endotracheal tube

Basics for the Wards: Reading a Chest X Ray

Chest X-rays (aka CXR) are one of the most basic imaging studies done in medicine. Almost every hospitalized patient has one and you will see hundreds of them by the time you finish med school.

But it was be super easy to get distracted by the huge glaring pathology (like a giant mass) that you miss other pathology (like a broken clavicle). So, like with reading EKGs, it’s best to have an algorithm you run through for every CXR so you don’t miss anything.

Disclaimer: Again, this is just a general introduction with some basics to help you start out on wards. There is a lot more to interpreting chest x-rays that what I mention, that is why radiologists are awesome.

First: What is the view- is it AP (front to back) or PA (back to front)? Lateral CXRs are obvious.

PA

AP



If the patient is able to stand, a PA view is generally preferred. AP is generally when patients are confined to the bed- also you usually cannot diagnose cardiomegaly from an AP view because the heart is almost always bigger in this view. How do you tell the difference between them? Look at the scapula- in a PA view the scapula are usually clear of the lungs, whereas in an AP view the two generally overlap. Sometimes the clavicle positioning can be a good clue too- see the differences between the two?

Lateral

Second- what is the quality, because that can have a major effect on your interpretation. A good mnemonic is RIP.

- Rotation - Measure the distance of each clavicle from the spinous processes at that level, if they are equidistant then the patient is not rotated.

- Inspiration - If you can count nine posterior ribs within the lung fields before you reach the diaphragm, then there was enough inspiratory effort. Poor inspiratory effort will look like the patient has an airspace disease.
Note: Posterior ribs = more apparent, look more horizontal. Anterior ribs = less visible, 45ish degree angle towards feet

- Penetration - With flawless penetration, you should be able to see the thoracic spine through the heart.

Underpenetration= Left hemidiaphragm and left lung base will not be visible, and pulmonary markings will appear more prominent than they actually are. Ahhhh!!!!

Overpenetration= what is even happening here

OK, now you’re ready to see what is going on with the patient. I suggest the systematic approach, which has the handy mnemonic ABCDE= airway, bones, cardiac, diaphragm, everything else (lungs). I’m not going to go into all the pathology associated with everything, because that would take forever.

- Airway: Is the trachea patent and midline? Can you see the mainstem bronchi and the carina? If there is an endotracheal tube in place, make sure that it is 3-4 cm above the carina. Also check to make sure the mediastinum is not deviated or abnormally wide.

- Bones: Is anything broken or dislocated? Any lytic lesions? 

- Cardiac: How clear is the cardiac silhouette? Is the heart enlarged? What about all the vessels- the aorta, SVC, IVC, etc. 

- Diaphragm: Is the right side higher than the left but not like wayyyy too much? Are the costophrenic angles clear (if not, could be an effusion!)? 

- Everything else: NOW you can look at the lungs. Is there an infiltrate or a mass? What about pneumothorax? Also check for you friendly neighborhood gastric air bubble, it’s supposed to be below the diaphragm. 

Easy enough, right? Good luck! 

Usually, I lie. At a party, someone asks the question. It’s someone who hasn’t smelled the rancid decay of week-dead flesh or heard the rattle of fluid flooding lungs. I shake the ice in my glass, smile, and lie. When they say, “I bet you always get that question,” I roll my eyes and agree.

There are plenty of in-between stories to delve into; icky, miraculous ones and reams of the hilarious and stupid. I did, after all, become a paramedic knowing it would stack my inner shelves with a library of human tragicomedy. I am a writer, and we are nothing if not tourists gawking at our own and other people’s misery. No?

The dead don’t bother me. Even the near-dead, I’ve made my peace with. When we meet, there’s a very simple arrangement: Either they’re provably past their expiration date and I go about my business, RIP, or they’re not and I stay. A convenient set of criteria delineates the provable part: if they have begun to decay; if rigor mortis has set in; if the sedentary blood has begun to pool at their lowest point, discoloring the skin like a slowly gathering bruise. The vaguest criterion is called obvious death, and we use it in those bizarre special occasions that people are often sniffing for when they ask questions at parties: decapitations, dismemberments, incinera- tions, brains splattered across the sidewalk. Obvious death.

One of my first obvious deaths was a portly Mexican man who had been bicycling along the highway that links Brooklyn to Queens. He’d been hit by three cars and a dump truck, which was the only one that stopped. The man wasn’t torn apart or flattened, but his body had twisted into a pretzel; arms wrapped around legs. Somewhere in there was a shoulder. Obvious death. His bike lay a few feet away, gnarled like its owner. Packs and packs of Mexican cigarettes scattered across the highway. It was three a.m. and a light rain sprinkled the dead man, the bicycle, the cigarette packs, and me, made us all glow in the sparkle of police flares. I was brand new; cars kept rushing past, slowing down, rushing past.

Obvious death. Which means there’s nothing we can do, which means I keep moving with my day, with my life, with whatever I’ve been pondering until this once-alive-now-inanimate object fell into my path.If I can’t check off any of the boxes—if I can’t prove the person’s dead—I get to work and the resuscitation flowchart erupts into a tree of brand-new and complex options. Start CPR, intubate, find a vein, put an IV in it. If there’s no vein and you’ve tried twice, drill an even bigger needle into the flat part of the bone just below the knee. Twist till you feel a pop, attach the IV line. If the heart is jiggling, shock it; if it’s flatlined, fill it with drugs. If the family lingers, escort them out; if they look too hopeful, ease them toward despair. If time slips past and the dead stay dead, call it. Signs of life? Scoop ’em up and go.

You see? Simple.

Except then one day you find one that has a quiet smile on her face, her arms laying softly at her sides, her body relaxed. She is ancient, a crinkled flower, and was dying for weeks, years. The fam- ily cries foul: She had wanted to go in peace. A doctor, a social worker, a nurse—at some point all opted not to bother having that difficult conversation, perhaps because the family is Dominican and the Spanish translator wasn’t easily reachable and anyway, someone else would have it, surely, but no one did. And now she’s laid herself down, made all her quiet preparations and slipped gently away. Without that single piece of paper though, none of the lamentations matter, the peaceful smile doesn’t matter. You set to work, the tree of options fans out, your blade sweeps her tongue aside and you battle in an endotracheal tube; needles find their mark. Bumps emerge on the flat line, a slow march of tiny hills that resolve into tighter scribbles. Her pulse bounds against your fingers; she is alive.

But not awake, perhaps never to be again. You have brought not life but living death, and fuck what I’ve seen, because that, my friends at the party, my random interlocutor who doesn’t know the reek of decay, that is surely one of the craziest things I have ever done.

But that’s not what I say. I lie.

Which is odd because I did, after all, become a medic to fill the library stacks, yes? An endless collection of human frailty vignettes: disasters and the expanding ripple of trauma. No, that’s not quite true. There was something else, I’m sure of it.

And anyway, here at this party, surrounded by eager listeners with drinks in hand, mouths slightly open, ready to laugh or gasp, I, the storyteller, pause. In that pause, read my discomfort.

On the job, we literally laugh in the face of death. In our crass humor and easy flow between tragedy and lunch break, outsiders see callousness: We have built walls, ceased to feel. As one who laughs, I assure you that this is not the case. When you greet death on the daily, it shows you new sides of itself, it brings you into the fold. Gradually, or maybe quickly, depending on who you are, you make friends with it. It’s a wary kind of friendship at first, with the kind of stilted conversation you might have with a man who picked you up hitch- hiking and turns out to have a pet boa constrictor around his neck. Death smiles because death always wins, so you can relax. When you know you won’t win, it lets you focus on doing everything you can to try to win anyway, and really, that’s all there is: The Effort.

The Effort cleanses. It wards off the gathering demons of doubt. When people wonder how we go home and sleep easy after bearing witness to so much pain, so much death, the answer is that we’re not bearing witness. We’re working. Not in the paycheck sense, but in the sense of The Effort. When it’s real, not one of the endless parade of chronic runny noses and vague hip discomforts, but a true, soon- to-be-dead emergency? Everything falls away. There is the patient, the family, the door. Out the door is the ambulance and then farther down the road, the hospital. That’s it. That’s all there is.

Awkward text messages from exes, career uncertainties, generalized aches and pains: They all disintegrate beneath the hugeness that is someone else’s life in your hands. The guy’s heart is failing; fluid backs up in those feebly pumping chambers, erupts into his lungs, climbs higher and higher, and now all you hear is the raspy clatter every time he breathes. Is his blood pressure too high or too low? You wrap the cuff on him as your partner finds an IV. The monitor goes on. A thousand possibilities open up before you: He might start getting better, he might code right there, the ambulance might stall, the medicine might not work, the elevator could never come. You cast off the ones you can’t do anything about, see about another IV because the one your partner got already blew. You’re sweating when you step back and realize nothing you’ve done has helped, and then everything becomes even simpler, because all you can do is take him to the hospital as fast as you can move without totaling the rig.

He doesn’t make it. You sweated and struggled and calculated and he doesn’t make it, and dammit if that ain’t the way shit goes, but also, you’re hungry. And you’re alive, and you’ve wracked your body and mind for the past hour trying to make this guy live. Death won, but death always wins, the ultimate spoiler alert. You can only be that humbled so many times and then you know: Death always wins. It’s a warm Thursday evening and grayish orange streaks the horizon. There’s a pizza place around the corner; their slices are just the right amount of doughy. You check inside yourself to see if anything’s shattered and it’s not, it’s not. You are alive. You have not shattered.

You have not shattered because of The Effort. The Effort cleanses because you have become a part of the story, you are not passive, the very opposite of passive, in fact. Having been humbled, you feel amazing. Every moment is precise and the sky ripples with delight as you head off to the pizza place, having hurled headlong into the game and given every inch of yourself, if only for a moment, to a losing struggle.

It’s not adrenaline, although they’ll say that it is, again and again. It is the grim, heartbroken joy of having taken part. It is the difference between shaking your head at the nightly news and taking to the streets. It’s when you finally tell her how you really feel, the moment you craft all your useless repetitive thoughts into a prayer.

At the party, as they look on expectantly, I draft one of the lesser moments of horror as a stand-in. The evisceration, that will do. That single strand of intestine just sitting on the man’s belly like a lost worm. He was dying too, but he lived. It was a good story, a terrible night.

I was new and I didn’t know if I’d done anything right. He lived, but only by a hair. I magnified each tiny decision to see if I’d erred and came up empty. There was no way to know. Eventually I stopped taking jobs home with me. I released the ghosts of what I’d done or hadn’t done, let The Effort do what it does and cleanse me in the very moment of crisis. And then one night I met a tiny three-year old girl in overalls, all smiles and high-fives and curly hair. We were there because a neighbor had called it in as a burn, but the burns were old. Called out on his abuse, the father had fled the scene. The emergency, which had been going on for years, had ended and only just begun.

The story unraveled as we drove to the hospital; I heard it from the front seat. The mother knew all along, explained it in jittery, sobbing replies as the police filled out their forms. It wasn’t just the burns; the abuse was sexual too. There’d been other hospital visits, which means that people who should’ve seen it didn’t, or didn’t bother setting the gears in motion to stop it. I parked, gave the kid another high five, watched her walk into the ER holding a cop’s hand.

Then we had our own forms to fill out. Bureaucracy’s response to unspeakable tragedy is more paperwork. Squeeze the horror into easy-to-fathom boxes, cull the rising tide of rage inside and check and recheck the data, complete the forms, sign, date, stamp, insert into a metal box and then begin the difficult task of forgetting.

The job followed me down Gun Hill Road; it laughed when I pretended I was okay. I stopped on a corner and felt it rise in me like it was my own heart failing this time, backing fluids into my lungs, breaking my breath. I texted a friend, walked another block. A sob came out of somewhere, just one. It was summer. The breeze felt nice and nice felt shitty.

My phone buzzed. Do you want to talk about it?

I did. I wanted to talk about it and more than that I wanted to never have seen it and even more than that I wanted to have done something about it and most of all, I wanted it never to have hap- pened, never to happen again. The body remembers. We carry each trauma and ecstasy with us and they mark our stride and posture, contort our rhythm until we release them into the summer night over Gun Hill Road. I knew it wasn’t time to release just yet; you can’t force these things. I tapped the word no into my phone and got on the train.

I don’t tell that one either. Stories with trigger warnings don’t go over well at parties. But when the question is asked, the little girl’s smile and her small, bruised arms appear in my mind.

The worst tragedies don’t usually get 911 calls, because they are patient, unravel over centuries. While we obsess over the hyperviolent mayhem, they seep into our subconscious, poison our sense of self, upend communities, and gnaw away at family trees with intergenerational trauma.I didn’t pick up my pen just to bear witness. None of us did. And I didn’t become a medic to get a front-row seat to other people’s tragedies. I did it because I knew the world was bleeding and so was I, and somewhere inside I knew the only way to stop my own bleeding was to learn how to stop someone else’s. Another call crackles over the radio, we pick up the mic and push the button and drive off. Death always wins, but there is power in our tiniest moments, humanity in shedding petty concerns to make room for compassion. We witness, take part, heal. The work of healing in turn heals us and we begin again, laughing mournfully, and put pen to paper.

Daniel José Older

Spirit in the House - Chap 4/10

Modern!AU Bucky Barnes x Reader

Summary: Reader is in a coma after a car accident. Bucky moves into your apartment and find your spirit still hanging around. (Based on Just like Heaven)

Word Count: 1,483

Warnings: Ghost!Reader, Coma, Language

A/n: I’m screaming, please scream with me! 
Happy Birthday @barnesndnobles Idk what’d do without you ♥ ILY!

[Part 1] [Part 2] [Part 3] [Part 4] [Part 5] [Part 6] [Part 7] [Part 8] [Part 9] [Part 10]

Originally posted by heartsandwheels

Bucky spent the next few days in complete silence. Every time he opened the wardrobe he expected to see you.

You used to hide in there and jump out at Bucky to scare him. Now that you were gone, he missed the excitement.

Bucky kept his promise and cleaned the apartment. He even decided to take care of himself. He sat down at the kitchen table and ate with gusto. It was the first home cooked meal he had eaten in a while.

On Saturday, he agreed to go out with Steve.

“What the hell happened to your face?” Steve smirked as Bucky approached the bar.

“I cut my hair, Steve. No big deal.” Bucky rolled his eyes. Steve took Bucky into a hug and patted his back.

Keep reading

anonymous asked:

I once read a story (that claimed to be based on a true one but, well, grain of salt) where a character got hit in the throat by a rock and lost their voice permanently, thus becoming mute. Is that kind of thing possible? Could there be any injury/illness to the throat that would only damage the, I guess vocal chords, without screwing up everything else?

COMBINED WITH: 

Anonymous said:

Can someone permanently lose their voice if they have their throat slashed? Would that cause other permanent issues? 


Hey nonny. I’m getting a lot of questions on traumatic muteness, so let’s rap a bit. 

Yes, I would believe a blunt injury to the throat causing vocal cord damage. Here’s why. 

The vocal cords sit in a cage made of cartilage (specifically, the thyroid cartilage). 

That shield-looking  thing in the middle? That’s where the vocal cords hang out. It’s pretty well protected from slashing trauma. 

However, blunt trauma can crush, or at least partially damage, the thyroid cartilage – and thus alter the shape and length of the cords. It’s not impossible for the vocal cords to be damaged in such a way that they can no longer produce vocalizations, or at least, in the same ways that the character would use them before. 

With slashing it’s a little less likely, but still not at all impossible. 

Slashing the throat usually doesn’t affect the cartilaginous cage at all. Usually when someone gets their “throat” slashed, the affected area is the trachea below the level of the cords, meaning that the vocal cords themselves aren’t affected. 

But what often happens with that is that the trachea gets opened and breath comes out through the new hole rather than going through the mouth. Air will follow the shortest path of least resistance, which can mean “oh look new hole!”. Basically, the character has gotten a stoma from an unlicensed medical professional. 

What’s usually done in that case is that the unlicensed stoma just gets corrected into a full tracheostomy by the trauma team, so that they have someplace to breathe through. (I’m a BIG fan of just shoving an endotracheal tube into these injuries and rolling right along with them.) 

But having a trach in place still makes it hard to speak, because remember, the air still wants to come out of the hole in the front of the neck. So many (not all, but many) trach patients have to hold their finger over their trach, exhale, and then speak on the exhale. It takes more work and  more effort. 

Could a character lose their voice from a slashing injury? Yes, but it’s a lot more difficult. Could they lose it from a blunt injury? Absolutely. Would your audience likely believe either? I’m pretty sure they would. 

Best of luck to the both of you! 

xoxo, Aunt Scripty

(Samantha Keel)

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Traps for New Vets: Part 3, Emergencies

You are rarely fully prepared for an emergency. For one thing, you often don’t know exactly what the emergency is until you’ve examined the animal. I’ve often had owners diagnose ‘bloat’ at home, which later turned out to be haemabdomen, heat stroke or even pregnancy once they arrive at the clinic.

There are things you can do, however, to be as close to prepared as you can be, especially in your first few weeks after graduation.

  • If you remember nothing else then please remember to go back to your first principles. If you go back to your first principles you will be able to figure out how to triage even a curly toed bunyip should you be presented with one. If you ever think you don’t know what to do, you are WRONG. You go back to your first principles and work your way up.
  • Most of emergency medicine is just buying time. Do one thing to buy a few minutes here, then you’ve got another ten minutes to spend buying another hour, which might let you do a procedure to buy a few more days which might be enough to buy the animal enough time to live the rest of its life. You can certainly do something in the first few minutes to buy yourself a few more minutes with a textbook or calling for help.
  • FLUIDS. OXYGEN. PAIN RELIEF. Not necessarily in that order, but for basically all emergencies until established otherwise. Say it with me now, FLUIDS, OXYGEN, PAIN RELIEF. Say it again. FLUIDS, OXYGEN, PAIN RELIEF. When you are in a panic because this dieing creature is placed in front of you and everyone expects you to save it, remember: FLUIDS. OXYGEN. PAIN RELIEF.
  • Every species except the snake has a cephalic vein. If you can’t remember where you’re supposed to perform venepuncture or place a catheter, there is always a cephalic. I have personally used cephalic veins in dogs, cats, rabbits, goats, sheep, a guinea pig, a ferret (anaesthetised) and a meerkat.
  • That said, it is worth knowing where alternative veins are if you blow them. If you have to clip half the patient bald to save its life, do so. If the owner complains that their pet is ugly after its near death experience, then their priorities are wrong.
  • On your first day at work as a veterinarian, spend a few minutes to find out where to find the following equipment in a hurry: endotracheal tubes, adrenaline, atropine, iv catheters, diazepam, euthanasia solution, opiod pain relief, calcium gluconate, hypertonic saline, iv glucose, apomorphine, tissue glue and the oxygen cage/box. The nurses should know where the blood pressure monitors are and the anesthetic machines should be unmissable. Most places will have a chart with emergency drug doses for different body weights on a wall. If there isn’t one there, make one.
  • If you do not have an oxygen cage or oxygen pox, but the patient will fit into a carrier, place the patient in a carrier and then put the carrier into a body bag. Close the bag and pump oxygen into one end, and make a hole at the other end for air to come out. It is difficult to monitor your patient this way, but when you really need oxygen, you really need oxygen.
  • Most creatures that need CPR will not come back. Of those that do, many will need CPR again shortly afterwards. Don’t be disheartened if you have a low success rate. Take every step you can to prevent the need for CPR in the first place.
  • Know when to be a team leader. In CPR somebody needs to take control and tell everyone else what to do. Communicate. If someone else has already taken charge, let them. If nobody has, step up.
  • If you’re doing cardiac compressions and getting tired, say so. Someone can swap with you.
  • Establish from day 1, or even at the job interview, who you can call for support if you can’t handle something on your own. It’s fine to not be up to doing a GDV or caesarian surgery on your own when you’re green, but you need to know what you’re doing until support shows up.
  • If you are doing CPR and getting nowhere, you probably can’t make it worse by giving more adrenaline. After all, technically the patient is already dead.
  • Humane euthanasia is sometimes your only valid choice.
  • Learn to recognize what owners see in an emergency over the phone. Sometimes the 'constipated cat’ is actually a blocked tom desperately trying and failing to urinate.
  • Above all, do not panic. You can, in fact, do this.

Traps for new Vets, part 1

Traps for new Vets, part 2, Euthanasia edition

I am...A Nurse

I am. A Nursing Student, 99% of the time I have no idea what I’m doing. The 1% is what gives me hope in the early hours of the morning when I’m about to begin again.

I am. A Graduate Nurse. I’m not sure what I’ve gotten myself into, or what area I’m going to end up working in, what area is the right fit, what will make me feel like I belong, but I’m getting there.

I am…An LPN. I’m a nurse too, I work extraordinarily hard and I am not given the respect registered nurses are given. I’m a nurse, and I’m proud to be a LPN, I wouldn’t change what I do for the world - but I wouldn’t mind challenging people’s perspective a bit.

I am. A Charge Nurse. It sucks to be in charge most days, a sort of juggling act where you keep dropping the balls, no matter how skilled you are. I’m a charge nurse, and I wish someone would support me for once, instead of the nurses complaining about their assignment, instead of management complaining about the nurses.

I am. A Nurse Practitioner. I remember how this feels, my heart goes out to the bedside nurses when I am rounding, and I wish I could jump in and help them instead of leaving after consults, I sometimes wish they understood we aren’t so separate, I’m still a nurse too.

I am. A CRNA. It’s a title that confuses people. Hell, it confuses me. I’m a a certified registered nurse anesthetist. But, people mix me up with the anesthesiologist - and when corrected, they say, “oh you’re the nurse. Not the doctor.” I slaved my way through graduate school. I can recite anesthetic agents in my sleep, I can manage people’s pain, and I can throw down an endotracheal tube so fast you would miss it if you blinked. I’m a nurse, I have all the heart of what I did at the bedside, and the badass side of a masters prepared graduate in my specialty.

I am. A Nurse Educator. I still don’t have all the answers, and that’s ok. If I could go back in time, I would tell myself it’s ok to feel like you’re on a roller coaster as a student. It’s ok to drown as a new grad and ask a million quesrions until you surface and it’s ok to feel the drain of everyday nursing. Not every day will be a great one, but every one will be worth it.

I am a nurse. I’ve lost count of the amount of patients I’ve lost, but miraculously I can remember their faces, what occurred and the devastation surrounding each and every event. I’m a nurse. I’ve shared hours, and shifts of joy & heartaches with my coworkers - and these are some of the most significant memories I will carry with me, as etchings of the nurse I’ve become, and the guiding point of the nurse I someday aspire to be. I’ve held the hand of patients dying with dignity, and grieving families, praying for and comforting them long beyond my shift, and I wouldn’t expect any patient satisfaction survey to reflect the importance of how this feels. I am a nurse, and I appreciate what I get to do every day.

arlessiar  asked:

Thanks for your reply. I didn't quite know how to send you the Kingsman screenshots so I made a tumblr post with them, I'll send you the link in a second. Btw, one thing one cannot see in the caps is that the heart rate is actually changing in the scene where he wakes up, which is sth I don't see often on TV.

No problem!

(And thanks for your reminder! I know I haven’t done much on this blog recently… I have very little motivation for a lot of things as of late and this week in particular sucked pretty terribly, but I’m going to try to answer the best I can)

Disclaimer: I’m not an ICU nurse, nor have I seen (or read fanfic of) this movie. Everything is based on my critical care classes/clinicals in nursing school and my conjecture as to what happened based on what I’m seeing in these screen shots.

From what I’ve seen of ICU settings, this was pretty well done. They clearly did their research and/or hired a consultant when designing this set. Certain things I particularly appreciated were the presence of a central line (an IV that ends in a large, central vein- necessary for drugs that could injure smaller vessels, like many that would be used in an ICU setting), the not-overly-neat wires/tubes/hoses, and the changing vitals on the monitor screen.

(The following is mostly an explanation of what you’re seeing in the screenshots- nitpicks and a real-life pic for comparison at the end)

Here’s what’s present in a couple of those screenshots:

Monitor display: Showing two leads’ worth of ECG readings (green), heart rate (green), central venous pressure (the pressure in the vein that carries blood into the heart- yellow), oxygen saturation (blue), and non-invasive (cuff) blood pressure (purple).

  • The blood pressure cuff: Hooks up to the monitor display and will cycle (take a reading) at set intervals. While manual blood pressure is taken by listening to a pulse as the cuff slowly deflates, automatic cuffs sense vibration in the blood vessels as the cuff deflates, which can be interpreted by the computer.
  • Hardwire ECG leads: These are leads that go directly from the pt and physically plug into the monitor. They measure the electrical activity of the heart and present a graph of that electrical activity. They are common in ICU settings but mean the pt has to be physically disconnected if they ever want to get out of bed. 
  • Pulse-Ox/SpO2: This is a device that optically or physically measures pulse (which can be different than heart rate as measured electrically) and optically measures oxygen saturation. In this case, it would be helping to determine whether the ventilator settings were correct.

Syringe pumps: syringe pumps are used when only teeny-tiny volumes of medication are needed. They’re a lot more common in pediatric settings, but are definitely used in adult ICUs for very high potency drugs (especially drugs to increase blood pressure, sedatives, and painkillers). Syringe pumps are usually not the only pumps in the scene though- likely there would be at least a few “line pumps” controlling delivery of larger volumes of fluid like IV hydration, antibiotics, and electrolyte replacement fluids that come in hanging bags. Line pumps look like this:

(EEEP EEEP ………… EEEP EEEP<— that’s the sound they make. A lot.)

Endotracheal (ET) tube and securement: This is a tube that goes from just outside the pt’s mouth to their lungs, maintaining the pt’s airway and allowing the ventilator to deliver breaths while the person is paralyzed/sedated and unable to breathe for themself. The securement device keeps it from accidentally coming out or moving out of place. Missing is an NG or OG tube to deliver tube feedings, which would be necessary in this situation.

Central Line: This is an IV with a very long catheter (tube) that is placed in a vein (inserted surgically into the arm or upper chest) and that ends near the heart. This allows for administration of drugs/fluids at high pressure/volume and administration of drugs that could harm smaller peripheral veins. Simple versions (PICCs) may just provide reliable IV access to people who don’t have great veins, but they can be very advanced and include monitoring devices built in.

Because the monitor display is reading central venous pressure (CVP) (something that can only be measured by a sensor very near the heart), this guy’s central line is one of the more advanced ones (I’m still not seeing the external component to the CVP monitor but maybe its just hiding).

Also I’m going to guess that his injury has something to do with his chest and they’re monitoring for tamponade/pneumothorax? Because he seems a little young and healthy to be stricken with heart failure.

Peripheral IV: In addition to the central line, he’s also got a peripheral IV. These are much shorter catheters (about two inches at most) that can take IV fluids and many IV medicines that don’t need to go in a central line.

Miami-J collar: These are hard collars that do not allow movement of the neck (versus the soft foam ones that are for comfort only). Usually you see them in the field when injury is suspected, and they’re taken off once it’s ruled out in a hospital. The fact that he’s wearing one in this scene means that they’ve done the necessary imaging and determined that his neck was indeed injured in whatever happened to him. I’m guessing this guy was in a coma for a while (it would be arguably more important when he’s awake and moving around, so I’m guessing he had some time to heal and they took the collar off).

Ventilator: These devices breathe for pts who can’t breathe on their own, or assist for pts who find breathing prohibitively difficult. The screen shows a real-time graph of the breaths delivered and how much air was given with each breath.

There’s really not a whole lot that I’m downright “well that’s not realistic” about, but here are a couple nitpicks based mostly on ease of nursing care for him:

  • How would you suction that ET tube? (I’m sure there’s a way to do it but I’ve only ever used in-line suction before and it seems strange that this setup doesn’t have that given this movie came out so recently)
  • Why no line pumps? Why is EVERYTHING going through a syringe pump? That seems tedious…
  • Why are no lines labeled? That seems dangerous and confusing…
  • If they gave him a CVP monitor, why not also give him an arterial line? Especially since they’re probs going to need lots of arterial blood samples to make sure the vent settings are working right and it would be easier than sticking him that many times IN AN ARTERY…
  • Feeding tube- if he’s out as long as I’m guessing he’s out for (via the collar) and there’s no problem with his digestive tract, I’m gonna guess he’ll need some food (but tube feeds are rather icky for the whump community, so I get why they omitted it aesthetically).

Compare the screenshots you took with a similar scene from an actual ICU:

NOTE: I got this pic from a google image search, if you recognize it and would like it removed, let me know!

4

Scenes from the operating room - Part 1

I know a lot of my readers are interested in my profession and have asked me many questions regarding how I got to where I am today. I thought it might be fun to make a post about a few of the things I see everyday and the tools commonly used in anesthesia!

1. Laryngoscope blade and endotracheal tube - if there is any one tool that BEST signifies anesthesia it is the laryngoscope. This tool is ESSENTIAL to an anesthetists’ practice and comes in many different variations. It is basically a metal ‘blade’ attached to a handle with batteries that causes a little light bulb at the end of the blade to illuminate. Once a patient is fully asleep we use the laryngoscope to sweep their tongue out of the way, lift up their epiglottis, and view the vocal cords. If you’re lucky you’ll get a nice clean view of what looks like a white upside down ‘V’. In between the V is where you place the endotracheal tube (ETT). The vocal cords lead to the trachea, and the trachea branches off into our two lungs. The ETT sits inside the trachea and then a little balloon is blown up at the tip to form a seal. This is then how we deliver oxygen, air, nitrous, and anesthetic gases to the patients lungs.

2. Drugs! (Of course) - you learn more about the way drugs work on the human body in anesthesia school than almost anything else. It is MUCH more than, ‘this drug is for blood pressure’. Pictured are only a very MINUTE sample of the many drugs used in anesthesia on a day to day basis. The drugs up top happen to be what we refer to as ‘pressors’ and the red syringe is a drug that is synonymous with anesthesia - succinylcholine. Pressors, or vasopressors, are drugs we use to manipulate (increase) blood pressure. Some examples are Phenylephrine, Ephedrine, and Epinephrine. Phenylephrine causes constriction of our blood vessels by acting on the alpha-adrenergic receptors in the vessel walls. The constriction of the vessels causes an increase in blood pressure. Succinylcholine is a depolarizing muscle relaxant. I would say it is most frequently used when a breathing tube needs to be placed in someone who has a perceived difficult airway. Suxx (common nickname) is used because it is VERY short acting. It lasts about 1-2 minutes and then because of it’s quick metabolism it is gone. It is also used in emergencies/traumas when an endo tracheal tube needs to be placed and the patient has to be paralyzed. This drug you will know IN AND OUT before graduating. ….more to come!
Your First Code

You’ve learned about it, you’ve been warned about it, and today you’re expecting it. Sort of.

You haven’t really been a nurse for all that long, and today’s the day everyone is telling you, “your patient is probably going to code today.”

You’re scared. You’re prepared, but you’re not prepared.

You’re familiar with the crash cart, you’ve watched codes before, you’ve been a code recorder,  handing over medications, and carefully documenting every detail of the cardiac arrest. You’ve helped a little, but mostly got in the way when you’ve been in the room.

But it’s never been your patient.

It’s never been one you’re responsible for.

You’re at the nursing station when you catch the extreme bradycardia on the central monitor, and before you can scurry into the room, there’s already someone shouting down the hallway to call a code, a crash cart rolled into the front, and with your heart pounding, you reach your room.

It’s your patient, but not the one everyone predicted….it’s the sweet little lady next door, the one who was admitted for a simple sacral wound debridement surgery,

…the one you never saw coming.

Your world slows to a standstill as you take in the scene; your colleagues working, lightening quick, throwing pacer pads on, compressing her chest, bolusing fluids, whooshing breath into her endotracheal tube. Shaking on the inside you spring into action, despite your confused mind, which is saying, “what did I do? What went wrong, why is she coding?”

You push your way into the crowded room, you aren’t going to be a spectator, this is your patient, your responsibility.

You work hard, your hands work faster than you thought they were capable of, yet it’s not enough. You dance around the crowd of coworkers, duck under tangles of tubing, invasive lines, and your mind is still ticking over, trying to figure out the origin; was it crappy labs? Was it an undetected respiratory, cardiac or neurological event? Were there signs you didn’t see?

You feel the tears fall, as her time of death is called, and you try to hide it, you don’t want to appear weak, but they fall anyway. She was your responsibility,  a simple wound debridement, and you failed her.

But you will learn.

You will learn to not only prepare for the expected arrests, but to expect the unexpected.

You will learn, responsibility comes with an intense price, despite people telling you, “it isn’t your fault.”

You will learn, even on your best day, it isn’t always enough

You will learn, that you won’t always get answers as to why a patient coded, or died.

And you will learn, to go on,

You will go on to the next room, the next patient.

instagram

Tracheal intubation , usually simply referred to as intubation , is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain
drugs.
*To begin the procedure,open the patient’s mouth by separating the lips and pulling on the upper jaw with the index finger.
*Holding a laryngoscope in the left hand, insert the curved blade into the mouth of the patient with the blade directed to the right tonsil.
*Once the right tonsil is reached, the laryngoscope is swept to the midline, keeping the tongue on the left to bring the epiglottis into view.
*The laryngoscope blade is then advanced until it reaches the angle between the base of the tongue and the epiglottis.
*Next, with the handle of the laryngoscope pointing away from you at 45°, the laryngoscope is lifted upwards towards the chest and away from the nose to bring the vocal cords into view.
*With the right hand, insert the endotracheal tube, made of flexible plastic, into the mouth directly between the cords to the point that the cuff rests just below the cords.
*The markings on the tube at the incisors will show between 21 and 24cm in the average sized adult when the tube is in position. Finally, remove the laryngoscope. The cuff is inflated to provide a minimal leak when the bag is squeezed.
*Using a stethoscope , the anesthesiologist listens for breathing sounds to ensure correct placement of the tube.

#anesthesia #trachealintubation #premed #anesthesiology #usmle #premedlife #premedstudent #university #usmlestep1 #usmlestep2 #doctor #doctordconline #nhs #nurse #nursing #video #instavideo #hospital #hospitallife #medicine #medlife #medstudent #mbbs #md #amc #plab @doctordconline

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Codes: What Should Loved Ones See?

Dear Mr. X., today your wife stopped breathing, I understand you wanted to be with her, I understand you were scared. I understand you wanted to see for yourself what we would do to help her.

But, you see, codes aren’t like the heroes they show on TV - where two or three doctors neatly revive a person and they spontaneously wake up, talking. Codes, to the outside viewer can be devastating to watch, but your wife - she was not alone. She had a swarm of care providers in the SICU; she had a medical team of doctors, the surgical team, an anesthesiologist on standby, a respiratory therapist, and a cohesive nursing team all with one goal - to work fast to save her life.

What you may see if you were watching, is the shaky hands of a resident, attempting intubation, but what you won’t hear is the calm voice of an attending physician by her side guiding her.
What you will hear is the resident’s fear, and see her dropping the tube, but what you won’t hear is the nurses in the background doing what nurses do, advocating when things aren’t progressing safely, and they are paging anesthesia stat, for this is a difficult and bloody intubation and the time for teaching is now as an observer. The resident may look to you as though she had failed, cost your wife valuable time, and you may be annoyed at her, but today she learned a vital lesson and will go on to save many lives. It’s how each of us learn and remember. It isn’t much solace to you today though. But perhaps this is not for you to understand.

You may see a baby nurse uncertainly holding a packet of IV tubing, trying to prime fluids, but what you won’t see right behind her are the calm hands of an experienced nurse guiding her, without skipping a beat. The baby nurse is learning today too, next time she will be faster, and she won’t need guidance. But this isn’t what you want to see today.

You may see a medical student doing his first chest compressions, and the chief resident shouting at him to move his hands closer to her heart - and you may wonder why there’s so much noise, and why people are shouting this, but you see, there’s a controlled sort of chaos with elevated voices, and the medical student isn’t taking it personally - he knows it’s imperative that he learns the right way, he knows the chief resident is experienced, and he moves his hands to deliver quality compressions.

You may see blood spurt out of the endotracheal tube, narrowly missing the respiratory therapist as she’s ballooning oxygen via the ambubag, and you may see blood oozing out of her mouth, as it becomes apparent to everyone in the room she was bleeding profusely into her abdomen, and we are now perhaps at the point of no return.

What you won’t hear are the voices of the nurses, advocating that it is time to consider her quality of life. It is now the 4th time she’s coded, and your wife of 60 years is perhaps telling us she wants to be free.

What you may want to shout, if you were here, is that we should continue beyond the 60 minutes we’ve been coding her, but what you may not understand is the experienced caregivers in the room have now begun to slow code your wife.

To you, Mr X., it may look as though we aren’t doing everything we could, but you see, there are moments of understanding where we know there isn’t any coming back from the level of anoxic brain injury or DIC, her cancer had metastasized to the point of severe pain, and a level of dementia where she couldn’t make her own decisions, we remembered your own words about trusting us to do what was right for her when the time came, so today we are setting her soul free.


In retrospect, perhaps we made an error by not allowing you in the room - we have done it before, sometimes it’s worked out, and most of the time it’s devastating to the families when they see first hand - sometimes we are pulling loved ones off the floor after they’ve passed out in shock, and sometimes we are fielding abusive comments from loved ones as we are trying to save a life. Sometimes we are listening to threatening commentary of lawsuits and watchful eyes that take away valuable moments of us attempting to save a life.

Dear Mr. X., you may not understand today, and I understand you wanted to be there. But I hope one day you will see your wife was not alone; she had a team of caregivers with a sole focus on doing what was inherently right for her, and as her time of death was called, each of us grieved her loss in our own ways - some bowed heads in prayer, some quietly held her hand, and some quietly stood by.

Caregivers aren’t heroes. We are just trying to make the best decisions we can.

kjierstisaysthis  asked:

Pardon the barrage of questions, but I have an OC who's studying to become a vet, and I'm prettyf pumped that this blog exists. Anyway, on to business: I know that vets run the risk of getting bitten by their patients while at work, but how often does that actually happen in practice? Have you (or maybe a colleage) ever been bitten badly enough that you required medical attention? Do most offices have a policy in place in case that happens?

Most clinics have a general policy that goes a bit like this:

  1. Make sure nobody else can be injured
  2. Secure the animal
  3. Seek immediate medical attention
  4. Fill out insurance forms later
  5. Meanwhile, someone else deals with the animal. Depending on circumstance may refuse to see it conscious ever again.

I haven’t been bitten, but I have had lacerations from nails and second degree friction burns on both hands thanks to a horse, which is the reason I don’t see horses anymore. A colleague got trampled by a cow and concussed. Sometimes we die. 

I’ve been ‘nipped’ by dogs on two occasions, not the patient’s fault in either case, and no blood drawn. For one dog I was examining their teeth, the dog sneezed, and smacked my hand with its canine teeth. For the other, it was being anesthetized and was a little too awake when I tried to place the endotracheal tube, and the jaw twitched strongly.

My boss and a nurse was badly bitten last year. A canine patient was waking up from anaesthesia, and still had an endotracheal tube in because it was brachycephalic and we needed to keep it alive. It woke up far too quickly, promptly went through an excitement phase and chomped down on the nurse’s hand as she removed the ET tube.

Boss came in to help nurse, dog is still freaking out and chomped down on his hand when he pried its jaws open. Boss then proceeds to sort of bear hug dog while it’s clamped on until it’s fully conscious and lets go.

(Dog apparently has no memory of this and since comes into the clinic sweet as pie)

Boss then stupidly scrubs into an orthopedic surgery he was scheduled to do (wouldn’t listen to me! Justified it by double gloving over the bandages and everything inside the glove was sterile anyway) and complains that the puncture wounds in his palm make it harder to do the surgery.

He sent the nurse straight to hospital, but fully intended to complete his working day before going. We rescheduled all his evening appointments and kicked him out straight after surgery anyway, but he intended to make a martyr of himself.

Now if you have an OC who’s studying to be a vet, I bet you’ll be thrilled to know there’s a whole vetblr tag on tumblr, filled with vet students. Despite the holiday season, many of them are probably still studying. You could consider following them to know what their lives are like in vet school.

Love and other Drugs

Okay, so… This is my second gift for the beautiful and amazing @lilousmustaches - if you haven't noticed yet, hon, I really do love you.
Well, this is my first time ever writing anything Supernatural-related, so I just hope it’s not total crap.
This is a Jensen Ackles x Reader fic, and it’s way bigger than I initially expected, so this is just the first part…
Hope you enjoy!

Keep reading

Reality Beyond Nursing School

You read about it in books. You hear the stories. You….Graduate, braced to face whatever may come, and despite even the best preparatory programs, nothing quite prepares you for reality.

1. The deafening sounds of silence in the moments after you remove a patient’s endotracheal tube, as the family stands by gently willing their loved one to breathe, breathe on their own. Time passes slowly. Absent of heart sounds, absent of lung sounds. Absent of life. Absolute silence.

2. The raw fear in the first few seconds when you find a patient unresponsive. The stillness, uncertainty, and wonder of how this happened on your watch. Seconds that feel like an eternity.

3. The crushing sound as a patient falls out of bed to the floor, and the frustration that follows, where you realize it doesn’t matter how vigilant you are, it’s impossible to be by every patient’s side, every minute of every shift. And no matter what you say, you’ll be judged for it happening.

4. The pure joy of a patient being discharged home, when you’ve been taking care of them for months, the simplicity of happiness that’s reflected on their faces as well as those of their families as they chatter about being able to finally go home and enjoy the comforts long forgotten.

5. The anxiety and self-doubt the first time you make a serious mistake, an error in calculating a drip, near misses with medication errors that instill terror in you as to how close you were to unintentionally harming your patient.

6. The frustrating times when try as you might to please a patient, or their families, there’s just no winning, and everything you do makes it worse.

7. The blessings of supportive coworkers, when you are so intensely overwhelmed, and they just sort of appear to help, like guardian angels.

8. The intense grief when you lose a patient, and all the experienced nurses tell you “you just get used to it” and you think to yourself - the day I get used to it, is the day i quit.

9. The internal sense of failure when dream jobs turn into a daily tug-of-war, the heightened fear beyond quitting - and the understanding that nobody can take away your values, your degree, or your motivation to find the role you inherently believe is right for you.

10. The shock of being blindsided by a friend, coworker. What’s worse; the betrayal of a friend, or the friendship of an enemy?

10.5. The moments where you leave for the day, and despite the day full of frustrations, reflect on the idea that you perhaps made a very small difference in the life of at least one patient - and that may have been something as simple as shampooing your stroke patient’s hair, brushing it back into a neat ponytail, and cleaning her fingernails. A difference, perhaps not important to the outside world, but monumental in preserving your patient’s dignity.

Room 13

It was 7:14pm, when I received report, two intubated, on pressors - typical night in the ICU.
“Also,” said the charge nurse, “Can you wrap patient in room 13?”

I paused, confused. She was referring to end of life care - that part didn’t confuse me, it’s why the nurse who took care of her wasn’t doing the post mortem care, but never mind - we’ve all had those shifts, so I understood. I looked in on my assigned two patients. Stably unstable, (whatever that means). Nearing room 13, located in the far end of the unit, I noticed a solitary figure crouched in the corner, crying. I glanced through the glass doors at the patient; endotracheal tube in place, connected to the ventilator, although switched off. Cardiac monitor leads removed, IV tubing attached. Silence.

I learned her name was Ms. W, she was a grandmother to 18, mother of 6, the heart of her family. And she had passed 1 hour ago. I explained gently the process of post mortem care, and asked if she had any religious requirements.

“She can’t be in an enclosed space for 8 hours. Please. Can she stay here? My family is coming. We will pray for her, for her next life.“
I touched her arm softly in silent understanding. It wasn’t the practice I understood, but the need to be mindful of and honor the patient’s religious & cultural wishes.

“It’s a busy ICU,” said the nursing supervisor, once I explained the situation. I looked around. We had 8 empty beds. It was a 25 bed ICU, and zero screenings/admissions on the board. Furthermore, we were at this precise moment housing a patient from a different culture to that of Room 13. A patient who no longer required intensive care, a patient whose family had requested she not be moved during their sabbath. A patient whom the hospital was honoring the religious requirements of. It was the compassionate thing to do, and collectively our ICU staff respected them for honoring that.

I looked on as the family in Room 13 began to gather and chant prayers, quietly in the privacy of the room. They looked back through the window, fear of interruption in their eyes every time an administrator passed by. It was difficult not to become angered. As a community hospital, we were diverse, presumably accepting of all cultures, all religions. As caregivers, we do not discriminate, and we do not impart our beliefs or lack thereof, onto others, nor do we choose to afford better care based on them.

In nursing orientation you are required to pass a test of practice on Cultural Diversity, simplistic true or false questions that spoke to honoring the dignity of all, regardless of who they were, where they came from or what they believed in. These tests of ideals, like many quotes that profess kindness and compassion, are meaningless unless you apply integrity and action.

It was five hours of arguing with the Nursing Supervisor, and the battle was lost - the patient was moved to the morgue, an enclosed space, the sum total of six hours post expiration. That’s a mere two hours from the requested religious observation.
Our ICU remained relatively empty, and so did my heart.

I may not have understood the practice, I didn’t need to. I understood there was a family grieving and what they will remember the most is not that their loved one passed peacefully as a DNR, but that this hospital refused to grant them a spiritual need. It was the day I learned you don’t always win the battles, but you continue to fight the war on advocacy & hospital politics.

- Diary of a Beginner ICU Nurse, 2010 (approximately)

Radiograph of an older man who was admitted to the intensive care unit postoperatively, note the right sided pneumothorax induced by the incorrectly positioned small-bowel feeding tube in the right sided bronchial tree, marked depression of the right hemidiaphragm is noted, and mediastinal shift is to the left side, suggestive of tension pneumothorax, the endotracheal tube is in a good position