MarkHammerschmidt

It's simple enough - slowing a patient's rate when they're in rapid AF or whatever gives them better chamber filling time, so their pressure improves. Breaking the AF will also give them back their atrial kick, which is something like 25% of cardiac output, so that's helpful too.

Sure. Afterload is just SVR, which you get from your PA line numbers. Augmentation you measure manually on a printout, or by using a cursor on a screen-freeze, it's the difference between the patient's systolic peak and the "assisted" systolic peak, after the ballooned beat. Take a look at http://www.icufaqs.org, we have a nice article up about balloons.

We go as high as 100mcg/min, straight drip. This is usually a terminal situation though.

I can't get past the feeling that a new grad has enough on their plate just learning the basics of practice, without the added stress of the ICU. There are lots of pros and cons to this, lots of opinions, and sure, some people do fine. But I think there's so much to learn to start with... people consistently underestimate the difficulty of the job, both technically and emotionally. I tell the new kids that it's "right up there with nuclear submarine", which is quite true - and they always laugh, as though it couldn't possibly be so. It is. Doesn't mean they can't do it - but I was never sorry I worked the floors first.

I can't get past the feeling that a new grad has enough on their plate just learning the basics of practice, without the added stress of the ICU. There are lots of pros and cons to this, lots of opinions, and sure, some people do fine. But I think there's so much to learn to start with... people consistently underestimate the difficulty of the job, both technically and emotionally. I tell the new kids that it's "right up there with nuclear submarine", which is quite true - and they always laugh, as though it couldn't possibly be so. It is. Doesn't mean they can't do it - but I was never sorry I worked the floors first.

Another aspect... suppose an attending made a "wrong" call, and "allowed" a "clearly terminal" patient to pass away, possibly in good faith that everyone in the family had been in agreement... and some previously undetected member of the family popped up and successfully sued for - whatever it is they could sue for. And won. How many times do you think that would have to happen before that attending would decide never to let that happen to her/him again? And do you think she/he would tell the nursing staff why she/he'd made that decision? Doubtful.

Another aspect... suppose an attending made a "wrong" call, and "allowed" a "clearly terminal" patient to pass away, possibly in good faith that everyone in the family had been in agreement... and some previously undetected member of the family popped up and successfully sued for - whatever it is they could sue for. And won. How many times do you think that would have to happen before that attending would decide never to let that happen to her/him again? And do you think she/he would tell the nursing staff why she/he'd made that decision? Doubtful.

I think your concerns are totally on the money, and the resistance you're encountering is just what they used to call "chickens**t", in the service. We use four three-liter bags of replacement fluid, running a 1.6 liter/hour volume turnover - but we use the B Braun machine. I think your concerns about liability and your practice are totally valid. I'd keep a careful narrative of events, too, in case something untoward occurs. Well done both on your estimation of the hazards, and your efforts to remedy them.

My wife and I run a cottage-industry website, offering free-access FAQ articles for new ICU nurses, at http://www.icufaqs.org - we've got upwards of 20 files up now, which are being serially updated over time. Something like 600 pages, we think, covering subjects like PA lines, balloon pumps, pressors and vasoactives, along with a newer series: NG Tubes for Beginners, Peripheral IVs the same, and so on. Hopefully helpful. All feedback, commens, editorial suggestions always welcome! And dog pictures - we like those :)

Hi all - our article on blood transfusions, products, and the like has bee updated on the MICU faqs website, at http://www.icufaqs.org - let us know what you think? As usual, free of access, and all comments are welcome. Also dog pictures, we like those :)

Hi all - a new article: "Foley Catheters for Beginners", is up on the MICU faqs website at http://www.icufaqs.org - this is the second in a series for new grads coming into the unit, covering topics that deserve a close look, for people unfamiliar with them. Last time - "NG tubes". Next time: "Peripheral IV's for Beginners". Let us know what you think? As always, our materials are entirely free of access.

Hi all - our article on "Pressors and Vasoactives" has been substantially updated on the MICU FAQs website at http://www.icufaqs.org - let us know what you think? Thanks!

Hi all. Our file on "Sedation and Paralysis" has been updated on the MICU faqs website, at http://www.icufaqs.org - let us know what you think? As always, our materials remain free, and comments and advice always welcome :)

Hi all. Our file on "Sedation and Paralysis" has been updated on the MICU faqs website, at http://www.icufaqs.org - let us know what you think? As always, our materials remain free, and comments and advice always welcome :)

Hi all. A quick note to say that we continue to (slowly!) update the articles at http://www.icufaqs.org - most recently we've started adding quiz questions at the ends of the files, in our own style, which we hope you'll both enjoy and find useful (grin!). So far, quizzes are up for the arrhythmia review and the blood gas article. As usual, please let us know what you think, what should be added, taken out, burnt, or just send us notes saying hello. We especially like dog pictures!

Hi all - after a really long break, we've got a new article up at http://www.icufaqs.org - "Reading EKGs II". Access to all our materials remains completely free. Let us know what you think? Thanks!

Hi all - after a really long break, we've got a new article up at http://www.icufaqs.org - "Reading EKGs II". Access to all our materials remains completely free. Let us know what you think? Thanks!

My experience has been that the nurses who do this the most are the ones who don't care much about the quality of their work...they know that they basically stink, and they compensate for it this way because they know they can intimidate new people. It's just mean-spirited stupidness. Happens everywhere. Don't let it throw you - regard it as a social exercise workout. Makes your interpersonal muscles very strong!

Hi all - our article on nutrition has been updated on the MICU faqs website at http://www.icufaqs.org - let us know what you think? Next up: "Pacemakers" - they've changed where you put the Zoll pads...

Yup, happens all the time. The only thing to do is to keep them physically safe, and if that means restraints and meds, then that's what you have to use. Get orders for everything, document everything - big legal issues inherent in the situation. IV haldol is often the way we try to go, since it inhibits breathing the least. Sometimes po seroquel works. These patients usually re-orient after a day or so, unless their primary medical problems are what's making them go bonkers, like uremia, high ammonia, stuff like that. Not nice, tying people up to keep them safe. Maybe it's time for me to join the IV team...

Hello all. The MICU faqs at http://www.icufaqs.org continue to be updated - most recently: "PA lines" and "Reading EKGs". Currently under revision is "Med Tips", after that maybe "X-rays". As usual please send in comments, questions, relevant stories and experiences, dog pictures (we like those), omissions, or anything else you think might be useful. We'll happily give you credit as Consulting Wizard/ess, or any other title you'd like, which you can then go on and use to impress your friends...as if they cared what we thought! All the best!

Given the family history of diabetes and all, even without any documented renal problems, you might want to ask about pre- and post-cath doses of mucomyst /acetylcysteine, which does a nice job of preventing some/most of the damage inflicted on the beans by the iodine-based dye. I'm a type 2 guy with no discernable renal problems at all, but I would absolutely request it, even though it tastes godawful nasty. Maybe mix with cranberry juice, ice, etc.? Best of luck.

Laura Gasparis Vonfrolio's study tapes are useful, comprehensive, and hilarious.

A trick you can try - if the patient can handle it saturation/ventilation wise, you can suction her airway and oropharynx, then ambu-bag her with the ETT cuff deflated. Briefly. With positive pressure from the bag, she'll be able to speak pretty clearly. Even better if she can already speak with a cigar in her mouth...

"Anticoagulation, by preventing clot propagation, allows endogenous fibrinolytic activity to dissolve existing thromboemboli. The rate at which this process occurs is variable. Although complete clot lysis has been reported after as little as 7 days, resolution typically occurs over several weeks or months; in many patients, however, resolution is incomplete after several months." http://www.chestjournal.org/cgi/content/full/115/6/1695