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ghillbert MSN, NP

CTICU

Content by ghillbert

  1. ghillbert

    Question for NPs working in Acute Care Setting

    I work in critical care. I round with my attending, present my patients, we come up with a plan of care. I outline my plan for the day and he may/may not have changes or suggestions to add. After rounds, I go put in the orders we decided on, if I didn't already enter as we rounded. The nurses throughout the day often come to ask me for orders for things (meds, restraints, changing orders po to iv, iv fluids, vasoactive med adjustments) and I decide whether to place the orders. If it's a patient I'm not familiar with or a serious issue, I may discuss with my attending then decide what to do and let the nurse know, and enter the order. If it's something I am comfortable handling then no, I just put it in and later when we round at the end of the shift or when I do my signout, I just let them know what I did for each patient. I do not put in orders for the physician, I am not their scribe. Unless we are rounding and whoever isn't presenting the patient usually enters the orders for the other. Sometimes we disagree sure, and if they explain and I see what they mean, I may change the treatment plan. Some are more "do it my way" than others and I usually just go with it. If I truly disagree, I would tell them to do the order as I am not comfortable - but I have never had that level of disagreement with one of my colleagues so far. There are many ways to skin a cat, as the saying goes, and with medicine there are usually many opinions and no black or white answers. It's a team practice and we all have equally valued input.
  2. ghillbert

    Swan-Ganz Usage

    Well, that's your opinion. Surveys tend to show that a majority of cardiac surgeons continue to use them in certain patients; apparently they disagree.
  3. ghillbert

    CMC exam study materials

    The handbook lists very clearly what info is covered. I didn't really study as I had many years in cardiac when I took it, but I recall many questions about STEMI, NSTEMI, IABP, PA cath readings, cardiac pharm
  4. ghillbert

    Understanding IABP values

    The IABP is reading correctly. If however you used a NIBP cuff for a BP reading in a patient with 1:1 IABP, yes it would read the augmented diastole as "systolic" bc it's the highest number in the cycle.
  5. ghillbert

    Swan-Ganz Usage

    I don't know that this is true. There are many pathophysiologic changes after cardiac surgery that are ameliorated within 12 hrs postop. My large tertiary center CTICU and our CCU uses pa catheters very frequently in our population.
  6. ghillbert

    Advice?? Having trouble finding NP job.

    I think adult-gero primary NP is limiting - its very specific, and most outpatient primary care clinics want FNP. You could try long term facilities or home visits to get some experience. I see a ton of jobs in Pgh but almost all ACNP or FNP. You could consider a post masters FNP or other cert if you need to broaden your marketability. Network also- contact local NP associations, your alumni assoc from your school etc for job opportunities
  7. 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?
  8. 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.
  9. ghillbert

    Critical Care NP/PAs

    Makes a lot of sense, thanks for the info!!
  10. 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 :)
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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!
  16. 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.
  17. ghillbert

    Compensation for Call Pay

    For reals. I am not one of those that take call lol
  18. 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.
  19. 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.
  20. 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?
  21. 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.
  22. ghillbert

    Pennsylvania CRNA vs NP

    FNP and CRNA are worlds apart in terms of practice - do you like acute care or family practice? I would choose a path and then choose the degree that gives you most of that. It sounds like ACNP would be a good compromise. I don't agree with "independent" practice necessarily because I work in critical care and know that I will never have the depth of knowledge of one of my intensivist attendings. I am extremely intelligent and excellent at my job, but I just don't have the same breadth of knowledge base they do. I rely on having them available to consult with as needed. If "independent" practice really means we cut out a bunch of BS paperwork and red tape ie. collaborative agreements though, I am all for it. They delay care and made it take 4 months for me to switch jobs recently waiting on state approval for my agreement.
  23. ghillbert

    Salary and Negotiation

    City/State: Pittsburgh, PA Specialty: ACNP, working in critical care unit. I am the only NP in critical care and it is a new position in this unit. Years in current position: Salary: $114,000 annual salary Benefits: Healthcare subsidized, CME $1500, 403b (not matched), PTO 3 wks Bonus: No Negotiation tips?! - ask for more than you think you should. At the beginning is the only time you get to negotiate, overall. Raises are generally a % of your base so get your base as high as you can.
  24. ghillbert

    ACNP credential being retired

    If I (ACNP-BC) was considering going for PhD or DNP, is there any way to "upgrade" to become eligible for the AG-ACNP certification exam since ACNP is retired? Or would you just do the DNP in current specialty then have to do another post-certificate?
  25. ghillbert

    Vanderbilt ACNP Intensivist Program

    University of Pittsburgh has a critical care track in their ACNP program.
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