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GreyGull

GreyGull

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  1. GreyGull

    did the Dr. have a right to scold this nurse?

    Our IT people set up some of the most complex technology on the market. They are present in the patient care area to troubleshoot and make sure everything is functioning as well as to TEACH RNs and MDs how to use it. That may definitely be during a code if that is when the technology is being trialed. They or Biomed may also have to help us switch a patient off of a very delicate and expensive piece of equipment if it has failed for some reason. They also make sure we can stay up and running during an emergency such as an earthquake (West) or hurricane (East) with adequate backup. The list is endless to their importance. You may only notice them if your internet password on the computer doesn't work.
  2. GreyGull

    did the Dr. have a right to scold this nurse?

    You guys tickle me sometimes and I'm the one who is 2 - 3x your age and grew up with the stone tablets. Get over your arrogance. You need computer specialists and the more they know about your job, the easier they can make it.
  3. GreyGull

    did the Dr. have a right to scold this nurse?

    Define "record a code". In my hospital it has many meanings since we do teaching and have electronic gadgets everywhere. Someone writing events on a piece of paper is just one way and may be done while other methods are also be used to "record a code". 20th century today and maybe the 21st century hopefully by the end of this decade.....
  4. GreyGull

    ABG treatments?

    Then allow me to introduce you to the Philips elearning website. Philips bought Respironics who makes many pieces of RT equipment including the Vision. There is a good Vision inservice and NPPV courses along with ETCO2 and other noninvasive monitoring. Registration is free and so are most of the courses. https://theonlinelearningcenter.com/default.aspx The Vision will be under Philips Hospital Respiratory Care. The V60 is the next generation but the module is being updated.
  5. GreyGull

    did the Dr. have a right to scold this nurse?

    I see someone who is asking questions about the things he is seeing or reading and would like an explanation from those directly involved in patient care. Maybe he does not want to bother those where he works with these questions especially since many of the forums stress they are overstressed and too busy to pee. He might get that but feels an open public forum might be a great place to learn. It is no different than some of us popping on to some of the computer wiz or tech forums to ask a question about some of our gadgets which are probably too intense for us but we must have them and now we turn to those forums and ask what might seem like really stupid questions to those in that specialty. But, fortunately someone always takes time to explain to a mere health care professional how to turn on my new TV set. How many times has someone here picked up the telephone and screamed like it is a life or death situation if a computer expert does not get up to the unit real fast and fix (resuscitate) the technology before the paper order forms must come out of the closet? Bystanders may interpret your voice, words and actions to be a serious event and somebody really important has coded in the nurses' station. Anyone who keeps the technology running in a hospital is definitely part of the team.
  6. GreyGull

    ABG treatments?

    That would depend on the disease process (underlying and acute), the plateau pressures, the waveforms of the ventilator and at what stage of the acute or recovery/rehabilitative process the patient is in. ARDS protocols will run from 6- 8 ml/kg (emphasis on plateau pressure as a guide) but will also allow for PEEP to make up the FRC and increase oxygenation. http://www.ardsnet.org/system/files/6mlcardsmall_2008update_final_JULY2008.pdf Specific criteria must also be met for ARDS and a package deal including possibly a buffer might be included for the protocol. In extreme cases paralytics might be used for the patient to tolerate the low VT and high RR. Rehab units (SCI patients) may run from 10 - 20 ml/kg to inprove FRC, lower FiO2 and decrease secretion causing atelectasis and infection. ORs may run high VTs and lower respiratory rates since they rarely will use PEEP. The ICU will then adjust the VT and RR to maintain the same minute volume achieved in the OR.
  7. GreyGull

    ABG treatments?

    But then over simplification is why some don't understand ABGs the way they should especially if they are in a position to assess and maybe treat. Over simplification is also why some still use "no more than 2 L for COPD" or toss out something like "hypoxic drive" without of an explanaton thus leaving some patients struggling at 88% and hypoxic. Over simplification is also what has led to the misuse of the term "high flow" and not taking time to explain inspiratory demand. Over simplification has led some to believe BiPAP™ is a life support ventilator and a misunderstanding about the "rate" which is set on it. Over simplification has led some to believe CPAP pushes lung water out. Over simplification can lead to a misunderstanding of all the components of the acid-base and fluid/electrolyte systems. Over simplification has led to a misunderstanding about when to give NaHCO3 for a low pH and when it is total inappropriate. Over simplification has led some to believe a "normal" or "compensated" ABG means everything is okay or "let's wait and see" without realizing it can very much be like "shock" in a compensated stage. The crash and burn might happen very quickly and some just didn't see it coming because of over simplification. Instead of always trying for the simplest approach, dissect the information given and study it thoroughly in pieces. ABGs should come after one has some indepth knowledge of fluids, electrolytes, acid-base, cardiac, circulation, BP and the respiratory components. A well structured approach to Anatomy and Physiology will help with this. Unfortunately ABGs are sometimes included with the respiratory section before some of the other components are covered, thus giving some the impression there no more to the story. The analysis of the ABG then becomes very limited.
  8. GreyGull

    Home sleep study test

    I would check with the sleep lab about ANY medications, OTC or prescription, to see what they do allow. Many machines are now auto titrating (APAP) and many insurances do allow these. Some patients may have this study done in the hospital near the end of their stay. The program card is downloaded and it shows what the patient required t/o the night. You'll be seeing more of this in the future with new protocols in place for hospital admissions and especially those for surgery. The patient can be observed, diagnosed and educated easily. Sending a patient home, waiting for them to see their PCP who may or may not be well versed in sleep apnea and who may not give them the referral to a sleep lab is a hit and miss process with a lot of misses.
  9. GreyGull

    ABG treatments?

    I apologize for my lengthy posts. To summarize, sometimes patients are "assumed" to be a COPDer or in exacerbation with sole focus on the respiratory component. The clinical presentation and the ABG iare useful for the inital rescue but as the bedside clinician, the history, duration of overall illness and the acute situation must be considered and how it has affected the respiratory component. If a COPD patient by confirmed diagnosis tells me has have been sick for 3 days, looks clinically stressed but has what some would think is a normal compensated ABG, he might be looking at a ventilator in his future rather than NIV. CO2 narcosis should not be assumed to be just COPD or even too much sedation. Other major issues are missed due to the focus on the pulmonary issue for assessment and treatment and of course the "OMG they have COPD, hold the O2". Understand the difference between the rescue treatment and that which addresses the underlying cause which may not necessarily be pulmonary. Lots of breathing treatments may NOT be the answer either and may harm more than help in some situations. Be careful when assuming all COPD patients need Albuterol and have it distract from what treatments should be done especially in the face of an MI or CVA which are sometimes overlooked. Another issue which should be assessed before any NIV is initiated is a GI problem. You do not want to exacerbate vomiting or any situation where air in the gut with gastric distention or perforation might be a problem. Alcohol intoxication and NIV also do not mix very well but once the ABG is obtained or the patient snores you will usually hear someone yell "BiPAP STAT".
  10. GreyGull

    ABG treatments?

    You must monitor the intrinsic or auto PEEP and plateau pressures. High Peak pressures are also just one small part of the story. By knowing the plateau pressure you can make an informed decision about whether it is a problem with secretions, bronchospasm or compliance. http://anesthesia.slu.edu/pdf/plateau.pdf The CXR would be a necessity to determine the strategies for protecting the lungs to achieve the amount of oxygenation required. But then, initiating one of these strategies would come with a package deal of CVP monitoring, fluids, pressors and maybe a buffer depending on the etiology of the lung disease and permissive hypercapnia. I would also still look at the other lab values to determine the correct path for treatment. Stabilizing with a ventilator is just short term or maintenance. It may only buy a little extra time.
  11. GreyGull

    ABG treatments?

    The over simplified teaching of ABGs do an injustice to the bedside clinical health professional. Many focus on the disease process of "COPD" without considering the many other pulmonary and non-pulmonary disease processes which are interconnected. Treatment is not going to depend solely on the ABG. The anion and OSM gap must be considered when it comes to acidosis. The other lab data can also help determine if the results of the ABG are an early or later stage and determine the path of care. Sometimes a patient with a low pH can avoid intubation based on this data. We've also extubated patients post operatively with a less than ideal ABG by understanding the other data used for differential diagnoses. Here's a little more detailed ABG interpretation. http://www.thoracic.org/clinical/critical-care/clinical-education/abgs.php http://revisemedicine.com/forum/medical-students/1947-guide-abg-interpretation-medical-students.html For Respiratory Acidosis you may need to determine if it is hypoventilation from: (taken from the above articles) 1. Chronic obstructive pulmonary disease 2. Neuromuscular diseases - e.g. Guillain-Barre syndrome, Myasthenia Gravis, Muscular Dystrophy 3. CNS depression - e.g. drugs (opiates, barbiturates), neurological disorders (trauma, brainstem disorders) Or failure due to V/Q mismatching and hypoemia. 1. Atelectasis 2. Pulmonary edema 3. Pneumonia 4. Pleural effusion 5. Haemo/pneumothorax Some of these you can help correct or influence as a bedside clinician. The support (O2, NIV, ventilator, positioning) offered will depend on the determined underlying disease process and the clinical symptoms determining the amount of "rescue" required. Pulmonary Emboli is also another consideration but the ABG will probably appear as "hyperventilation" initially.
  12. GreyGull

    did the Dr. have a right to scold this nurse?

    This is also a very public open forum. The OP expressed a concern for a nurse over something he/she thought he/she withnessed. The OP is also a member of the hospital team even if he does not have RN behind his/her name. The OP's question also seemed to be out of respect for nursing. Since this is a very public forum, how we treat each other and anyone who happens to post BECAUSE it is a nursing forum, forms an opinion by those who might stumble upon this website. This website does appear on several search engines since it covers many different topics. Also, a situation simiar to this is not that uncommon and how we respond is important. In the hospital it is not uncommon for a visitor, family member or patient to ask about something they may have witnessed or overheard. You could have patients, nurses, CNAs, various techs, doctors and visitors who could be shouting, crying or making some type of fuss in a patient care area. Being able to explain a situation without be a real turd is an art as much as it is a valued skill. There are also closed forums where you enter by a professional membership and your real name, title and facility are posted. Those forums rarely if ever have fluff, laid back or snippy posts. They are all busines. This forum is sometimes a delightful change from the all busines attitude and to see newbies get advice from the more experienced.
  13. GreyGull

    did the Dr. have a right to scold this nurse?

    Since this was a teaching hospital there might be several ways to "record a code". We record the actual code in action to be played back. There are also electronic markers on a computer screen that has all the monitored data sent to it and it takes is someone to press a button on cue. The OP might have been near the monitors where the ECG was printing. We've also had our Computer Technicians standby to limp our equipment along until a better solution is found or the equipment is replaced. They are more than capable of "recording" or ensuring the equipment continues to gather information and sometimes they are the Masters at doing this by knowing the equipment better. Without knowing what actually was said between the MD and RN, it is hard to judge. Since the OP did not actually hear harsh words it could have been anything from comfort to questioning the events and an RN who was shaken by the event for some reason. But, had it been a loud verbal attack to where bystanders noticed, then yes that would be very inappropriate regardless of the title of the person doing or rec'g the verbal attack or "scolding". No such exchange should take place in a patient care area or in view of others.
  14. GreyGull

    Swan-Ganz Use

    Is the PA catheter used by Habit Based Medicine or Evidence Based? Because we've always done it like this no longer holds up in Evidence Based Practice. http://anestit.unipa.it/mirror/asa2/practice/pulm/pulm_artery.html Any invasive procedure will now face scutiny and CMS will be taken seriously. These procedures are also no longer the cash cows they once were for physicians. We used to have docs stumbling over themselves for procedures. We used to put in an Arterial Line into every ventilator patient and now we rarely do an ABG unless there are multiple conditions that exist which warrant one.
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