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  1. Cowboyardee

    Magic Mushrooms as Medicine? Mind-Body Connection Pt. 3

    I suspect that guiding patients toward research on hallucinogens and currently-illegal psychotropic drugs may be both a little premature and possibly out of our scope, as Here.I.Stand mentioned. For one, most of the studies on these drugs have had relatively few participants and have not been repeated or verified. It is difficult to draw firm conclusions from them, given these limitations. Patients are seldom well-versed in interpreting medical research and studies, and those exceptions who are likely don't need the nudge to start looking. The difference between a nudge and an endorsement is pretty fuzzy. However, I do think it behooves us as medical professionals to keep an open mind about potential therapies, and possibly even to advocate to governing bodies those therapies which show real promise of efficacy but are taboo for political reasons. And to that extent, I admit that some of the small-scale studies about using psilocybin's use for treating depression have been remarkable. Specifically, I thought the results of this study were very impressive: https://journals.sagepub.com/doi/full/10.1177/0269881116675513 In 51 patients with life-threatening cancer diagnosis, one-time high-dose psilocybin was associated with depression and anxiety symptom remission of 71% and 63% respectively 6 months after administration, with no serious adverse effects. On the one hand, one could certainly quibble with the study's results on the basis of possible self-selection bias among participants, small sample size, or the somewhat unorthodox control group. But on the other hand, if some new anti-depressant achieved similar results in a clinical trial, it would be generating a whole lot of buzz. If nothing else, we should be clamoring for larger trials.
  2. Cowboyardee

    How to best handle this situation with my instructor?

    I suspect that explaining yourself without reconsidering your attitudes, assumptions, and response to the day could potentially do more harm than good. If you genuinely believe that your instructor shouldn't have been talking to a colleague or that any mistakes you made should have been overlooked as brain farts, then those assumptions are likely to leak through in your explanation, and probably won't help you out. Re-examine your expectations of your instructor and yourself, or else just let it go and get through clinicals, doing what you need to do to pass whether or not you agree with your instructor's style. You're a grown up who can decide for yourself - you can ignore my advice if you like. But it's honest and well-meant.
  3. Cowboyardee

    Please tell me what to do

    Damned if I know. Ask her about it. Or hire a private eye. Or move. Or find something else to focus your anxieties on, like that shifty-eyed squirrel that always seems to be staring at you when you walk under his tree.
  4. Cowboyardee

    How to best handle this situation with my instructor?

    You probably came off as standoffish and confused about the directions because you were standoffish and confused about the directions. On the upside, it doesn't really sound like your instructor came down particularly hard on you. My advice: 1) Be less standoff-ish. If you instructor spends some time talking with other clinicians or instructors rather than passing meds with you on a day you're not scheduled to pass meds, don't begrudge her. She knows what she's paid to do much better than you do. It's likely enough that your attitude shows through. Do your best to adjust it. 2) Apologize sincerely for any confusion, and ask sincerely if there's anything you can do to perform better. A brain fart is just a mistake, like any other mistake. Do what you need to do not to make mistakes. Go to sleep earlier, drink more or less coffee, ask for advice. Brain farts happen to everyone, but that doesn't excuse them. 3) If you're still confused about your duties and responsibilities, ask away.
  5. Cowboyardee

    Pr interval

    What does "and so forth..." mean? With no other information available, the most likely scenario is a first degree AV block, with a very slight PR interval variation as a kind of normal variant. But I'd much rather see the rhythm, and preferably several leads and a long strip, before saying that with any confidence. A wandering atrial pacemaker would be one alternative possibility, as would multifocal atrial tachycardia, or AV dissociation wherein both the atrial and ventricular pacemakers are firing at very similar rates.
  6. Cowboyardee

    Cdiff question

    The number of loose bowel movements is not particularly the decisive factor. C diff infection will most often be accompanied by a fever and/or leukocytosis in a patient who doesn't have other conditions that would suppress these findings. Presence of unexplained fever and elevated WBCs might be good enough reasons to test for c diff in a patient who has only one loose stool. Absence of these findings along with some other known source of loose bowel movements might be reason not to test in a patient having many, many loose stools.
  7. Cowboyardee

    Adrenergic agonists cause vasoconstriction or dilation???

    Different adrenergic receptors, different sites of action. Clonidine affects alpha 2 adrenergic receptors especially in the brain stem. Epinephrine affects all major adrenergic receptors (alpha 1 and 2, beta 1, 2, and 3) and contributes to both vasodilation and vasoconstriction at different sites. Look up the various adrenergic receptors and what they do. They're a good deal more complicated than you appear to have understood so far.
  8. Cowboyardee

    Can they just switch me from days to nights?

    There's no law saying she can't change your schedule (although if the notice is short enough, sometimes state laws may apply). If you signed any contract, read it closely. If the switch is a deal-breaker for you, polish up your resume, look for job openings in advance, and tell your boss that you can't work day shifts. Maybe she'll back down if it's a choice between losing you or keeping you on nights only. Don't count on it though, unfortunately.
  9. Cowboyardee

    Interesting case of the spilled pills

    Agreed with Jed. The BON was in the right. 'Just following orders' isn't an adequate defense when those orders are obviously unethical. It would have been a more interesting and ambiguous case if the pills had been temporarily irreplaceable rather than merely expensive, which would have made the choice between giving possibly contaminated medicine and not giving medicine at all.
  10. Cowboyardee

    Can We Monitor Our Patients Too Much?

    Depends on the pacemaker and the arrhythmia. Pacemakers correct bradyarrhythmias. Impanted cardioverters correct some but not all kinds of tachyarrhythmias. Implanted defibrillators can defibrillate v fib or v tach. All are prone to failure at times. Also, many of the same conditions that lead to a need for pacemakers in the first place also cause a plethora of not-easily-fixable-but-still-significant rhythm changes that show up on monitor to a trained eye. For whatever its worth, I certainly don't think having a pacemaker should automatically qualify you for a monitor. On the other hand, I also would never say: " at least this septic, renal failure patient with 3 vessel disease and an active GIB on three pressors doesn't need a continuous monitor - he has a pacer/aicd! Ill go grab 4 units of rbcs and the prismaflex. {whistles}."
  11. Cowboyardee

    Can We Monitor Our Patients Too Much?

    Several thoughts: 1) I don't know if you meant to post this in the critical care section, but it would seem relevant to point out that the study you posted excluded critical care patients, and the guidelines for continuous cardiac monitoring include the broadly-defined "critical illness" as appropropriate criteria for said monitor. 2) Over- monitoring is a problem that would seem closely related to misinterpretation of monitored data and over-treatment of said data. In other words, it seems likely to me that we could address the same problem by improving the quality of clinical education among nurses. I would hazard to guess that few nurses, for example, are thoroughly familiar with the pathophysiology and relevant treatment considerations of qtc monitoring, despite being responsible for monitoring and reporting these values to physicians. This is a recipe for bad decision-making. When I look at nursing school curriculum, I see substantial potential for improved clinical education. 3) We're discussing continuous monitoring primarily as a means to identify patient decline or emergencies, but it also offers one huge benefit not mentioned in the OP - it can provide substantial data about an event AFTER it has already occurred. This helps both in determining the best treatment regimen for a patient already in crisis, and in root cause analysis of critical failures and informing quality improvement efforts. Considerations of cost, impaired patient mobility or comfort, over-treatment, etc, are of course important and relevant. But be careful not to leave some of the major advantages of continuous monitoring out of the equation.
  12. Cowboyardee

    Freaking out over a patient fall!!

    Indeed. You forgot to add "spineless." The take-home lesson here is: don't help anyone. At least not without bringing in a team of half a dozen staff members who have signed affidavits in advance that you won't be personally liable for any mishaps. Waiting to go to the bathroom is, of course, a common cause of falls in the hospital. But at least the OP wouldn't be liable if the patient fell on his own and cracked his skull, rather than falling with assistance and bumping his butt.
  13. Cowboyardee

    M/S Nurse to pick up ED patients

    I've been in hospitals that do this occasionally. It can work as a rare solution to a crisis in the ED where the staff are stretched too thin to move patients along effectively. However, I would hazard to guess that if a hospital decided to have med-surg nurses routinely pick up their own patients from the ED, it would slow down the process of getting patients out of the ED rather than speed it up.
  14. Cowboyardee

    New grad on cardiac floor just cannot relax after today

    It is unlikely that the ICU transfer had anything to do with you. Not impossible but unlikely. That said, get in the habit of asking doctors for their pre-procedure orders, not fellow floor nurses. They both gave you bad advice. The correct answer would have been to check the orders, and if the orders don't have an answer for you, then call the doctor or the cath lab.
  15. Cowboyardee

    New grad in CVICU

    You've got a good attitude, which should help. Being interested and engaged usually makes for a successful orientation. Many times, first-time orientees to an ICU are so overwhelmed with information that I suggest not hitting the books too hard in the off-hours so as not to burn themselves out. But that depends a lot on the orientee in question, and you know you better than I do. Some people do best by completely immersing themselves for a while. The best references for you might depend on what your strengths and weaknesses are at this point. Paul Marino's "The ICU Book" is frequently recommended for very good reason, but there is a good chance that will be over your head for a year or two still. The book most specific to your new environment might be "Cardiac Surgery Essentials for Critical Care Nursing" by Sonya Hardin. It's a little pricey, but is probably a good reference for the kinds of things you'll be seeing. After that it depends on the gaps you personally have to fill. For basic EKG interpretation, Dubbin's "Rapid Interpretation of EKGs" is pretty good, and for more advanced interpretation, I like "12 Lead ECG: The Art of Interpretation," though online sites like https://litfl.com/ecg-library/ and http://ecg-interpretation.blogspot.com/ are quite good for free resources. For hemodynamic monitoring, I guess I wasn't enamored with "Hemodynamic Monitoring Made Incredibly Visual," but it's probably decent for a beginner if it happens to be suited to your learning style. For vents, "The Ventilator Book" is great, though again it may be a bit above your head until you've been in critical care a little longer. And frankly, a lot of the better education materials I've used on many subjects have been free online references intended for med students and residents. Also, take a look at your orientation materials. If there is a list of things you need to know by the end of orientation, great. If not ask your preceptor to maybe dictate a list to you. When you start in an ICU, almost everything you encounter will be new and unfamiliar, and it can be hard to know what to focus on. You should get in the habit of looking up things you encounter that are unfamiliar as you're going, but early on that may be too much to be practical. Instead, make sure you are at least looking up and fully understanding those things you need to know to function independently on your new unit. Congrats and good luck.