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ghillbert MSN, NP

CTICU

Content by ghillbert

  1. ghillbert

    Bradycardia during surgery

    Per the website TOS, no medical advice can be given. You should talk to your medical team if you have questions about your operation or postoperative care.
  2. ghillbert

    IABP waveform clarification

    It also depends what his LVEF was. Often with a high grade lesion plus a bad EF, preop CABGs will get an IABP. If your actual balloon waveform was abnormal, you check your balloon placement first - was it in the right place on XR? Check the inflation signal waveform to see if it's inflating and deflating appropriately. Put it on pause or 1:2 and see if it changes the blood pressure. Try manually timing if required (or get your engineers or perfusion to, if they run the IABPs in your hospital). Definitely as a first step, if you are taking care of IABP patients, and before you try manually adjusting - you should know exactly what each waveform point is and what it means (dicrotic notch, augmented diastole, unassisted and assisted systole, patient end diastolic pressure and balloon-assisted end diastolic pressure) and what you are trying to achieve with your timing adjustments. Manufacturers have plenty of cheat sheets and info available on their websites.
  3. ghillbert

    Meds

    There are many websites and books to practice medication calculations. If you are not good at mental mathematics, then it's just a matter of repetition and practice to be able to work it out on the run. You can also download med calculators to your phone.
  4. ghillbert

    ICU NP/PA schedules

    Thanks guys, you always have answers for me! For now I haven't even given the bosses the option of weekend or night coverage until I have more FTE's. Between the 2 of us, I am planning to cover Mon-Fri 6a to 7-7:30p with one APP each day, and 2 on Mondays which is the busiest OR day. Juan, what is your FTE? That is nice that seniority means less nights. David - you have 10 FTE but 5 person schedule..? So how many people per shift on weekday days, weekday night, and weekends? Sorry if I am being dense. Do people rotate days/nights by a week at a time, or do both days and nights within the same week? I don't really know what a blended RVU is, but I am going to investigate! I have had 1 new NP, 1 NP student, 1 medical student, 2 residents and one PACCM fellow rotating with me this month after having zero people last month, so I don't know what to do with all the help!! Thanks again.
  5. ghillbert

    Calling all educators and NP's!

    You can become an NP and also teach! Some programs permit you to do a minor in Nursing Ed, otherwise if you do a masters you can teach undergrads or a DNP you can be faculty teaching undergrad or grad students. Many of my best NP program educators were still currently actively practicing as an NP as well as teaching. I'm an ACNP in critical care, but I teach rotating residents, fellows, new NPs and NP students just about every shift, while practicing clinically.
  6. ghillbert

    Acute Care NP without ICU experience?

    I hire ACNPs for critical care, and I do not think I would hire a new grad with no ICU experience. I would have the same problem with a new grad PA with no ICU experience, although they do more clinical during their course. I just don't think you can assume a lot of basic knowledge in someone that hasn't worked as an ICU nurse. Not saying I definitely wouldn't hire one, but they would have to have really stellar recommendations from their NP clinicals in critical care, and be willing to do extended orientation and learn.
  7. ghillbert

    Any Thoughts on why Orthopedics Hire PA more than APN

    Honestly, I think more PAs are interested in working OR/surgery than NPs are. People that are interested in operating probably gravitate more to the PA model than to becoming a nurse/NP. I know I work in a surgical specialty, but have no desire to go to the OR, which is what I have seen a lot of in my area. I agree though, regarding job ads - my job was advertised as PA but I applied and was hired as an NP.
  8. ghillbert

    Swan-Ganz Usage

    Nice hyperbole.
  9. ghillbert

    What would you do? Selecting the right job!

    I would only take Job #2 if you plan to do a post-masters in acute care. FNP does not train you for that job.
  10. ghillbert

    Ohio Atty Gen opinion on non-ACNP working inpatient

    An acute care NP can work anywhere the patient population is acutely ill adults. So yes, if you are taking care of patients with acute issues in an outpatient clinic, that is permitted. Many ACNPs work for cardiology practices and both cover both inpatient and outpatient patients. What you should NOT do it work in primary or preventative care with stable/chronic issues. Because you're not trained for that.
  11. ghillbert

    DNP Touro Nevada

    From what I recall when I checked it out, the Touro DNP program is more executive than clinical, isn't it?
  12. ghillbert

    Critical Care NP/PAs

    I am the first APP hired into critical care in my hospital. Now that they see the benefits, the docs are all about hiring more. I currently work 4x10s, weekdays, no weekends or nights. Obviously as we get more people, the intensivist attendings would like to change that so that we have 24/7 coverage and less nights/weekends for them. How many APPs does your unit have? What is their schedule? How do you organize your coverage? How many patients do you see and chart/bill for? Who do they report to? How did you integrate new hires, if you started with a few and grew your APP presence? Does your intensivist APP group cover hospital codes? Does your MD intensivist work inhouse overnight/weekends or on call? Thanks for any assistance! Trying to have some involvement as we start this growth as obviously it will affect my schedule and my compensation. I also love having an intensivist in house with me at all times now for learning purposes so I want to ensure we have adequate clinical support by MDs if we transition to APP coverage out of hours.
  13. ghillbert

    Critical Care NP/PAs

    Makes a lot of sense, thanks for the info!!
  14. ghillbert

    FNP vs AGACNP? Need help deciding.

    Sounds like you should be a good fit for AG-ACNP all the way! I am an ACNP who works in critical care - I am not sure what you mean about being superfluous. I prepare for rounds, present my patients on rounds to the attending, liaise with my patient's nurses, communicate with other teams and families of my patient, and write notes/bill. I would not say it's an independent role, particularly as I have been in this unit for only 6 months, and I certainly would not want to be alone in our very high acuity unit, but I feel I have a lot of autonomy. My attending physicians provide as much "supervision" as I ask for. I have them around for intubations still, but I am comfortable placing chest tubes, central or arterial lines etc by myself. I would hate being an FNP. I have thought about doing it as a post masters certificate, but the thought of doing primary care or peds clinical make me want to strangle myself, so I'll stick with ACNP for now :)
  15. ghillbert

    Hospital NPs & Lounge Access

    Ooh I never even thought to ask if my new hospital HAS a providers' lounge... now I must find out. I think it's very petty of the physicians to vote to keep NPPs out... very childish. What are they worried about? Or do they just want to be an exclusive club and feel more important? Ugh. Either way, a hospital that permits that attitude is not somewhere I would like to work.
  16. ghillbert

    Reported to the BON

    Thank you for sharing your experience. I often think about what incredible responsibility is on my shoulders in my work position. It does not take much at all to make an error, especially with an electronic record where clicking one wrong button can mean something very different gets ordered. I am sorry for your struggle and I hope you are on the upswing now.
  17. ghillbert

    Critical Care NP/PAs

    After six months in the role, I am still amazed by those of you with no MDs on at night etc - we have such a high acuity with people crashing onto ECMO and having chests opened, difficult airways for intubation etc that I cannot imagine a time I wouldn't need the MD around! I hope I am able to become as autonomous as some of you with more time. Next challenge will be creating an on-boarding process for our new hires. I have found some literature with helpful orientation tips and checklists but welcome any other tools you have or know of to help with APP orientation to ICUs.
  18. ghillbert

    Nurse Practitioner

    There is no $130k salary requirement for the H1b visa. Salary will depend on the area you plan to work in - it varies widely across the US.
  19. ghillbert

    Critical Care NP/PAs

    Thank you so much for the detailed responses, I appreciate your time! These numbers amaze me, given that we have a total of 1 APP lol. Our unit is 24 bed SICU, mostly cardiac surgery, vascular, transplant (heart, liver, kidney, pancreas). There is only one MD intensivist on 24/7, 12hr shifts rotating days/nights. They are actively recruiting but having trouble finding someone with that schedule. So far since I started, myself and the attending are splitting the unit but I really am feeling overwhelmed with 12-15 (counting transfers and new postop admissions during the day) patients to round on, examine, write notes on and bill on. I wasn't sure if it was reasonable to put my foot down about the ratio given that whoever I don't see, the attending has to, but everything I have read says APP:Pt ratio of ~6 is reasonable. They are very happy with the help and quickly saw the merit of hiring more APPs, so we just have to get budget approval, but may be able to transition the advertised MD job into a few APPs... just have to find appropriate staff to hire now. Again thanks, it's fascinating how the ICU APP role has evolved in different centers across the country - I guess we are where you guys were 10-15yrs ago lol. I do have SCCM so I will look for that talk, David. I saw a conference listed for you a couple years ago about the staffing etc for ICU... if only I wasn't 2 years too late for it!
  20. ghillbert

    Visascreen certificate checked in USA?

    To be honest, I was never, not even once, asked for my VSC during the time that I was employed on a working visa.
  21. ghillbert

    Compensation for Call Pay

    For reals. I am not one of those that take call lol
  22. Mostly but depends what they are looking for. They can evaluate intraparenchymal tissue and lesions also with transbronchial lung biopsy, especially if less invasive testing is preferred prior to surgical biopsy.
  23. Why biopsy? Because you ruled out cardiac causes of acute respiratory failure with an acceptable LVEF on echo and low filling pressures (CVP 1, WP 15). Mind you this was after aggressive diuresis with bumex, and BNP was elevated on admission so could have still account for some acute resp failure. Then you ruled out infective causes with bronch, BAL, antibiotics, steroids. Ground glass opacities is a non specific way to describe what the lungs look like on CT scan. It can be from edema, pneumonia, fibrosis etc. Just a radiologists way of describing what they see. "Air space disease" is a nice way to say the lungs don't look right, without actually saying what you think the problem is. Like saying you see "bilateral pulmonary opacities" on a chest xray - so what does that mean? Is there edema, consolidation, atelectasis? Now you need to figure out why the respiratory failure. So lung biopsy it is. Why open biopsy versus EBUS I don't know, but may be to do with the patient's specifics.
  24. ghillbert

    Neurocritical care for the non-neurocritical care provider

    For basics - - immediate stroke management, when to anticoagulate vs not - EVDs and ICP management - Fundamentals of which strokes need higher BP goals and which need lower etc in the acute phase Overall - what things can I do in the immediate acute care phase to improve the patient's long term outcome?
  25. ghillbert

    Compensation for Call Pay

    My last hospital pays surgical NPs like $3.50/hr for on call so good luck with $1000/weekend! Also, once you accept it, this won't go away every again, so be prepared for that. My new hospital just removed the surgical NPs call pay entirely - they "adjusted" their annual salary some to "make up for it".. I feel like it doesn't make up for it, or they wouldn't have changed it if it didn't help their bottom line lol.
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