phiposurde

I finally got my first mission. It was a month old baby with possible obstruction. At the sending hospital before transport I try to insert an NG but there was resistance and I sure didn't want to do any damage. Any trick of the trade? Do we have to do anything different vs adult?

Back home ( Montreal), when i use to work there it was nightmare. My understanding is that it didn't improved. Minimal stay in the ER before admitting was almost 2 days I even saw one staying 6 days. I remember , she Had bed sore cause we were to busy to turn her q 2 hour. We had 17 actual bed. We would go up to 45 patient sometimes. Some of them the "cardiac monitoring" was to be hook on a defibrillator. Sometimes the authority would announce on the radio to stay home cause we didn't have any more space in the ER during flu season. Now here ( Calgary) It is better. Still overcrowded and there still some waiting but the region works very hard to improved things. The last statistics showed that we decrease our waiting time and admitting time by almost 50% compare to last year!! http://www.calgaryhealthregion.ca/newslink/emergencydepartment/performance_measures.html

**** I went to a talk once give by a toxicologist and He was saying that paralyzing can become mandatory if we can't control the temperature!!

Oh No. It was going in direction of the heart but is arm was flex( hand toward the head) and no way we could undo that. So I had to stand up and start the IV that way.Sorry for the scare!!8)

A few trick. First get use to the IV cath your using. Some of them require different technique. After a few years working with the one we use I came out with some little trick to make it better. But that is IV specific. -BP cuff at 100. You would be surprise how many time people had trouble finding veins. I put the BP cuff and boom there one right there. It work very good especially on patient with a lot of edema or with a lot of fat tissue.On that note if the patient has edema ++ put pressure at the site you are looking for the vein for a few seconds. It with push the fluids away. Concentrate mostly at the wrist and hand fro that one. -Rolling vein angle you IV cath more. Use it almost like a Forch then and do a J motion. Hit the vein then role up. It also help to stabilize the vein very well on those people. Sometime i even go pass the skin then I start playing with them. -Turn the patient on his R side. Since the venous return come back from the right it apparently will help with the pooling of blood. Never really tried it cause the other trick work in 95% of the time. -When looking for the vein. Close your eyes. Your sens of touch will be enhanced. Then you just move slowly all over the arm.Also sometime( but that one you didn't heard from me). I broke the tip of the glove of my most sensitive finger. -Practice to start IV with your non dominant hand. It can come handy. In the last month I started 2 difficult IV because of that. One was because of the position of the vein. The person was flexing and very rigid because of some disease. I had to start the IV from the top toward the bottom. The other I use my dominant hand to have a better feeling and stabilize my vein. Then i started with the left hand. -If you see but cannot feel them. Angle you IV more( close to 45 degree) and go very very slowly. There a big chance you may go through. But sometime if you see a nice blue line but can't feel them it just mean it's very deep. Try those. Hope it help!!

I always say;" nursing is not a job but a way of life!" You know people in office the get out and they become regular people, nurse not so much. I remember when I use to work night shift and was in the ER I would dream of taking care of a vent patient and been alone and he would crash. Then awake brutally not really knowing if i felt asleep at work or at home. Since you can't just let go you need to find ways to achieve balance. That is personal to everyone but a good book that help me with that was " the 7 habits of the must effective people" By Steven Covey( I think that's how it's spell). After reading that book I came with different trick to cope with the stress.When I go to work in don't go with my scrubs. I change at the hospital. Cause when I change I do a psychological switch. I try to leave my personal problem in the looker and when I leave my work trouble in it.You have to learn to detach yourself from a situation. But careful with that one. Some people become so much detach that they forget to care about there patient and co worker. Or the deny there own emotion when they become to strong. Detaching yourself help in most case but sometime the situation is to much. In those case, talk with coworker you trust or you manager. Maybe even try to have a system in place where people could vent. Don't be afraid to take days off. Sick days are not just there for when we cough blood and can't walk. Mental health is very important and don't wait to late. There many time now I do prevention. When I start feeling going down the path and no days off coming soon. I call sick. I spend the day in front of TV not doing anything, letting my brain resting. Exercise is very important. On must of my days off I am in the mountain. Also, movie, plays, opera are all activity that help me to detach myself. Stay away from overtime. Many nurse at my center are working like crazy. What don't realize is they are cough in a vicious circle. They want to go on a trip or buy something. They work more to get the money. Work more get more tired. More tired more they need to go on trip or buy things to feel better.And here it goes again, the circle start again. The other practice is to switch shift to get vacation time. Some of them switch so much. They end up doing 7-8 shift in a row. Sometime full 12 hours. Is it really worth it for 1-2 weeks of vacation?? Schedule yourself sometime off, some relax time. One things lately I've been doing is using my i-pod a lot. When I get a break, I disconnect myself for a few minutes by listening to music. Also, I like social science a lot but never had time to read. So now I download pod cast on the subject , even audio book, and listen to that before going to bed. In last, I still enjoy knowing about my profession cause IT,s a passion of mine. But try to keep up with magazine and book is very time consuming. So now I buy DVD of conference of review of program. They come to almost the same price as book but In an hour i can learn way more then by reading.One other thing we do at a center that help. Our significant other are authorize to come and have a shadow shift with us. It help them really understand when you come home and tell them:" it was crazy today!!" Hope it help.

4:1 none acute. 3:1 acute side. WE also have a "float nurse" there to relieve us during break. So unless she is in the trauma room, she's also helping.

Well couldn't find too much info, but we have a dedicated team at my center. Here a web page with some info. I'm sure you could get to talk to someone that would give you info. They actually get an advanced training to be on the team. http://www.calgaryhealthregion.ca/neonatology/Professional_site_1.htm

I found that one: http://mobiledoc.net/

let's say I get patient A, a chest pain with a positive history, has had two ntg, an IV, and NTP placed to chest en route via EMS; pressure is now a 4/10. While I am converting his IV to ours/attempting to draw labs from said site, the tech is getting the ekg etc. Dr. orders aspirin and metoprolol. i send the labs off, but before I can give him his meds, i get patient B who also has similar history, no ntg, no paste, (chest pain obviously), but is getting an EKG. *** Get B hook on monitor, run automatic BP. While the BP is running I.m going to get my meds for A ready and bring some NTG, ASA to bedside of B since I'm in the med room. Come Back to B bedside leave med. Bp normal. Give Meds ASA + first dose metropolol( I presume 5 mg IV x3 q15 min). Put BP machine on q15 automatic. Now I have 15 minutes to go see B.**** Neither EKG shows acute abnormalities. **** 15 minutes later I go back to bed A give 2nd Dose of metropolol if appropriate. Return to B. If MD saw follow orders for the next 15 minutes. Just before I leave to go to med room for B( if required) I go check patient C( we have 3 patient on monitor assignment). press on automatic BP while I go. Now I'm on my 15 minute before 3th dose of metropolol and 2-3 minutes the BP cuff take for patient C. By the time I come back to patient B bedside, I have a pressure for C which I do a quick note. Go check patient A then concentrate on B. Then I start bitching that nobody is helping me!!!

I believe there not just one answer, it depends. I guess if we would have to come with basic rule: 1) Have a quick assessment( do they look sick vs none sick?) 2) always try to find ways to multi task and delegate task. ( Is there someone else that can do some of the job?) Make kind of a " grocery list" what need to be done and prioritizes it and delegate it.For example,at my center we have patient care attendant( PCA) they help with cpr, patient transport, etcetera. Well if I get 2 patient at the same time. I have a quick assessment of my patient then I go to the sickest. The other one , I would call a PCA to help get undress, hook to a monitor and in the mean time I call for an ECG. While all that is happening I do nursing stuff( medication, IV, reading the other ECG, taking HX).In that example the list is:the patient need to be undress to be assess, I need an ECG( MI vs angina or non STEMI), I need vitals before giving medication, need hx to evaluate. Put all that come with experience. It's like people talk about critical care thinking. Can you really describe it?? Not really after seeing 40 cp your starting to know what you need or have to look for. 3) keep your ABC in mind. For example, this week we were waiting for a patient in the trauma room and suddenly one went bad in the hallway so he got rush back.4-5 nurses jump on him. They all went to cut clothes, hooking monitor, starting IV, getting BP. He had a snoring respiration. I had to maintain airway open. But no one really payed attention to it( tunnel vision). I find in those situation just before you get throw into adrenaline country taking 2-3 deep( even one if your rush) breath help me concentrating. 4) do not be afraid to stop think and talk to yourself. When I was in college, I was in a first aid team that did competition. I learn a great deal on priority, delegating and taking quick decision. 5) Don't spread to much. There more chance to forget things I find it hard to explain how I take decision, but hope I was able bring some light a little bit. I could suggest you to practice at home.Make a list of your patient or the patient of some of your coworker. Write down the initial presentation, the EMS story, the vitals. Then play the "what if game?". What if patient A at arrive at the same time as patient B? What if C went bad while B arrive? Practice and try to rationalize what is needed and what can wait. But at the end the best decision to take is to go work in a hospital that as enough staff so you will not have tho make those choices !!!

**** Will be, starting in August. I'm at the new base in Grande Prairie,AB.

*** The canadian never get special thanks!!!LOL:lol2:

Depends the amount you are ready to pay. There of course the 3 tome encyclopedia on emergency medicine. But last year, I bought a good book that is concise and review most treatment and disease. I like it cause it separate the content by complaint and give you an approach to it. There some good algorithm as well. Current emergency diagnosis and treatment, c. Keith Stone;Roger L. Humphries, Lange medical books/Mc GRaw-hill(ISBN:0-8385-1450-2)(ISSN:084-2293) Hope it help!

*** What's the physiologies of the seizure??

****Been the boy in the world of the ladies, I have seen my share of clique. It's part of the job. Unfortunately it's the part that would make me leave it. At my job, they are so bad, that not in the clique= bad nurse. Your not judge by your competence anymore but by who you know!! I am even considering making t-shirt with the inscription: " to cool to be cool !".It got worse especially since everyone is on face book. I feel I'm back in high school all over again."I have 200 friends you just have 40. I am more popular". I think we got 3 memo so far cause patient have complaint. They put pictures of RN drunk as wallpaper on our working computer. Last week the talk of the week was:" who's butt it is on the computer?":trout:

I found that website, maybe it could help you: https://www.greatnurses.com/exp/index.php/products/item/cen_review/

As for metal illness. Like everything in life, when we do a change we have tendency to go to far on the opposite. We steer L before coming back to the middle. Right now we are to much on the L cause kids and psychiatric disorder is a new thing, a new research domain. So of course there will be alot of false positive. A MD goes to a conference, they them all the new things out here. A kid come in and present himself with some similarity boummmmmmm get a DX. The problem I believe is that, family MD shouldn't treat mental disorder. They should send them to a specialist. Even then, like we all know in our profession, not all specialist are very good. The things with mental disorder is you can't really DX them beside with an HX. I remember in nursing school when we did psychiatry. Every time we learned about a new diseases we thought we had it. Cause if you read the symptoms, we all have some of them. The difference between someone that as the disease is that there at not correctable by itself and they are continuous. If only, bipolar would turn green when they have episodes. If kids with high dose of WASTKS enzyme( wait a sec this kid is sick enzymes). But we are not there with technology yet. So yes there will be false positive, yes people will try abusing the system. But I think, just like we tell CP to present to the ER, I prefer having them consult and follow up. That way the one that are really sick could get help, cause those disease can create a lot of damage if miss DX. As a society I think we also have a responsibility. We have the responsibility to make our social laws better and increase the quality of living. We blame teacher, doctor, etc to be too quick on " finding" a solution. But yet, we agree of doing 3 jobs. We jump on the overtime when we have a chance. And refuse things like paying a parent who would want to stay home and raise a family. I think the increase mental disease is a symptom of a much bigger disease. Like we don't treat the cough of the pneumonia but try to treat the pneumonia itself. We should try to change our social perspectives on life and ask ourself some serious question. Then when it come to vote, remembering those decisions and using the power of democracy for creating a better world! Where a 5 years kid could be DX with bipolar but would receive all the help needed( not just pills) and his friend would get some different help, even if his mom is sure of the DX, thanks to the internet.

I found this: " Ninety percent of the children meeting criteria for mania also had a depressive episode, and 84 percent had the depressive episode overlap with the manic episode into a mixed state. Children will switch in and out of depression, irritable mania with explosions, and euphoric mania throughout the day, almost every day. Because of this switching, it is very difficult to meet the clinical criteria of a "full week of irritability," or "a full week of euphoria." Oddly enough, "only in a minority of the most severe cases do children demonstrate their most abnormal mood states at school or in the outpatient clinician's office." The mean age of onset was 4.55 years, with 75 percent of parents describing their child's symptoms as beginning under age five. This contrasted with mean age of onset of ADHD at 2.98 years. Ninety eight percent of the children under age 12 who met criteria for mania also met criteria for ADHD. In contrast, 79 percent of referrals to the clinic met criteria for ADHD without mania. If ADHD rating scales are used, a manic child and a child with ADHD cannot be distinguished from each other. The Mania Rating Scale, on the other hand, can identify manic children. Manic children generally have "greater psychopathology and poorer functioning." The authors note it is also important to look for co-occurring ADHD with mania, and not to mistake these symptoms for residual mania. Other co-occurring conditions include bipolar with conduct disorder and anxiety (52 percent of children with anxiety also have bipolar)." http://www.mcmanweb.com/article-30.htm

Well I don't know if I chart the best way but here my 2 tricks. At the beginning of each shift I take a "picture" of my patient. I assess each system and spend more time on the system is in the ER for. For example, Come with N/V and LLQ pain: " alert. pink, dry warm skin. 2/2 L radial regular pulse. No distress. None labored breathing. C/o Nausea. no vomiting. Normal BSX4.abd soft. Tenderness with no guarding with light palpation LLQ. Pain 4/10 describe as sharp increase with mvt . Some relief with medication. No BM. State last voided at 1300. denies any other complaint.Ns lock patent.Waiting for blood result. will continue to monitor." If they have a relevant medical HX( asthma, diabetes, HTN, etc) I spend some time on that. For example I would auscultate an asthmatic. Then I chart every hour( if possible) and concentrate on breathing, skin, neuro, system in trouble and plan.For example an hour later: " Alert.pink. mild distress. None labored breathing. State pain increase to 7/10. No vomiting. Morphine 5 mg Iv. will reassess pain and continue to monitor". So right at the beginning it kind give me a picture of the patient at that point in time. I always ask myself that question when I write a note:" If i go to court in 3 years, what would I like to be able to remember?". Cause mostly that's the main reason we chart. So imagine yourself answering a question to a lawyer and you only have your note in front of you. Write to yourself the things you would like to know. I never had to go to court. But I feel when I do a follow up like that with my note, I would be able to answer. Also, it's a reminder to verify for those thing. for example if the patient would be pale now, I would intervene. I would look at his pulse, verify his vitals, etc. Hope I help!

Last week I took care of a little lady that a nursing care center send her in pre-renal ARF( creat 580). So she was dehydrated ++ and I look at the CO2. of course, it was low as we spoke before. I just wanted to share and prove that I keep my promises!!:welcome:

*** The only thing I could see, is you could send the patient in hypothermia. Then is to determine if your patient could tolerate it. If his a post-cardiac arrest or a isolated head injury good. But if his a multi trauma, it could increase is risk of bleeding. There is 2 kind of patient with high temperature. The one with there thermo regulator system intact and the one that is not so much. If I have someone with a temp because he as an infection, that temp is good and that patient is actually creating that temperature as a mechanism of defense, so his in control of it . There not much chance that it will hit the 41 degree or 42 degree, cause the body will compensate. The person that come with a sympathommimetic OD. That patient is loosing the battle, and you need to cool them at any mean possible. In some case in the ER, we even paralyze them. Cause if not, soon he will have a brain sunny side up!! Well that's my 2 cent!( I know is is Canadian money but right now it is not so bad) LOL

for your first question about the mi. any process that increase the metabolism demand increase the demand on sugar.in that case patient with diabetes since they have difficulty producing the right amount of insulin won't be able to cope correctly. the body is a great machine but don't make a difference between an infection, a mi, a laceration, atrauma. the only info it receive:" dammage cells please activate repair system" it always use the same system. that's why anaphylactic shock and sepsis are in a way the same process but with different causes!! as for the sesond question,i found that possible explanation on the net. taking that this patient was propably alreay with high level. probably why he had an mi: "in dka, the low insulin levels combined with increased levels of catecholamines, cortisol and growth hormone will activate hormone-sensitive lipase, which will cause the breakdown of triglycerides and release of free fatty acids. the free fatty acids are taken up by the liver and converted to ketone bodies that are released into the circulation. the process of ketogenesis is stimulated by the increase in glucagon levels.5 this hormone will activate carnitine palmitoyltransferase i, an enzyme that allows free fatty acids in the form of coenzyme a to cross mitochondrial membranes after their esterification into carnitine. on the other side, esterification is reversed by carnitine palmitoyltransferase ii to form fatty acyl coenzyme a, which enters the ß-oxidative pathway to produce acetyl coenzyme a. most of the acetyl coenzyme a is used in the synthesis of ß-hydroxybutyric acid and acetoacetic acid, 2 relatively strong acids responsible for the acidosis in dka. "http://www.cmaj.ca/cgi/content/full/168/7/859 hope i help.

****There a technic I saw on a DVD that maybe could help you. It is very simple but don't include everything. As a comparison it would be reading only the rhythm and rate on a 12 lead without Reading all the axis, hemiblock, etcetera. Here goes: You woke up one day in a new world. In that world everybody have 3 name: a first name, a middle name and a last name. But you are limited in your choice: for first name you can only choose compensated or uncompensated. Middle name respiratory or metabolic and last name acidosis or alkalosis. So you give birth to a baby, in that land baby have ph on the forehead. When they get born you know there first and last name: first name, between 7.35-7.45 is compensated otherwise, uncompensated. Then for the last name less then 7.4 acidosis. More then 7.4 Alkalosis. Now you want to know who's the dad of that little one so that you can give him is first name. So you will try to find the dad with the same last name. Remember the other normal CO2:35-45 and HCO3: 22-27/32( in some book). Remember those are text book normal. You have to look the normal with your center. ABG change with altitude.Let do an example: ph 7.25 co2: 55 and Hco3: 34 so our little baby his first name is uncompensated( less then 7,35) and last name acidosis (less then 7.4). Now for his middle name let see who has the same last name. we have the choice between Mr. respiratory acidosis( co2 more then 45) Mr. metabolic alkalosis.( HCO3 more then 27) So the name of our baby is uncompensated respiratory acidosis. there an other technique recommended by the ACLS for experienced provider. This one is more complex a little bit. But i find it take in consideration mix metabolic state. It has 6 step: 1) determine if PH normal( between 7,35-7,45), acidotic or alkalosis 2)determine if there hypocarbia( CO2 less the 35) or hypercarbia( CO2 more then 45) 3) 40-Co2( result can be positive or negative) 4) multiple by 0,008 5)add to or subs tract from 7,4 6)if ph greater then the calculated PH there a metabolic alkalosis associated. If it's less ,there a metabolic acidosis associated. Example: ph 7.30, pco2:80, Po2 58 HCO3:38 1) acidosis 2)40-80=-40 3)-40X .008=-0.32 4)7,4 - 0.32=7.08 5)metabolic alkalosis associated 6)primary resp acidosis with partial metabolic compensation. One rule to remember:"compensatory mechanism are unlikely to overcompensate in acid-base abnormalities". Meaning in this case it would be very doubtful that the pt would have retain Co2 to compensate the alkalosis state and therefore transfer to acidosis. Hope it help.