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Mully

Mully

SICU
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Just a friendly guy making a name for himself.

Mully's Latest Activity

  1. Mully

    NYC CRNA Program Clinical Sites

    Anyone on here in one of NYC's CRNA programs? I would be extremely appreciative if you would give me the Christmas gift of answering a few questions I have. Thanks ya'll
  2. Mully

    Starting neuromuscular blockers

    Interestingly enough, the BIS was never actually tested on patients who were paralyzed when it originally came out. So a few crazy anesthetists in Australia did a study where they paralyzed each other, placed a tourniquet on an arm so they could still move their arm to answer simple math questions, and put a BIS on there head to see what it would say. In some patients, it read less than 60 with a perfect SQI while they were answering questions correctly. In other words, the BIS is worthless. Check it out... http://bja.oxfordjournals.org/content/115/suppl_1/i95.long
  3. Mully

    ICP and D5NS

    Main thing is you don't want anything hypotonic. Isotonic or a little hypertonic (Like D5NS) is okay. Hypotonic fluid like D5W (It actually starts isotonic, but as the dextrose gets metabolized it becomes hypotonic) will cause fluid to move into cells creating edema and increased ICP. Hypertonic fluid will actually pull from fluid into the vascular space. Just keep checking BMPs.
  4. Mully

    so cold in OR!

    I usually just splice into my patient's bair hugger. Y it into my pants, puff up like the Michelin man. Warm my hands on the Des vaporizer. What happens behind the drape stays behind the drape.
  5. Mully

    I&O Goal Clarification & Nipride vs Nitroglycerin

    This. Nitro is purely venodilation, with a small amount of arterial dilation at really high doses. Nipride is a mixed dilator, meaning it dilates both venous and arterial sides.
  6. Mully

    Fentanyl Drip

    I don't believe it was either of the drips. These explanations for the bradycardia are essentially zebras when there was much more likely a horse which caused it. Fentanyl does not cause a vasovagal response. The only time you'll see a change in hemodynamics when administering fentanyl is if the hemodynamics are being held where they are due to a stress response from patient being in pain. This patient, having OD'd on narcotics, was so used to them from home that 15 mcg/hr is probably juuuust keeping them from DTs. It's not even touching them. You can give 15 mcg of fentanyl to a 80 y/o little old lady and she won't blink from it. It must have been running at 0.3 ml/hr! They probably didn't even get any in there IV lol! It just gets funnier the more I think about it. The propofol isn't "maxed out" either, maybe it is by your unit's policy. However 50 mcg/kg/hr is again, nothing for this patient. The bradycardia was certainly from another cause.
  7. Mully

    Anticoagulant Preventing CVC Insert?

    Where have you gotten this information about small IV sizes being better for pressor administration? Do you have any research or manufacturer's guidelines? You seem pretty adamant.
  8. Mully

    Anticoagulant Preventing CVC Insert?

    Subcutaneous heparin is low-dose heparin (5000 U subq). This usually doesn't even alter the INR at all. Patients get these shots right before surgery to prevent DVT post-operatively. You know... surgery. Where we cut people open and whatnot. We also perform spinals/epidurals without consideration of a patient's current subcutaneous heparin status. And if a patient were to bleed from a spinal/epidural, they could very quickly become paraplegic. What I'm trying to say is, that doc wanted a cop out. Next time politely ask the doctor to reference his research article so you can further educate your peers.
  9. Mully

    new job/letter of rec

    She gave me a good rec. A couple reasons I attribute to it. 1. It was a large teaching hospital and they were always giving out LORs. 2. One of my preceptors had just gone to this manager and complimented me highly on how I was doing while on orientation. This manager came and told me that as one of my first interactions with her, so I knew we were off to a good start. 3. I don't know how much this mattered but I really downplayed it. I was like "I'm only applying to this one school and I don't think I'll get in it's just more of a practice run I plan on applying to a few next year". That was mostly true, although I had confidence that I would actually get in, which I did. But talking with her I tried to make it like it was not a big deal. Idk, I've been told that I'm a good BS'er. Plus I emphasized that even if I got in, I would still work there for a full year before moving on. All ways round, it just sucks. I wish there were an easier way, but there's not.
  10. Mully

    new job/letter of rec

    I had the same situation. I think I asked my supervisor for an LOR after 4 months of being there! Hahaha, it sucked I didn't want to do it but I had to. I'd probably stay where you are just to avoid that. Or ask for an LOR from your current supervisor before leaving. In my opinion, experience isn't everything. Certainly it helps. But don't think there's something magical about managing 6 gtts instead of 3 gtts or whatever. That's not what teaches you anesthesia. You'll learn how to do anesthesia in anesthesia school. I think it's more important that you're not lazy and that you can learn and adapt and stay humble; that you're on top of things, extremely vigilant, anticipating problems and prepared to make a decision and act. They assume these things correlate with the best nurses with the best experience but that's not always true.
  11. Mully

    How long did it take you to become a CRNA

    By the time I'm done next year it will have been 8 years. That includes a semester doing a CNA course and a little over 2 years as a nurse. Basically all of my young adult life lol. I'll be 28 when I graduate. Phew!
  12. Mully

    Failed CCRN - Need Encouragement

    I never got my CCRN and I'm a year out from being a CRNA. That should be encouragement enough lol One quick rec for retaking it though. How you study is a big deal. Clearly what you did before didn't work. You need to change something this time. Figure it out, but just don't do the same thing as before. The road to where you want to get to, especially any expert level, is filled with failures and bumps along the way. We like to pretend that that's not true in America. We make films and teach our children to expect success no matter what. Even when a main character fails at something in a movie, its usually some quick music montage of he/she getting things back on track and the next thing you know, they've succeeded or won at whatever. That's just not how life is. CRNA school is so freaking hard. You're going to have days when you're sure you can't do it and you feel like quitting immediately. That's okay. Those days are grooming you for your future, and are entirely necessary for your success. Learning how to comeback after failure is going to be, in my opinion, the best thing that the CCRN has taught you. Good luck.
  13. Mully

    Code blue in OR

    Anesthesia. The surgeons rarely have any clue what the patient's vital signs are unless we tell them (not talking down, simply because they're performing surgery). Certainly it's a team effort, but who decides what drugs to give, when, and how? Anesthesia. Who gives the drugs? Anesthesia. Most OR nurses that I've worked with aren't ACLS trained. Their roll is more r/t calling the code/anesthesia stat, and other things that I'm not sure of lol. I've experienced one almost code in anesthesia during a craniotomy. We directed the OR nurse to call anesthesia stat which resulted in an MDA and 3 CRNAs in our room in about 3 seconds. Someone along the way brought the crash cart in. Myself and my CRNA gave what drugs we decided and directed the other CRNAs as to what help we needed. The surgeon did end up re-opening the head to make sure nothing funny was going on. Patient survived, anyway. Hope this helps.
  14. Mully

    extra P wave?

    A couple things... It could in fact be a PAC, termed a "non-conducted PAC". This is when there is a P wave which occurs earlier than its expected time (hence premature), not followed by a QRS (hence non-conducted). These are relatively common and relatively benign. If the additional P wave is in time with when it is expected with no QRS, this is a second degree type II block. This is a more serious condition, as it often progresses to complete heart block. The key to differentiating the above is whether or not this additional P wave is premature or not. If it is premature, and there is no QRS, it means the conduction system distal to the AV node is refractory from the previous beat which is why there was no QRS. If it is on time and there is no QRS, this is more serious as there is some sort of block in the conduction pathway. The best leads for looking at P waves are your inferior leads which are II, III, and aVF. Since this did not appear in any of these leads, it is unlikely that it is any of the above. This makes me think it was the stupid u wave. U Wave basic ECG patterns Here's a site that explains more than you'll ever want to know about a u wave. Don't spend too much time on it though, the u wave is pretty low in specificity and doesn't really play a role clinically, at least in my experience.
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