group_theory

Automatic BP machines detect blood pressure by measuring oscillometric waveforms (and not by detecting Korotkoff sound) After the cuff inflates, sensors (electronic tranducer) measure pressure oscillatory pattern as well as the cuff pressure in a stepwise deflation pattern. Based on these measurements, the computer determines what the mean arterial pressure is by determining the maximum amplitude. It then uses a propriety algorithm to determine systolic, and then diastolic pressure based on the mean arterial pressure. Each company have it's own algorithm to determine systolic and diastolic pressure from the mean arterial pressure. Because the algorithm is proprietary, you can get different systolic and diastolic pressure reading if you were to theoretically take the BP at the same time using different machines made by different companies (even if the MAP readings are exactly the same). So the most accurate portion of automatic BP is the MAP since that is a measured value (via indirect method via oscillotometery reading), followed by SBP, then DBP. Factors that can influence BP reading (in addition to having different proprietary software/algorithm) include regularity of the pulse (since measurement of MAP and the algorithm to determine SBP and DBP are based on standard models without variation), cuff size, movement of limbs, compliance of the arterial wall (again, this is due to mathematical assumptions based on standard model, and calcified arteries do not behave according to standard model)

Could be a lot of reasons Prevention and management of tumor lysis syndrome Acidosis management (renal tubular acidosis?) renal disease and need for IV contrast Hyperkalemia Chemotherapy (methotrexate?)

The RVR is due to the multiple foci from the atrium overdriving the heart, causing the ventricles to contract 130-140 times a minute. The problem with RVR is that it decreases diastolic filling time (meaning less time for blood to fill the ventricles before it is pumped). In the setting of CVAs, the compensatory mechanism is actually hypertension to ensure perfusion. That's why in the setting of a stroke, you don't go crazy trying to normalize someone's BP. The stroke is likely from his afib. He either wasn't properly anticoagulated, or he had contraindications for anticoagulation (GI bleed, fall risk, etc). Even if he was properly anticoagulated, it only reduces the risk of CVA (doesn't eliminate it completely). Same thing can be said of his afib - usually it is controlled with medications - either a betablocker, calcium channel blocker, digoxin, etc. . It can be through non-compliance, but sometimes the multiple atrial foci can still drive the ventricles into RVR despite medication. Hope this helps.

I think the "risk/benefit" that the material is referring to with PSA is not about the actual blood draw itself but the usefulness of using PSA as a screening tool for prostate cancer. Like others have mentioned before, PSA is neither sensitive or specific. A "normal" PSA doesn't mean you don't have prostate cancer, and a high PSA doesn't mean you do have prostate cancer. Imagine trying to discuss the specifics of PSAs with your otherwise healthy asymptomatic patients :trout: Besides the risk of false negatives and false positives, there is also the risk of any subsequent workup/procedures (ie prostate biopsy) resulting from an elevated PSA. Also, even if it is prostate cancer, depending on the staging and aggressiveness, the patient may likely die from something else before the prostate cancer can even have a remote chance to kill the patient. If this was the case, would you ignore the prostate cancer or treat it (and subsequent risk of treatment along with side effects of cancer therapy). case scenerio: If an 85 year old male with DM, HTN, CAD, COPD, ESRD, h/o CVA x 2, h/o STEMI, h/o DVTs and PEs along with mild dementia, was found to have prostate cancer, would you subject him to aggressive treatment for his prostate cancer? (the treatment itself can kill him). Is the risk worth the benefit? If you can turn back the clock, would you do a PSA level on him? (there is no right or wrong answer here ... it's up to the patient, his family, and his physicians to discuss the risk/benefit/prognosis and decide where to proceed)

Stage 3 Chronic Kidney Disease is when the Glomerular Filtration Rate (GFR) is between 30-60ml/hr. Stage 5 CKD (end-stage renal) is when it drops below 15ml/hr. You don't necessarily have to put patients who are ESRD on dialysis if they have good urine output and are asymptomatic from their azotemia because you want to try to hold off on dialysis as long as possible due to possible complications associated with hemodialysis. For most Stage 3 CKDers, they don't need dialysis unless there is a clear indication for one. It's usually management of their underlying causes, and management of their chronic kidney disease. You would expect increase BUN in patients with CKD. The creatine level in the blood, creatine clearance, albumin level, and also the BUN/creatine ratio will be helpful in determining what's going on. Also look at the meds ... is the patient on lasix, bumex, or other diuretics? Would that explain why you have good urinary output but still clinical evidence of dehydration? There are other potential causes of elevated BUN, such as lower GI bleed as another poster have mentioned. Does the patient also have CHF? Did the patient suffer a recent fall? Did the patient suddenly start an Atkens diet?

I would be careful about starting calcium or mag supplements without input from a healthcare professional ... not all supplements are harmless and could be detrimental if someone has kidney disease or other metabolic/endocrine issues Definitely make a follow-up appointment with the doctor concerning the UTI ... and raise your concern about the muscle cramps/aches again ... and ask "do you think there might be something wrong with her electrolytes?"

The legal and liability risk involved with this is BIG, both for the person handing out the "free samples" and the employer. Handing out food/candy/pens/trinkets that the drug rep gave ... ok Handing out lipitor to people ... danger!!! Handing out sample antibiotics to people ... danger!!! Handing out psych meds to people ... DANGER!!! The board of nursing might not look too kindly upon these actions ... the board of pharmacy might not look too kindly on your dispensing either ... the DEA might want to investigate to see if you handed out other stuff too ... the local district attorney/prosecutor might be a little interested. The state health board and JHACO might be involved since the standard is to keep samples in locked closets with proper documentation whenever samples are given out. And should you face a civil lawsuit if there is harm resulting from such action, your insurer might not cover you (or provide you an attorney) if the insurer determined that your action was not done as part of a normal clinical practice/standard If you are unsure what you are doing is legal, seek the advice of a qualified healthcare attorney

One of the pilots for Fox 2007-2008 lineup Philadelphia General Production Co.: 20th Century Fox TV Production Team: Samantha Goodman, Andrew Stern, Barry Josephson, Eileen Gallagher, Ann McMorifice, P.J. Hogan Comedic drama about the lives and loves of a team of nurses in a big-city hospital http://www.hollywoodreporter.com/hr/content_display/television/features/e3ibc9653989093dd91769226429b563e66 From the Philadelphia Daily News http://www.philly.com/mld/philly/entertainment/columnists/dan_gross/16737924.htm Fox is developing a pilot called "Philadelphia General," about the work and sex lives of nurses at a big-city hospital. Think "Grey's Anatomy," with nurses instead of doctors and hopefully without an annoying lead character. The show's slated to air in June. Another site with some info http://www.tv.com/philadelphia-general/show/68704/summary.html "The lives and loves of a team of nurses are chronicled in this new drama."

I second David Carpenter's (core0) advice - proceed with extreme caution. The last thing you want is to spend time and money (lots of money) and end up having a "Doctor of Medicine" degree but no residency or even worse ... no medical licensure. Caveat emptor!!!!! Medical education/training/licensure is extremely complicated and involves many hoops ... understand the system well before you jump into the pool

The reason why you start on both lovenox and coumadin is because starting coumadin will make the blood initially hypercoagulable ... and thus you need either lovenox or heparin to prevent further clot formation. Coumadin works by inhibiting Vitamin-K dependant factors, such as II, VII, IX, and X, along with Protein C and Protein S. Protein C and Protein S responds a lot more quickly to decreased Vitamin K caused coumadin compare to other Vitamin-K dependant factors. As a result, the patient is in a hypercoaguable state. It is only when factors II, VII, IX, and X are decreased is when the patient goes from the hypercoaguable state to an anticoaguable state (and hence why it takes several days for the INR to be elevated) Lovenox is given in the meanwhile to keep the patient in an anticoaguable state until coumadin kicks in. Lovenox (and heparin) works by a completely different mechanism (mainly by activating antithrombin III) and thus have an immediate effect by inhibiting thrombin and Factor Xa. Neither coumadin or lovenox is intended to remove the clot either in a DVT or a PE ... it is to prevent further clot formation. The body will take care of the clot by slowing removing it using its own thrombolytics, but it usually take a while ... that's why people with DVT or PE will have to be on coumadin for months on end

I think spending some time with nurses and doctors will help you decide which path you will want to take. Both fields, while similar, are also very different in terms of tasks, educational requirement, hours, pay, etc. If you have time, see if you can spend some time with other healthcare professions, like NP or PA, Respiratory therapist, Physical therapist, etc. They all have their plus and minuses. Get a feel of what their average day is like and try to see if you can picture yourself in that role on a daily basis. If you're almost done with your pre-reqs for Med School, there is no need to wait till 2009 to take the MCAT. As long as you are done with Biology, General Chemistry, Organic Chemistry, and Physics, you can take the MCAT when you feel ready. These are the subjects tested on so it would be wise to have these courses material mastered before you decide to take it. Most pre-meds spend 4-6 months studying for it ... some longer, some shorter. There is also a verbal component to it that is similar to the verbal component of the SAT. Student Loans - when you enroll in an accredited school (either nursing or medical school), if your loan was from a reputable bank, you may be able to place them into deferment while in school ... meaning you don't have to pay them while in school. If any part of your loan is federally subsidized (stafford loans, perkins), the federal government will pay off the interests while in deferment. Call your bank and see what your options are should you go back to school. Follow the path that you think will be best for you. If you have some sense of fiscal responsibilities, the loans, the debt shouldn't be a burden as long as you keep focus on the big picture and long term goal ... not just income but also lifestyle and your happiness. It's normal to worry about debt - it a good sign of responsibility and maturity. This might help should you decide to pursue med school instead of nursing school Here is a 2004 survery of average compensation for various medical specialities Anesthesiology - $332,216 Emergency Medicine - $246,760 Family Practice - $148,563 General Surgery - $256,111 Internal Medicine - $158,500 OB/GYN - $221,286 Pediatrics - $131,000 Psychiatry - $182,300 Source: Jackson and Harris Physician Compensation Survey, May 2004 (base compensation, incentives and/or production) EDIT: (adding this info) According to salary.com, the national average salary for "staff nurse - RN" is $59,046 - however, you can easily make much more than that depending on your workhours (overtime, which shift you work), what part of your country you're in, and what field you work in http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_HC07000001.html In the journal "Nursing" Oct 2004 issue by Robinson, Eileen. and Mee, Cheryl, average annual income was $54,574, with more than 25% of those surveyed making more than $65,000. Average income for ICU/CCU nurse was $58,400, Nurse Supervisor/Manager was $67,100. LPN/LVN average income for 2004 was $32,400. For NPs, the average income for 2004 was $73, 235 with a standard deviation of $20,505. 5th percentile was $38,000 and 95th percentile was $220,000 Source: http://www.nurse.net/cgi-bin/start.cgi/salary/index.html For CRNA, according to salary.com, average income was $130,776 http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_HC07000007.html Average income for physical therapy (PT) ranges from $55k-$75k Source: Journal of Physical Therapy Education, Fall 2004. Article by Redman-Bentley, Donna

Funny video called Study Back (parody of Sexyback by Justin Timberlake) made by students at NYMC ... I think any students working towards the healthcare profession will greatly enjoy the video - almost make you want to pick up a textbook and "get your study on" :uhoh21: Two links ... same video ... so you can pick and choose if you want youtube or google video (roughly 4 minutes in length) ... ENJOY Study Back - Google Video

What to do in order to get into medical school 1. You definately have to take the pre-reqs. Some schools have additional requirements (classes) but the general ones are 1 year of Biology with lab 1 year of Chemistry with lab 1 year of Organic Chemistry with lab 1 year of Physics with lab 1 year of English Some places require math/calculus/statistics. Other places require Biochemistry. Some require Genetics. Some schools won't accept biology/chemistry/orgo/physics course geared towards allied health/nursing. Others will. Call the school you are interested in to find out. 2. MCAT MCAT is divided into 4 parts, 3 of which are scored numerically (and 1 which is scored alphabetically but no one really looks at the score). The 3 parts are: Verbal, Physical Sciences, and Biological Sciences. The Verbal is similar to the reading comprehension portion of the SAT but with longer passages, more passages, and a shorter time constraint. The Physical Science will test your knowledge of Physics and Chemistry. Calculators not permitted and a formula sheet is not provided so you will have to memorize those physics formula for this section. The Biological Science will test your knowledge of Biology, Organic Chemistry, Genetics, and occasional Biochemistry. Score ranges from 1-15 per section. A combine score of 30 or above is considered a good score. The last section (scored alphabetically) is a 1-hr, 2 essay portion which is given very little weight in med school admission process. 3. Bachelor degree not required. However, admission is competitive, with some schools receiving over 10,000 applicants for 250 seats. Most applicants will have a bachelor, and some will have masters and others doctorates. Although most schools don't require a bachelor, those who do get admitted without a bachelor usually have other outstanding qualities (ie., ADN with 20 years of ICU experience at a tertiary care hospital). Some schools do require a bachelor degree upon matriculation, so check with the schools you are interested to find out their requirements 4. The application process - long and expensive. You will need to apply via a central processing service - AMCAS (for MD schools in the US) and AACOMAS (DO schools in the US). A lot of applicants apply a year before their anticipated start (if you want to start August 2007, you apply starting June 2006). The primary application organizes your personal statement, grades, mcat, extracurricular activities, etc. Then schools will mail you a secondary application upon receiving the primary application. Some secondary application will ask more questions, others will just ask to confirm your information. Each step of the process requires cash. The vast majority of schools require onsite inverviews (Mayo does it by phone). From their interview pools, the admission commitee then decides who to give offers of admission. 5. Foreign med schools - always a viable option but please do your research before deciding which one to go. Some states will not grant permenant licensure to alumni from certain schools (California and Texas comes to mind). Other states don't care. Also, if you want to do certain specialty (that is very competitive), you may be facing an uphill battle as a foreign med school graduate. The one true advice is this: be wary of any foreign medical school that will offer to give you credit or advance standing because you are a nurse/PA/NP/DC etc. Remember, your goal is to become a praciticing doctor. As of today, none of the state board of medicines have yet to grant permenant licensure to anyone who received advance standing from foreign medical schools. Hope this is helpful. A few good links to get investigate med schools in the US www.aamc.org www.aacom.org As to whether to go for medical school or stay as an RN or become a CRNA or CRNP, etc - that's up to you.

Because I'm interested in what's going on in all aspect of healthcare - not only to understand what my colleagues are dealing with, but also the topics and issues that are important to them. This is why I visit various forums - to learn and understand, and sometimes to give my input. You are correct in that I'm not a nurse or a nursing student. However, I do believe I'm not violating any TOS agreement. But if this board wishes to make this site exclusive for nurses, nursing students, and pre-nursing students ... then I'll abide by its decision and leave (it is your board, I'm just a visitor). But I still stand by my advice - retaliating is never an option and is "childish". It just exacerbates any animosity and can potentially turn a small fire into a conflagration.

I am a little disturbed at some of the responses in this thread. Nurses are professionals and as such, shouldn't use games as "paybacks". Whether the surgeon was correct or not in writing up an incident report, there should never be any repercussion for filing such report - otherwise, future incidents might not get reported for fear of any potential retaliation (and the problems will persist). Docs should never retaliate if a nurse writes an incident report, and nurses should do the same. It is quite childish to "call the doc for every single thing - that'll teach him/her". What happens if after the 10th page, the patient's condition takes a nose dive and you need to contact the doc. Do you think the doc will respond as quickly? Can you seriously look yourself in the mirror and say that you were not at fault because "that doc didn't respond to the page when the patient started to go downhill". Yes, retaliating by repeatedly paging will make you feel better - but at what cost? Your professional dignity? Your patient's health? What should you do? Talk to your hospital's management. Tell them you want a chance to submit your side of the story. Talk to the nurses on the floor whom you consulted. See if they're willing to submit their point of view on what happened. That way, all points of view will be represented in this "incident" and will on file. And continue on with your life. Show this surgeon that you are a professional. Show this surgeon that you are an excellent nurse, one that is reliable and knows the patient and knows when to call the surgeon and when not to call the surgeon. That will you earn you more respect "as a nurse" than if you constantly call the surgeon for every non-issues.

No program outside the US is accredited. Now the students at these foreign schools may receive federal funding, but true "accreditation" is limited to schools within the borders of the US (and PR) - and only the LCME (for MD) and AOA (for DO) can accredit medical schools in the US. If you go to a medical school outside the US, you will still have to take steps to get certified as a foreign-trained physician (ECFMG) - even if you attend an elite medical school in England or Australia. Exception is Canada where their schools are LCME accredited. Also, be wary of any programs that give advance standing to nurses, PAs, NPs, chiros, etc. First - will they adequately prepare you for all 3 steps of the USMLE? Second - will you be able to find a residency spot from a less-than-reputable foreign medical school? Third - will the state board of medicine allow you to practice in the state?

EXCELLENT RESPONSE!!!!! The US-trained DO is the professional and legal equivalent to an MD in the United States. Anything that MDs can do, DOs can do (including surgery). Depending on where you are, some of your docs might be DOs (and you just haven't noticed until now) I have seen some DOs doing MD surgery residencies. There are also DO surgery residencies that are exclusively for DOs (MDs can't apply). If you are interested in learning more about osteopathic medicine, check out the AOA's website (American Osteopathic Association) - http://www.osteopathic.org/index.cfm?PageID=ado_main

If you want to practice medicine, you will need to pass all 3 steps of the medical licensing boards (USMLE for MDs, COMLEX for DOs). Step 1 occurs after your 2nd year of medical school. Step 2 occurs during your 4th year of medical school. Step 3 occurs during your internship year. You cannot take step 3 if you are not doing/did not do an internship. Without step 3, you cannot get a unrestricted license to practice medicine. If you want the bare minimum (just internship, no residency), then you can legally work as a physician. But you will have a hard time getting listings in HMO, medical insurance, medicare/medicaid, etc. Many hospitals require physicians to be board-certified if they want hospital priviledges. Physician groups (private practice) will only hire BC/BE physicians. Many patients also want "board-certified" physicians as their docs. So unless you want to work in a severely medically-underserved area, good luck operating a cash-based practice with no priviledges (including admitting) at any hospitals. Also, get ready to pay insanely high malpractice insurance due to your "no residency training" status. What concerns me most though is throughout this post, you seem to be trying to find shortcuts to becoming a physician. If you were a patient, would you like your attending physician to be someone who took shortcuts to get to where (s)he is today? As a physician, how would you feel if your patients died or were severely harmed due to lack of knowledge/training? There is a popular saying in medicine: The eyes do not see what the mind does not know.

Just a word of caution You're on a nursing site so the responses will be biased towards NPs. If you go to a PA site, the response will be biased toward PAs. Nothing wrong with it since it is human nature. If you go to a neutral site, the response will be so politically correct or dull that your original question about the difference might not be answered. I guess to truly gauge the difference is to see the responses from both extremes, and the truth is probably somewhere in the middle. Also keep in mind that there are a lot of misunderstandings and misconceptions on both sides about both professions.

You might have something called Absence seizure (a.k.a. petit mal seizure) Need to be diagnosed via EEG. There are treatments out there for it that works pretty well - ethosuximide and valproic acid See a neurologist :)

You can make Vit D from tanning beds ... however the UV exposure from tanning beds is FAR MORE than you'll ever need to make Vit D ... sunlight for a few minutes is sufficient The poster probably also has hypophosphatemia, given the low Vit D and low serum Mg. Besides inadequate diet and intestinal malabsorption (Crohn's or other pathology preventing absorption), there are other causes to consider. Check the liver and kidney. Before Vitamin D can be active, it has to go through two hydroxylation steps, first in the liver, and second in the kidney. A defect in any of those 2 organs will result in low active Vitamin D level. The kidney also regulates vitamin D, calcium, magnesium levels so consulting with a nephrologist might be a good idea. Hypoparathyroidism is always possible but since you are already seeing an endocrinologist, ask him/her about it.

An obvious source is your hand/fingers. Perhaps you forgot to wash your hands after using the bathroom. You might have shaken hands with someone who didn't wash their hands after using the bathroom. Or you might have touched an object that was touched by people who didn't wash their hands. Common objects that people touch all the times - door knobs, handrails of escalators and/or beds, elevator buttons, clipboards/charts, pens, towels, etc So E.coli was growing/culturing on your fingers when you touched your ingrown toenail or absesses. The cellulitis caused by Staph created a perfect condition for this faculative anaerobe to grow.

Residents provide the hospital with cheap labor (compared to the cost of hiring attendings/PAs/NPs to do the same stuff) But also, funding for graduate medical education comes from the federal government through the medicare program. Funding does not come from the medicare trust fund, but from the federal government's allocation to GME, which is being administered through medicare. Funding per resident is guided by a formula, but it's around $100,000 per resident per year (rough estimation). Given that the average resident gross pay is $40k, the hospital pockets the difference. The argument given by hospitals for the funding-pay difference is that residents are less efficient and will order more tests/studies than necessary, eating away valuable hospital resources. In 2003, the cost of Direct GME (residency salary, benefits, attending physician compensation) was 2.59 billion dollar. The cost of indirect medical education payment (cost of ordering more tests, sicker patient population, greater technology needs, etc) was 5.30 billion dollar. I hope this explains the difference in why residents aren't required to stay on after residency while new nursing grads have to sign binding contracts.

Your husband needs to see a primary care doctor that is willing to lead a team to investigate this issue. This includes rheumatologist, hematologist, cardiologists, etc. It can be Raynaud's associated with connective tissue disorders (e.g. SLE, scleraderma, etc). It could also be CREST. It could also be clotting disorder, endocarditis, atherosclerosis, etc. Another possibility (esp when I read about the hx of smoking) is Buerger's Disease. The classic patient with Buerger's is a relatively young male age (20-50) with a history of smoking (however lately there have been an increase in females and people >50 getting this). "The initial symptoms of Buerger's Disease often include claudication (pain induced by insufficient blood flow during exercise) in the feet and/or hands, or pain in these areas at rest. The pain typically begins in the extremities but may radiate to other (more central) parts of the body. Other signs and symptoms of this disease may include numbness and/or tingling in the limbs and Raynaud's phenomenon. Skin ulcerations and gangrene of the digits are common in Buerger's disease. Pain may be very intense in the affected regions" http://vasculitis.med.jhu.edu/typesof/buergers.html However, this disease is pretty rare so don't assume that this is what he has. Remember, when you hear hoofbeats, think horses, not zebras (unless you are in South Africa where zebras outnumber horses) Just make sure your doctor understand your concerns and take that into account when he/she investigate this. Group_theory *disclaimer - please do not substitute the web or anonymous advice for medical advice from your physician*

The Hepatitis B virus is 100x more infectious than HIV. References: Mayo Clinic http://www.mayoclinic.com/invoke.cfm?id=DS00398 World Health Organization http://www.who.int/mediacentre/factsheets/fs204/en/ With regards to titers, what tests were done specifically? The HBV vaccine is design to produce antibodies against Hepatitis B surface antigen (HBsAg). That is the protective antibody. There is another test for antibodies for Hepatitis B core antigen (HBcAg). Positive titers for HBcAg IgG indicates current or previous exposure to the active HBV (not the vaccine since vaccine does not contain HBcAg). Another test is for the presence of Hepatitis B e-antigen. Presence of this e antigen indicate active disease and increase infectivity. So if you have never had HBV before, but receive the vaccine series, you should be + HBsAg IgG - HBcAg IgM - HBcAg IgG - HBeAg