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Stop 👏🏼 glorifying 👏🏼 being 👏🏼 obese

It isn’t healthy.

Work on it. Make healthier choices. Don’t stay there.

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Yesterday, an ER attending stood up for me, the ER nurse, in front of a patient who is insulting and sexist. I knew I was doing a great job, but it was really great for that doc to portray us on a level playing field. The doc told the patient that we are equal team mates that can't function without each other.

This is a doctor who has been in emergency medicine probably about as long as I’ve been alive.

It was nice. Really really nice.

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5. Dobutamine is a synthetic catecholamine that acts on alpha-1, beta-1 and beta-2 adrenergic receptors. dobutamine has a rapid onset of action and a short half-life. It increases myocardial contractility, while the reflex reduction in sympathetic tone, in response to augmentation of stroke volume, leads to a decrease in total peripheral resistance.

6. In patients with cardiogenic shock due to decompensated heart failure, dobutamine decreases left ventricular end-diastolic pressure and raises blood pressure by increasing cardiac output. The recommended starting dose is 5-7.5 mcg/kg/min. In this case study, norepinephrine was added after the patient went into cardiac arrest while placing a central line.

7. This patient is highly unstable and is in severe respiratory acidosis. She is most likely reaching end of life care. While BiPAP would be the best non-invasive option to blow off CO2, the patient experienced cardiac arrest and was intubated.

8. A common problem nowadays is boarders in the emergency department. ROSC was achieved after one round of Epi per ACLS guidelines. The patient continued to be hypotensive, so an epinephrine drip was added. Managing 3 vasoactive infusions, sedation, and 3 other patients can be challenging. Work with your teammates, charge nurse, provider, and pharmacist to maintain continuity of care. Although it is the emergency department, the patient and family deserves comfort. The patient was showing no signs of discomfort or pain, but a decision was made to add 25-50mcg/hr of Fentanyl. The family made the decision to make the patient DNAR/COT, and after 6 hours boarding in the ED, the patient was transferred to the ICU.

What are your thoughts??

References

https://pubmed.ncbi.nlm.nih.gov/1859148/

March Emergency Medicine Case Study

Your 72 y/o female patient arrives to your level 1 facility after receiving pre-hospital treatment from a BLS crew. She was found down in her home for an unknown length of time. Neighbors called 911 because they haven’t seen her “in a while.”

En route, the patient is GCS 14, BP is 74/55, HR 140, RR 35, shallow. IV access 18g left ankle running 1L NS. The crew is unable to obtain a pulse ox. You have a few minutes to look through the chart and discover an admission 4 months ago for cardiogenic shock/LVEF 8-10%.

The patient arrives and you are the primary RN.

What are your first steps?

The patient’s core temp is 89.2 F (31.7 C). How do you manage this?

What diagnostics can you anticipate?

How do you manage hypotension with a patient history of cardiogenic shock?

Reblog with your ideas!! I will post updates to the case.

Demographics, vitals, etc changed for privacy purposes. This case is theoretical.

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1. ABC’s. The patient’s airway is patent, breathing is labored, shallow, and fast. Breath sounds are diminished in all fields with fine crackles in lower lobes. Skin is cold with delayed cap refill. Quickly work on assigning tasks to your team. Someone should be getting vitals, obtaining access, and undressing the patient. Consider BiPAP or a non rebreather if unavailable immediately.

2. Use your facility’s warming devices, such as a Bair Hugger and warm blankets. Ask the provider if a Foley temp probe or esophageal temp probe is appropriate. As you are assessing your patient, keep other parts of her body covered and warm.

3. Septic work up labs - CBC, CMP, Lactic Acid, Coags, Blood Cultures, POC glucose. Consider a stat chest x-ray, VBG/ABG. A bedside echo may be indicated.

4. Small amounts of warmed fluids may support the hypotension, but a plan should be made to start pressors (or at least have them ready).

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After getting the patient undressed, under a warming device, placed on BiPAP, a chest x-ray is obtained and shows bilateral diffuse infiltrates in upper and lower lobes. COVID should be considered. The patient’s HR is down to 110’s, but the blood pressure is not improving. MAP is 53 and dropping. The patient is becoming increasingly agitated. The ABG shows a pH of 7.07, CO2 65, HCO3 28, SpO2 99%. The patient is started on Dobutamine.

5. What is the mechanism of action of dobutamine?

6. Why is dobutamine indicated in this scenario? What is your starting dose? Is there a better option?

7. Should the patient continue on BiPAP? Why or why not?

8. The ICU in your facility is full and you are making plans to keep this patient for several hours. What should you anticipate as an ER RN?

Like/reblog for part 3!!

March Emergency Medicine Case Study

Your 72 y/o female patient arrives to your level 1 facility after receiving pre-hospital treatment from a BLS crew. She was found down in her home for an unknown length of time. Neighbors called 911 because they haven’t seen her “in a while.”

En route, the patient is GCS 14, BP is 74/55, HR 140, RR 35, shallow. IV access 18g left ankle running 1L NS. The crew is unable to obtain a pulse ox. You have a few minutes to look through the chart and discover an admission 4 months ago for cardiogenic shock/LVEF 8-10%.

The patient arrives and you are the primary RN.

What are your first steps?

The patient’s core temp is 89.2 F (31.7 C). How do you manage this?

What diagnostics can you anticipate?

How do you manage hypotension with a patient history of cardiogenic shock?

Reblog with your ideas!! I will post updates to the case.

Demographics, vitals, etc changed for privacy purposes. This case is theoretical.

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March Emergency Medicine Case Study

Your 72 y/o female patient arrives to your level 1 facility after receiving pre-hospital treatment from a BLS crew. She was found down in her home for an unknown length of time. Neighbors called 911 because they haven’t seen her “in a while.”

En route, the patient is GCS 14, BP is 74/55, HR 140, RR 35, shallow. IV access 18g left ankle running 1L NS. The crew is unable to obtain a pulse ox. You have a few minutes to look through the chart and discover an admission 4 months ago for cardiogenic shock/LVEF 8-10%.

The patient arrives and you are the primary RN.

What are your first steps?

The patient’s core temp is 89.2 F (31.7 C). How do you manage this?

What diagnostics can you anticipate?

How do you manage hypotension with a patient history of cardiogenic shock?

Reblog with your ideas!! I will post updates to the case.

Demographics, vitals, etc changed for privacy purposes. This case is theoretical.

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YOUR TRAUMA DOESN’T MAKE SOMEONE ELSE’S TRAUMA INVALID

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I’ve been feeling down lately and I just called my employer’s EAP. They were able to speak with me for about 20 minutes and sent me a list of free counselors in my area. 

Use your resources and feel free to reach out to me if you have trouble finding something!!

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1. a lot of universities have almost every textbook in the library. back when I was going to school and living out of my car, I could not afford anything. So I set my ass up in the library, and if I needed to take information with me, I took pictures with my phone or used the money the school gave us to make copies of the pages I needed.  2. I also recommend buddying up with someone; this is easily done in classes with labs. you can share a textbook with a lab partner or someone else in class. You can easily send/receive pictures of textbook pages.

3. You can find PDF’s of a lot literally by just searching “Book Title” PDF in Google. Also check with people who have previously taken the course to see if they have a PDF version or are willing to sell/lend the book to you.

4. DON’T BUY YOUR BOOKS BEFORE SCHOOL ACTUALLY STARTS. I wait until the 2nd week, after i have been to all of my classes, seen the syllabus, etc. If that syllabus only uses the textbook twice, you bet I’m not buying it. You will find out what you really need by attending the first day of class. 

5. In some cases as well, professors may have the ability to post certain excerpts online or print them out for you. If you are truly struggling, it never hurts to try to talk to them one on one and explain the situation. They might be able to help you. One time, I leveled with a professor and she gave me copies of the first 2-3 chapters because I told her that I was waiting on one more paycheck from my job. 

To all my freshman babies who are panicking right now about how much your college textbooks cost: Yeah, you’re right, that’s some highway robbery. No, you don’t have to lie down and take it. You have options. Follow my advice and fly on your own debt free wings.

1. Forgoe the bookstore entirely. Sometimes you can get a good deal on something, usually a rental, but it’s usually going to be considerably more expensive to go through official channels. Outsmart them, babies.

2. Does your syllabus call for edition eight? Get edition seven. Old editions are considered worthless in the buyback trades, so they sell for dirt cheap, no matter how new they are. It’s a gamble, sure; there might be something in edition eight you desperately need, but that never happened to me. However, I’ve only ever pulled this stunt for literature/mass comm/religious studies books, so I don’t know it would work in the sciences.

3. Thriftbooks.com, especially for nonfiction and fiction. Books are usually four or five dollars unless they’re really new, and shipping is 99 cents unless you buy over 10$ in books, in which case shipping is free. 

4. Bigwords.com. It will scan every textbook seller on the internet for the lowest price available, and will do the same to find the highest price when you try to sell your books back at the end of term. Timesaver, lifesaver.

5. In all probability, your library offers a service called interlibrary loan which is included in your tuition. This means if your library doesn’t carry a book you can order it for free from any library nationwide in your library’s network and it will be shipped to you in a number of days. Ask a librarian to show you how to search for materials at your library as well as though interlibrary loan; you’ll need to master this skill soon anyway.  If you get lucky you can just have your required reading shipped to you a week before you need to start reading, then renew vigorously until you no longer need to item. I’m saving over 100$ on a History of Islam class this way.

You professors might side-eye you for bringing an old edition or a library copy, but you just smile right back honey, because you can pay your rent and go clubbing this month. You came here to win. So go forth and slay.

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Year of the Nurse: 2020

Year of the Nurse: 2020

December 17th, 2020 So much has happened this year that I’m already in tears thinking about how to convey the gravity of the Year of the Nurse: 2020 on me, on my family, on my colleagues, neighbors, and friends. It has been vicious, violent, and wicked. Scientists around the world immediately began working toward a solution for a dangerous and unknown problem. All we knew was that it was a…

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-ER Nurse Version-

- That an oral themometer has to go all the way under the tongue in order to be accurate. You wouldn't believe how many people can't deal with a themometer. Or follow basic instructions.

- The difference between the urethra and a vagina in a female and all the functions of each. Grown ass women get their mind blown around me.

- That you physically CANNOT get the flu from the flu shot.

- That their 5 year battle with toe pain is NOT an emergency at 3am on a Tuesday.

- That if you are being seen for nausea/vomiting/abdominal pain, you shouldn't be eating a whole bag of Cheetos in triage. We can see you....?

What’s the most simple thing you’ve ever had to explain to a fully competent adult?

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Check out her insta @alannacastromua

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Violence in the Emergency Department

Violence in the Emergency Department

“You don’t have a backbone.”

“You need thicker skin.”

“You need to suck it up.”

“It happens.”

“They didn’t actually hit you so it’s pointless to press charges.”

“She’s a really good nurse, I think you’re just over-reacting.”

These are some of the phrases that have been said to me over the past month or so. The emergency room is a fast-paced, intense environment that requires you…

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A Day in the Life of an ER Nurse

A Day in the Life of an ER Nurse

I know, it’s been a long time. It’s June. I last wrote over three months ago, and as we all know, life as we know it has changed. As a reminder, I am a new grad nurse in an busy inner city emergency room. This year has been one of the most challenging yet gratifying years of my life. This is a day in the life in my shoes.

At 1000 I wake up sore from the past two shifts. I take ten or so…

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Reality Check: Being a New Grad in the ED

Reality Check: Being a New Grad in the ED

Hellloooooo! It’s been a hot minute. Since I last wrote, I graduated from nursing school, started my residency, and passed my NCLEX! Woohoo! I wish I could say that the NCLEX was the last stop on the nursing struggle bus, but really starting to feel like it’s stop number 5 out of 100.

I accepted my dream job. I had a picture of how it was going to be. I spent over 300 hours in the ED during…

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Finals week got me like...