more than understanding narcotics and sticking needles into somebody's spine based on MRI findings.

there are many treatments for interstitial cystitis - including some cheap medications - some bladder treatments by urology, and then finally sacral root stimulation implants. go online and read up about it...

I know three who went back to med school - 2 became anesthesiologists and the other one went into internal medicine (go figure). there is no such thing as "CLEP" - even PAs can't bypass first year...

former addicts have a high risk of relapse even if the drugs are used for post-op pain control.... my recommendation would be 1) a lot of long-acting local anesthetic from the surgeon 2) toradol for 3 days followed by high dose motrin thereafter 3) ultram - a total of 10 pills for bad moments over the first 10 days 4) might want to consider neurontin peri-operatively and post-operatively as that has been shown to decrease total narcotic requirement.

1) the fact that you know who took your medications and you aren't reporting it to the police makes you guilty of diversion which is a felony. so your only real choice is to file a police report. 2) demerol is the wrong choice of medication for you - actually all narcotics are the wrong choice for fibromyalgia.

0.6mg/kg??? that may be a typo - i don't go over 70-80mcg/kg.

why would you take a foot IV out --- flush it and use it. Instead you subjected this poor patient to a bunch of sticks for no good reason.... And exlain to me how flushing an IV is going to cause a clinically significant thrombus (unless she has a wide open PFO with right to left shunt) in a patient whose INR is 6.... gimme a break

I have been at a LOT of airway shambles on the streets, in the ER and the OR... Most people who say they can do a quick surgical airway are full of c r a p ... If you ask the average ENT surgeon how many emergency crics they did during their 5-6 year residency? 3-4 of them that is close to average exposure for ER guys and General Surgeons... Emergency Crics are far more frequently done in the field by paramedics or in the battle field by paramedics... And I would say 1/3 to 1/2 of the crics I have seen were total disasters (most of which required significant tracheal repairs as well as esophageal repairs) Retrograde needs a firm wire... MWBEAH you were lucky you got the J-wire (central line wire) to the oropharynx... About a year ago, i was stuck in the ER doing one w/ the actual kit and the wire never made it into the mouth... I finally had to make a knick with a blade, threaded some of the wire towards the lung (so that i wouldn't lose access to the hole should it start bleeding like stink), then took the ET stylet and advanced that through the cric towards the mouth.... that worked... my perineum was all scrunched up though...

there are many case reports in the literature of patients with Von Willebrand receiving neuraxial anesthesia (primarily in the OB anesthesia literature). Most patients are responsive to DDAVP or at worst you can give them some Cryo or Factor VIII (factor 8 contains some VWF). However in an elective case where a General Anesthetic is permissible, then avoiding a regional technique makes sense - especially if the patient does not want it. But it does lead to one of my pet peeves where RNs tell patients how the anesthesia will be performed - when often it is very different from what we as anesthesia providers will plan to do. My favorite is when a nurse tells the patient in the induction room that they will get a General Anesthetic for a case that should be a MAC - and then I have to spend 20 minutes explaining to the patient why they aren't getting a GA and why it isn't appropriate...

papawjohn... 1) BP cuffs: it does not matter which way the cuff is applied (right side up or upside down... inside out is a lot harder though) 2) Placement: it doesn't matter where the BP cuff goes - even though systolic and diastolic are different at the calf and the upper arm, the MAP is the same... however, the BP cuff won't register much in the lower leg if the patient has significant peripheral arterial disease or diabetes with glycosylation of the arteries or anybody who has significant calcification of those arteries 3) I suggest you learn how a BP cuff works and the different kinds out there... before you call your colleague nurses negligent or ignorant.

if his BP is in the crapper because he is having coronary vasoconstriction in the setting of an acute coronary syndrome (ie: MI) then providing coronary vasodilation may actually improve blood flow to the affect ventricular wall, thus allowing for improved performance and improvement of the BP. This coronary vasodilation can sometimes/often be obtained with nitroglycerin... I use nitroglycerin often on my cardiac patients even when their BP is in the toilet with good results... it freaks out the Medicine people cause they really don't understand cardiac physiology that well :) you can always offset the systemic vasodilation you get with low to moderate dose nitroglycerin with some norepinephrine... it sounds though that your situation was a bit different. You started milrinone that dropped this guys pressure because of his systemic and pulmonary vasodilation from the milrinone.... if he was having chest pain because of the drop in coronary perfusion then what he needs is systemic vasoconstriction to improve his coronary diastolic pressures...

why couldn't you give nitro? it might have been appropriate for that guy...

not to mention that there are studies in the SURGICAL literature that show lower infection rates, less post-op hematoma formation, etc... when patients are maintained euthermic.... when surgeons want the room temp down, I only allow it if I am satisfied w/ the patients core temp, otherwise i say NO .... and when they bug me more about it, I tell them to read up on their literature in their own journals... and if they continue to bug me, i tell them to deal with it, and if it is really that bad and annoying for them, they should step out, get a cold glass of water and come back refreshed for more... If burn trauma surgeons can do it for 12 hours straight then so can anybody...

but if your afterload is appropriately reduced and the milrinone is improving your C.O., don't be surprised if your BP actually starts getting better after the vasodilatory dip... plus in some patients it might be better not to use a loading dose of milrinone, or maybe only half the usual weight based loarding dose...

dynamaps use a different system to measure BP that has its own bugs - and therefore in certain clinical situations should be correlated with a manual cuff (ie: irregular rhythms, fast rhythms, very slow rhythms, etc...)

nitecap... you are right on the money... the cost per year is about the same, in fact there are some med schools (state vs private) that are cheaper per year than some of the more private CRNA schools - so for everybody out there be careful with those loans cause they can take BIG bites out of you - especially if you start spending money like a big baller before you get a chance to make payments (then you are really hosed)!

rn29306 ... i agree with you, stereotyping on that other website is immature as well...

i love how this thread went from discussing the merits of choosing a field to the usual us vs them mentality.... doesn't it get old after a while of maintaining the same old stereotypes??? nurses/CRNA: love patients, protect patients, watch out for patients, don't care about the money, etc.. MDs: don't give a crap about patients, only care about money and their egos.... stereotyping is fun for sure - but haven't we outgrown that?

yoga - i am impressed that you still do so many big, long cases after 45 years in the OR. That is a really long time!!!! wow!!! for the original poster: your choice is a tough one. It sounds like you are interested in the practice of nursing (seeing as you are graduating with a BSN), and that is fantastic. But it also sounds like you are trying to make a choice between CRNA and MD... My recommendations (personal bias of course) would be for you to go the MD route since you are in a great situation (single, no children and so young). The MD route has some pros/cons 1) Length: CRNA for you would be 1-2 years of ICU experience followed by 2-3 years of CRNA school so you will be done in 3-5 years from now... MD for you would be 4 years of med school followed by 3-8 years of residency/fellowship (depending on what field you choose) - and for you that would be another 8-13 years from now (i added an extra year, because it is too late for you to apply to med school starting in 2005). 2) Fund of knowledge: what is your desire as far as your depth of understanding of medicine, pathology, physiology etc... 3) Lifestyle: The 3-5 years of training towards CRNA while grueling doesn't compare to 7-12 years of minimal free time, minimal social life and delayed gratification on all fronts 4) Income (i like how yoga says he/she is interested in good income, but physicians are interested in money - what is the difference?): Income for new CRNA grads is anywhere from 80-90k/year to 180k/year (if they do a lot of overtime) - Income for MDs range from 90k/year to 750k/year (depending on the specialty) 5) debt: most MDs finish med school w/ 120-150k debt - and are unable to pay that off during residency and therefore that debt balloons to about 200k by the time they start paying that off... now if your burning desire is to do anesthesia, and that is all you are interested in go for CRNA (shorter course of education time and less debt load)... now if your burning desire is to find out what else in the medical arts may be of interest to you, or you want to practice anesthesia from an art of medicine point of view with a deeper understanding of medicine than MD is your route.... either way, both are very noble fields and both are very rewarding in many ways

by now, most hospitals have adopted a peri-operative beta-blocker protocol - it is just a matter of being informed about it and following it...

funny thing about LMAs a neat trick for LMAs that just don't go down right: - use either a bougie or an OGT and advance it down the goose, then advance the LMA over the bougie/ogt into the mouth - until it sits... there you go!

hmm... so you had an intra-thecal catheter... no biggie, just wait till the motor blockade resolves then run it as an intra-thecal labor analgesic.... patients LOVE those, so much better than an epidural... Just make sure everybody knows it is intra-thecal so that there are no inadvertent spinal boluses :) .... by the way, doing a prophylactic blood patch is not based on current evidence based medicine....