TennRN2004

I had a patient a few weeks ago whose case we canceled based on a low lab potassium value 2.7. I was the first to review the chart and pointed it out to the CRNA in the room with me, we called the floor to verify if it had been treated or rechecked, and the am nurse wasn't even aware of the k level. We notified the ologist who called the surgeon and talked the situation over with him. Basically, he said what someone else has mentioned, that if the case was an immediate emergency, then we could do it, but if not the patient should be rescheduled for another day. The surgeon was fine with it, because he understood if we have a cardiac event from a low k in a case that could have waited a few days, it could be a big problem. Ultimately, if a bad outcome occurs with the patient intraop and anesthesia is trying to treat something that was recognized preop as a risk factor that was discussed with the surgeon, it leaves us and them open for liability issues. Of course, like someone else mentioned, you don't just go on your feeling about the possibility of something happening, anesthesia is expected to be prepared to treat a wide variety of acutely unstable scenarios in the OR. But, we do have evidence based practices that guide us on difficult situations. Provider experience and judgement is the bottom line. Surgeons may want fast turnover and lots of cases, but they don't want bad outcomes from doing a case that needs to be held off either.

What about going to cath lab but staying on prn in the unit? That way you can still keep your unit experience fresh on your application, and you'll be a well rounded applicant with a broader experience base.

I want to say before anyone reads this and goes crazy, I am just getting ready to start school in a month, so I am not entirely sure what the resposibility/pressure of an anesthesia case entails yet. However, to play the devil's advocate, I have also heard the arugment that when you are totally focused on the patient and surgery, some people find themselves drifting off mentally. One of the best anesthesiologists at the hospital I worked at as a unit nurse was reading an anesthesiology magazine one night when I walked in to watch my open heart patient. I would trust him with myself or any family member any day. I didn't feel in any way that he was neglecting the patient or not being as vigilant as he should. He felt that reading such an article kept him stimulated and he wasn't as likely to zone out during the case. I don't know about anesthesia providers talking on their cell phones doing stock deals and personal business like building a house, but I think professionally related material is not necessarily a bad thing to have in the OR. What do some of the CRNAs who've been doing it for a while think?

To The OP: I love my job, and I am so glad I decided to pursue nursing. I've had a run of rough shifts lately, but at the end of the day, I've never had a job where you feel so fulfilled and rewarded for what you do. It's not for everyone, as some of the posts have made clear. But, there are many many positives to nursing. You don't have to work in a hospital or at the bedside. Nursing is wide open with many avenues available. I like being in a career that is so flexible. Of course, there are plenty of aggravating things about nursing, but what job is perfect? For myself, I feel that there are more positives than negatives. If it is truly something you want to do, then go for it. You're not too old! Don't doubt yourself b/c of what he's telling you, follow a nurse for a few hours and see what you think for yourself.

How can any nurse get fired for missing narcs in this situation anyway? There's too much access to the meds, I wonder if any of the guards got fired for the missing narcs since they have unlimited access to them.

That a fiberoptic IABP does not need to be leveled. Gee, I went to nursing school, and even I know that one. If you don't want to be called in the middle of the night, just write the order "DO NOT CALL ME from 7p - 7a" and I won't bother you. When you come in the morning, you can like it or lump it what I've done to get your patient through the night. Forget to order labs and x rays on your patient and get mad when I didn't know that's what you wanted. But, then when I do order something I think you'd want, you get mad about that too. Complain to me b/c two other docs refused a patient and so now you're the consulting, I really don't care that you had stuff to do too...just take care of my patient. I did not get my nursing license at K Mart. I worked very hard for it and my education. Just because I don't have MD behind my name does not equate to my being stupid. If I call to ask you something, I realize you have more knowledge than I do, that is expected, don't have an ego and rub it in. Get mad when I do something you told me to do two hours ago...when you come back through, you want to know "who told you to do that?" I can't help it if you have short term memory loss and can't remember telling me to do something.

There's no set rule of NC O2 that I was taught not to give a COPDer. I was taught in school, that for a CO2 retainer, use caution in giving O2 b/c you can knock out their respiratory drive as others have discussed. However, keep in mind these patients can go bad and need higher flows of O2. Don't with hold the oxygen they need as others have mentioned also- you wouldn't not give pain medication to a patient screaming in pain, b/c you might knock out their respiratory drive from giving 2 mg of morphine, same thing applies with oxygen. But, if you have to give them O2, give it in a form that is better for COPDers. If they need higher flow of oxygen, use a venti mask.

One important thing we often forget is that these families need to feel that they've given their loved one the best chance at a recovery. It is often hard to give these families at straight answer on prognosis, length of recovery, quality of life if they do live through a period of being sick in the ICU. I personally can't tell you how many I have seen in my few years in the unit and thought they would never make it out of the unit much less the hospital, and they make a full recovery. Granted, the chronic long termers usually don't fare so well, but you never know. I know the families often feel torn between wanting to do what the patient wants, but also not wanting to give up. Nothing would be harder than letting your mom/dad/grandparent go and wondering if you would have continued with treatment if somehow they could have made it. Now, all that said, I also think we come to a point when enough is enough. I understand the families that choose to keep going with treatment when there is a feasible chance of recovery, but I have a harder time understanding those who come in with multiple admissions for end stage COPD, fibrotic lungs, chronic CHF with no heart left and the families refuse to recognize they are prolonging the inevitable and making their loved one continue to suffer because they can't let go. I think it is a situational thing- each member of the healthcare team must be evaluating the patient and response to treatment on a continual basis with realistic expectations and have frank open discussions to ensure the families understand exactly what is going on. Unfortunately, often these families don't understand half what we tell them, and the half they do understand, they still don't grasp the overall picture of how sick their family member is. I think in these situations, we still have a long way to go with effective communication.

Congratulations to you too endorphin. Doesn't it finally feel good to know you're in and be done with the waiting and worrying about the whole interview process? When does your program at UAB start?

Hi All, I am so excited! I just got my letter of acceptance from the Erlanger program. I was very suprised to hear back so soon since we just had interviews a week ago. Has anyone else heard the good news yet? Just wanted to say thanks to all the supportive people on this board, it really helps those of us who have the goal of anesthesia school. :roll

I've had several pneumonectomy patients who had orders to keep their chest tubes clamped, otherwise, we only do it to change out the atrium.

Check out the intermidiate care unit thread here. We don't have step down units at my facility, so I can't tell you specifically what they do from first hand experience, but that thread seems to be pretty inclusive of what I've heard they are like at the hospital in the town where I work.

We call it a "baptist dose" down here. It's not a common practice to my knowledge where I work, but on occasion I have been told in report someone recieved a baptist dose of insulin, morphine, ativan, etc. I have honestly never actually done it myself that I can recall. I know that if it was a common practice that was discussed openly, it would be quickly stopped. Instead of giving a baptist dose intentionally and charting the correct dose, I have actually had the opposite happen. I was in the room with a crashing patient, and my other patient was a climber trying to get out of the bed. The RN who had this patient the night before yelled in and asked me what it was time for the patient to have. I yelled back ativan, so the other RN goes to pull it and doesn't check the med record to see that the dose had been reduced. I charted the med and I charted the actual dose given, instead of lying and going back and wasting 1 mg that was actually given to the patient. I felt that if something were to happen, the physicians needed to know exactly how much the patient had gotten, but I got mouth about it when giving report the next morning that I had not given the proper dose. Funny thing though when I came in that night, the nurse tells me ..."now I actually gave her more, but I only charted the proper dose that was ordered." To my mind, neither is okay for us to do, but at least what my co worker did was an honest mistake, and not intentionally done to give the pt more than what was ordered. I can see times when it may happen, and I think for the most part ICU nurses have good enough judgement to not place patients at risk by overdosing medications. However, I think there is a fine line here, and nurses should tread very cautiously when giving baptist doses of meds, regardless what type of med it is.

All of our surgeons but one are still using it, in spite of the NEJH article a while back. We have excellent outcomes with our heart surgery patients. I tend to agree with the point the website you posted in that the Bayer study was not a randomly assigned study, so the patients who recieved trasylol based on need from the physicians work up were the sicker patients, and at higher risk for complications anyway. There is always a risk/benefit ratio to any drug/procedure/surgery that is offered to patients. I think in light of this study though that it bears heavy consideration for trasylol to be given to all patients, and that a little more research should be done before a definitive answer is reached on it's safety in the cardiac surgery population.

The Incredibly Easy series gives good info, just the basics in simple easy to understand format. They have topics like critical care, lab values, ekg, assessment, etc. You can find the series at any bookstore chain-barnes and noble, books a million. Also, you can find in these bookstores the medical/nursing section and get flip books that have references to what type of MI has what area of st elevation, basic rythms, etc. Have you taken ACLS yet? The ACLS course will also give you the option to buy a small flip book with information on the drugs used for arrythmias and what they arrythmias look like.

I agree totally. We actually do q 4 I/Os and adjust every 4 hours to help prevent this, but it is confusing. You really have to watch your numbers, and I always double check myself twice before I make flow rate adjustments. I think this way is more accurate b/c instead of guesstimating, I can show you exactly what the numbers are and where my calculations came from.

We also resuse the effluent bags. The only place to get new effluent bags at my hospital is when you open a new filter, it is in the packet with the new filters. The expense of opening a new filter each time you need an effluent bag would be cost prohibitive where I work. I am sure they probably make effluent bags separately, but we don't stock them. We actually have a stash that we squirrel away when we open a new filter and don't need the effluent bag.

dry weight

It does end up giving the pt a lot of volume. We will double mix it if needed for volume control. But, on our standing orders we have the order to keep the total of IVF, including gtts to 100 cc/hr in the hearts, maybe you could suggest something similar to your MDs. Personally, I've only had 2 patients I can think of need more than 5-7.5 mg/hr, which is 50-75 cc/hr of volume. These two pts ended up getting prns and home meds resumed so we could start working off the cardene.

Thanks everyone. It's been a week full of emotions. I was kind of in shock at first, not wanting to accept it. I had kind of prepared myself (I thought) for the possibility that he may not make it, but you always keep that hope with you that things will turn out well. Slowly they are taking it day by day and dealing with it very well, I know alot better than I would be able to. It's hard on the family though knowing what to say when you know nothing you say is going to make it better right now. We've just let them know we're here for them for anything they need, and atleast my SIL is doing well. She got a clean bill of health, and the doctor did tell her he had never seen a mom go through something like this twice. We were glad to hear that so when they are ready down the road, hopefully things will go better. She is an amazing person and has been so strong, she really did get alot of help from the nurses and you guys do a wonderful job with these parents and their little ones. Thanks again everyone for all you kind thoughts and words.

Wow, it does sound like this was an extreme case. I would be concerned about the clicking from the plating, b'c I honestly don't think it is a normal finding. But, with the pts severe injury, maybe over time as he heals it will go away. I would hate to guess in such a pt how long the healing time would be, but hopefully the plating will protect the sternum so he can heal properly and not have any more issues. I'll ask one of our docs next time I work and see if they've ever seen a case like this. We only do the sternal plates few and far between though.

Had this exact situation at work happen a while back. Pts aline was off the monitor, but left in for lab draws. Nurse goes in the check on sleeping pt, notices something on the floor, looks down there is blood all over the floor. Long story short, the aline ended up unconnected, stat h/h checked, pt got 2 units of blood. We were told to not do this either, b/c it is totally a patient safety issue. If you don't need the aline for continuous bp monitoring of vasoactive meds, or a sick pt on the vent for frequeny lab draws/abgs, I agree with the other posters. Why keep an invasive line you don't need and put patient at risk for numerous complications, especially if is not reading right and the patient is not a hard stick so getting labs won't be an issue? I wouldn't feel bad about it. Ultimately, pulling it is not going to do patient any harm in this situation, whereas leaving it in with the monitor of very well could cause patient harm.

I gotta say dinith, I'm glad this situation turned out well for the patient. I would have been of the same mind as you to give him morphine and let him go peacefully. Unfortunately though, we often see the opposite happen. The patient is suffering, the family won't agree when enough is enough, what we do to some of these poor patients is just terrible. I'm all for doing everything possible if there is any hope of a reasonable recovery/quality of life. But, for so many of these pts I feel we are just prolonging the inevitable, we keep them hanging on, and for what reason? It does make you feel good though when you have a good outcome like this, for the patient and his family. I do also agree that a lot of it is out of our control. For whatever reason, it sounds like it just wasn't his time to go. These type of pts are what I like about critical care that you go from seeing them so sick and working hard to get them better, then few days later he's up in the chair talking with the family. You just never know, but I know the family feels blessed that he is doing better now.

I use it all the time for the hearts...love it, it works wonders for both htn and afterload reduction. If I'm getting up to 100-150 mcg on my ntg gtt, I'll start thinking about some cardene. For htn, usually start it a 5 mg/hr, for svr reduction, usually 2.5 mg/hr. We use it over nipride, although they are both on our standing orders, because of renal issues and b/c it is much smoother pressure control and easier to titrate. When you're seeing it not work, what kind of doses and pressues are you using? We all love it in my unit, and I agree with above post that I've never seen it not work.

We also have the needles with the safety covers. BUt, ours allow us to choose the length/guage of the needle we want, so we can change ours out. In the situation you are describing, sounds silly, but the only thing I could think to do would be draw portion of the med up into ten different syringes.