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ICU, LTACH, Internal Medicine

Content by KatieMI

  1. KatieMI

    Strange prescribing practices

    Well, in order to make it in 99213, theoretically, one Dx of "chronic pain" is enough, but one still need to document at least a short physical. If the provider feels that documenting all other stuff and acting accordingly (i.e. prescribing BP meds and such) is "looking better", it is his right. It is not illegal as long as cases are not billed higher without good and documented reasons. I always use those "pain pills visits" for med refills, education, etc. People love it as they feel that they are "cared about", I love it because it helps to keep things under control and avoid accidental prescribing of 3 PPIs and 5 laxatives, labs falling through cracks, etc.
  2. KatieMI

    NP vs MA vs MD power struggle

    It is bizarre but indeed quite common. In my experience, hiring "to help with the influx of patients" can mean literally whatever. If office personnel has no knowledge of what "NP" means and only hear the "Nurse" part, they very well can think that the person is "still just a nurse", with functions assigned accordingly. Random "helping here and there" just out of wish to be "friendly and helpful" only increases confusion. I would advise a meeting with practice owner/office manager and getting the job functions/expectations in written and in details. Explaining what you can do (prescribing, etc) can help. Then just act accordingly with no exclusions and without caving for "they told me that you'll do it for me".
  3. KatieMI

    Written Up

    That was likely about me. As I said, there are lots of people who just cannot stand anyone who is smart and openly proud of it.
  4. KatieMI

    Written Up

    I would do whatever I can to use non-pharmacologic methods to comfort the patient and help him sleep I would explain him that what he was taking home may or may not be safe for him right now. He is in hospital because he is sick, isn't he? He takes many other meds now for that reason. Now, ALL meds are working in the same human body at once. Some of them work together, and it can be good or not. Some counteract each other, same story. I am a nurse, I cannot determine if that 1 mg of Xanax safe right now. Doctor can, would you like me to call? If I call, I will start from fresh set of vitals taken by me personally. And I will tell the whole story, not only "hi, this is KatieMI from X, about your patient ftom 1234, can he get something for sleep?". In the case I described sbove, I would sure mention loading amio, drip and quickly escalating opioids. I would not tell about "home dose Xanax for sleep" at all, unless it was verified or I can verify the dose. Most conscientious providers would not order it "for sleep" anyway. If a provider will indeed order Xanax or something equally borderline (say, Versed - I had such orders in ICU), I would politely doubt it right then and there. I would mention my discomfort re. possibility of respiratory depression and then "just suggest" Valium, low dose Restoril, eszopiclone, Remeron or Benadryl. If the provider still wants Xanax, I would call to whoever manages the amiodarone and cardizem and ask that person directly if they think it would be okay. Cardiologists are usually better verced in complicated pharmacology of their own drugs. I have strong pharmacology background, so doctors usually listened to what I said. About "1 hour apart" rule: For example, you work with IV dilaudid to be given q2h. 1) check renal and liver functions. 2) if they are more or less normal, proceed on your own; if clearly not, call pharmacy and speak with PharmD, not tech 3) go Google and search for "dilaudid half life". Or use free app like Epocrates or drugbook. You do not need a peer-reviewed article. The first link Goodle has is from something named "therecoveryvillage.com". It is good enough, as the number will be the same everywhere. Dilaudid half life is about 2 hours. So, if you gave dose at 10 AM and the next at 12, your dose #2 will be "catching tail" of the first one as 1/2 of #1 will still be there. After #3 at 2 PM, you will have 1/4 of #1, 1/2 of #2 and whole #3. After #4, you will be close to "doubling" (draw it if it is difficult to understand). Which can be fine if you treat acute postop pain or cancer pain, but not for chronic. Usually showing Higher Ups that you understand that works. But I must tell you - it sucks to be more than average intelligent person in general, and especially if you are a nurse.
  5. KatieMI

    Written Up

    Well, the same case I described before (without HIPAA details): Patient was started oral amio load while Cardizem drip was still running. Was also on IV opioid d/t NPO. Not opioid naive, but not high dose either. Liked it very much, so dose was increased. Then he was complaining on anxiety before EP lab, so was given one dose of Xanax and that pain shot plus phenergan for nausea. It was his luck that he was in ICU already because at one beautiful moment he just stopped breathing, but survived. Woke up right after Narcan + Romazicon. The two possible explanations were either synergetic actions of opioid, phenergan and benzo on respiratory center, or at large suppressed CYP3A4 by high loading doses of amio and diltiazem, adding to the benzo action.
  6. KatieMI

    Free teaching labor

    Where I am, preceptors are paid approximately the same as nurses who work PRN (i.e. $8-10/h more than full time staff) with them being responsible for all students and on top of it expected to "help" (read: do everything but the initial assessment) with admissions and discharges. Staff nurses who are assigned students are given certificates which can be converted to CE hours. They are not asked if they want or can precept that day or not.
  7. KatieMI

    Robot tells man he'll be dead in hours

    While I think that such talk is highly preferred to be done in person, we live in 2019. Technologies like essentially "moving screen" (as far as I understand, it was not a "robot" but telemed device with doctor sitting somewhere else but still talking in real time) are going to be everywhere pretty soon. I agree that we as providers and clinicians not only avoid inevitable talks, but in many cases consciously lie to patients under premice of "not robbing 'em of hope". There are tons of causes of us doing so, not the last of them being our (otherwise, very human) wish of provide comfort and what will be perceived as "caring and gentle attitude". The pressures of totally wrong in so many instances doctrine of "customer satisfaction" cannot be taken fr om the table as well. But there always comes that time where true words have to be spoken. Still, I couldn't imagine doing this through tele. I am not afraid of these talks. But I feel that, even for 15 min., I need to be there for these people, so at least they do not feel alone.
  8. KatieMI

    This MD culture

    When we're on the road, we also have the same goal: to get safely where we need to be. Sadly, some people choose unsafe ways to do that, get in trouble and put others in trouble too. Same way here: we all work on provide safe and appropriate patient care, but some of us choose to do things which unnecessary complicate the situation. And that can happen with everyone involved. The nurse who chooses to call at 3 AM to "just let know" that patient had loose BM after mag citrate is just as guilty as the doctor who yells at her. Probably even more so, because a provider carries much heavier responsibility about more patients and for him/her being overtired and upset is much more potential danger of making a wrong decision. But BOTH nurse and doc are placing absolutely unnecessary obstacles in the way of getting to the common goal - get patient out of there in better health.
  9. KatieMI

    Sitting down - New nurse looking for advice

    Option 1: find a GOOD pain specialist who knows more than just pills/shots. Such doctors are few and far between, but if you live in a large metto area, you might have easier time to find one. The ways to manage the pain are multiple, from TENS to muscle relaxers, corsages, massage, etc. Do not forget about core PT, stress management, comfortable shoes, nutrition, healthy weight, etc. Option 2: unfortunately, nursing is an area of occupation which is not very friendly to people with physical limitations. ICU in general and CVICU are not physically easy. Since you are expected to care for only 2 patients, you might be required to do total body care, including turning, bed baths, etc., etc., - alone. Option if you like machines, needles, acute management: acute HD (yes, you can found yourself pushing that 200 lbs machine around but it has wheels, moving can be done with proper body technique and after things are running you can sit back - for hours). I heard that NICU is better in the sense of less physical load but I am not sure if it is fully truthful. Case management can be another option, as well as going back to school for MSN. Unlike bedside nursing, most MSN specialties can easily accomodate physical limitations.
  10. KatieMI

    smokers and coughing

    "What my smoking can have in common with that cough?" "Nobody ever told me that salt is bad for my heart - NOBODY!!" "Do pickles REALLY have a lot of salt? Oh... but it says here "sodium", not salt... are you sure these two are somehow related?" "I eat only french fries, they have no sugar" "You tell me I cannot have coffee with caffeine, only decaf. Is it ok to drink normal coffee with some burbon - it feels relaxing!" "Do you know how much protein is in bacon? That little?? Oh, I'll have to have plenty of it then". "I cannot have STD. I washed myself right after I came home" "Daily activities of my wife are sitting in her favorite armchair and watching TV. She also has her meals and recites a prayer daily" "They told me I can have everything I can see through. I can see through a doughnut hole, so I figured that some of them would be OK with coffee" I can write a book of those...
  11. KatieMI

    This MD culture

    Well... to begin with, do you REALLY still believe to higher ups about anything in the world?
  12. KatieMI


    Can I please add to the list everyone who calls at 3 AM to just let me know that patient whom I ordered bowel regiment just had perfectly normal BM and if I want to do something about it, writes down full nursing note about this tremendously important event and then tries to justify it by stating that "it was just for me being patient advocate"?
  13. KatieMI

    Losing job due to injury

    BTW, that's what most of my buddies told after everything was said and done. They were not even aware of the world of interesting (or less interesting, but anyway good to know about) nursing opportunities available beyond their daily grind. Almost all of them changed careers after they recovered, most definitely to the better and more satisfactory ones. Sadly, in all cases it meant that bedside lost excellent nurses
  14. KatieMI

    Losing job due to injury

    Just for consideration: there are jobs in hospitals which are 90+% seated. Unit clerks are needed all the time. Yes, it is not a "nursing job" per se and it pays much less, but it is one way to keep your foot in the door, keep your networking alive and do something for some $$. Several of my nursing buddies did that (also case management, while using an one-foot scooter) while they were "limited in their mobility" under similar circumstances. Also, if you ever thought about going back to school and can afford it, online education is a God's gift for those who are "mobility challenged". I am so sorry it happened with you, wishing you all the luck and full recovery!
  15. KatieMI

    $750 CA RN License??? No way!

    They can do it, so they do it. The other choice is to get in and finish community college program here in the States, which will be significantly more expensive.
  16. KatieMI

    Thoughts on vegetarian/ vegan diet

    1). If you took Nutrition course as an RN, you should be able to offer some sensible advice. You cannot refer out 100% of everything. BTW, consulting services of RDs tend to be not covered by insurance and seriously good RDs are few and far between. 2). Vegans' (as well whoever else's) evangelical, philosophical, political and other such issues is out of our scope of practice as long as they do not do something clearly reckless with their dependants. 3). Categories of patients who must not go vegan by themselves (educate, discourage, get provider on board STAT): - coumadin users (too much vit K) - cancers of breast, ovary, uterus, prostate AND patients' BRSA-positive relatives, male and female (soy based foods have too much phytoestrogens, can potentially cause tumor growth and/or progression) - CHF and uncontrolled HTN (a lot of sodium in soy-based stuff and meat substitutions) - uncontrolled DM (carbs, especially in juices) - renal disease stage III and down, especially HD (sodium, potassium, phosphorus, aminoacids imbalance) - extracorporeal insemination/females (phytoestrogens can interfere with treatment) 4). Educate about: reading labels (protein content, vitamins enrichment); NO preference for "natural/organic" (these foods are frequently not enriched with microelements and vitamins, especially iodine), reaching beyond staples (seaweed is one excellent source of B12 and iodine, naturally pickled veggies like kimchi and homemade crout are rich in all B vitamins, and so is fresh craft beer), the fact that full and working vegan diet takes A WHOLE LOT of education, almost daily elements counting and money OR time spent in kitchen (people seem to be not aware of this simple fact). 5). Going vegan is OK. Making your baby vegan AND ignoring medical advice is not and will be reported to authorities.
  17. KatieMI

    Whiskey peg tube flush?

    And this is the deal. I work in a formally tertiary care, but in all senses regional center with tons of private practices which provide the main $$$$. There are quite a few off-label and other such things that are routinely overstepped in order to keep "customers" (both patients and private practitioners who bring them in) happy. If one of the Big Surgeons wants whiskey detox, that will be done, however much it is against current guidelines. And you probably cannot even imagine what is going on in "critical access" rural hospitals where what you and me consider as pretty ordinary treatment options are routinely not available. I saw with my own eyes a fluid bolus on patient in septic shock and liver failure with MELD 40 flowing into a varicose vein on his anterior abdominal wall. The poor fellow had only one hand, and that with AV fistula, lower extremities are out of consideration due to DM ("it's a POLICY!!!") and nobody in ER, run that day by a Family Practitioner, was able to throw in a central line of any kind. And nobody had guts even for EJ access. And the place had no kits for intraosseus access. And there was no ultrasound. And nobody except me seemed to care that flowing volumes of fluid directly to bottleneck of portal vein through cirrhotic liver was against of very basic logic of pathophysiology.
  18. KatieMI

    Whiskey peg tube flush?

    1) Surgeon felt that, addicted or not, the patieng needs surgery. Lower esophagoectomy with PEG on adult in >95% means low esophageal cancer (which is metastating quickly and resistant to pretty much everything else), the rest is for emergencies like Mallory-Weiss, Boerhaave syndrome, trauma, etc. Either way, there is little or no waiting time. 2). It really depends who is the boss where and why and under which service patient is admitted. Yes, in some cases surgeons can overstep everybody else, even in ICU. 3). We know nothing about patient's condition and when he was operated on. Just mentioning, alcohol by itself does not cause varices; increased pressure in portal vein system does. But if low esophagus is gone, varices at least there are gone as well. 4). Barbiturates are pretty much out of use in the USA except in very selected anesthesia and, anyway, they are not the best choice for someone with compromiced liver. Patient might claim that he is allergic to all benzos, for whatever reason. Or surgeon can be pretty much lost in the wonderful world of Pharma and use what he is used to use, and there would be no one to contradict him or her. Or the patient is in a smaller regional ICU with known "difficult airway" and they have paucity of really good intubating hands. Or another 100500 scenarios. And, BTW, at least barbs will be indeed more depressive on CNS in dose enough to suppress DT with all its sequela. Of course, benzos would be better choice but please see above. 5) Just out of my own love affair with pharma: ETOH does not "dissolve" methyl or glycol. It takes over the liver alcoholdehydrogenase, and that's the interval products of metabolism of both methyl and glycol that kill.
  19. KatieMI

    Fired two times and unable to get job now

    If you have clear license and some temerity, try agencies and/or travel. In many cases everything you need is unincumbrent license and breathing/circulation in your body. It will be hard work but you can be master of your schedule, above local politicking and paid higher. And if facility uses travelers, it means they will overstep A LOT of stuff in order to get some help. What is your Master's in?
  20. KatieMI

    MD notify question to all experienced nurses

    Ok, here is that very "doctor" (well, NP, but that's me who would be called): 1). You have The Holy Order of Parameters which say "above 100.4". It is written so with purpose to give you clear direction what to do. So you did just what was ordered and it was a good job. If parameter says "call when above 100.4", then do not call till it is 100.5. Plain and simple. 2). Otherwise, you may want to call when there is the fever of not quite those 100.5 AND something else. You do your assessments. IF you find something CLEARY unusual IN ADDITION TO that 100.4 fever, then PLEASE CALL. Dirty smelling urine. 6 liquid BMs that day. Patient being sleepy, not drinking, refusing whatever he/she usually enjoys. Do not treat your numbers, treat the patient. If all business goes as usual except that "fever" of 100.4, then PLEASE DO NOT CALL. 3). I do not know how your doctor goes about it, but if I hear about however old and experienced nurse abusing and threatening (yes, those are the words) someone with license loss for "not updating provider" about everything and anything, I bring things to screeching stop then and there. I did not forget, and did not forgive a monster in scrubs who used to call the State because she saw a piece of package of coumadin pill falling down on floor, and behave accordingly toward those who threaten and abuse others.
  21. KatieMI

    Destined to Be a Flight Nurse

    Leaving alone the question about being "destined" into something, I would say that trying for another ICU might be not a bad idea. As a former LTACH nurse, I would dare to say that after 4 years in that environment - providing it was "acute" LTACH - one should have same or better "prioritization" skills than an average med/surg nurse. And it is a well-known fact that some (and in fact quite a few of them) ICU nurses feel somehow way superior to those working long term acute without any perceptable degree of knowledge about what it implies. 'Been there, had that, done that, saw ICU floaters getting pale-faced when facing assignment of four vents, two of them simultaneously trying their best to catch Jesus' bus then and there. Get to any acute care floor you can now but keep your options open and CV updated.
  22. And every student who is about to suddenly change his or her mind and get out of some mundane and down-to-the-Earth professional course for "discovering yourself" into something like Bachelor's in History of the World cinematography, must be made standing to face the rock and read the aforementioned 10000 times, aloud and on public.
  23. No. Absolutely NO. Furthermore, getting some kind of Bachelor's and converting it to nursing BSN when you have no previous career and no money is just a sure way to burn your loan $$$$$. $85 grands is above the cost of typical midrange "all-inclusive" direct MSN, for which you might not need any prerequisites at all and from where you can start making those $85 grands a year or about it as an NP in urgent care. For PA, you'll need some sort of strong prerequisite and very good academic base, or you won't survive the program. You also can find an accelerated BSN, or go to community college and get ADN for less than $10000 typically, then work things up while working and earning money.
  24. KatieMI

    Nurse Charged With Homicide

    It looks just like trying to convict someone of homicide after accidentally hitting and killing a man while speeding 25 miles over speed limit. Yes, it is a tragedy. Yes, someone had died. Yes, there was spectacular level of stupidity demonstrated by more than one person. But, no, it was not a cold-bloody murder. It was, that is to say, a reckless driving. Stupid and tragic, but just... stupid, after all. And, BTW, things look like the doc who ordered a definitely gray-zone drug (as it was discussed on this very forum already, Versed is neither common, nor, actually, directly indicated for symptomatic treatment of claustrophobia alone as opposed to monitored intra-procedural sedation) got dry out of deep and hot water.
  25. KatieMI

    Worsening Health, Considering Resignation

    1). Just as much as you want. Better yet, nothing. It is not anyone's business to know why exactly you resigned. And you are not responsible for making your health history known to anyone. You might devise some short legend to keep things simple and preventing others from sticking their noses into your private life and let you not to burn bridges on your current job. Some suddenly seriously ill second cousin of your former MIL, for one example. 2). "I had some new and serious obligations in my life I couldn't bypass at that point. It's all over and dealt with now, so I can concentrate on my career". Just like this 3). It very much depends. Psych nursing can be just as stressful and back-breaking as any other bedside job. 4). Look in what you like and don't like to do as a nurse, then play from there accounting for your health (which must come first - always). You might need to make more long term plans, like getting your Master's (nursing education is one niche friendly and accepting for nurses with physical limitations), or look for less common positions like administrative nursing or case management.