et tube

What Do You Do: ICU Nursing, Hour One

I’m an RN in a 18-bed Med/Surg ICU. Intensive Care units are for the sickest patients in the hospital.  You get sicker than we can handle the only step up is to meet your Maker or have said Maker do a miracle.

This is our Mantra:

We care for people in Septic Shock, with CVAs, DKA, decompensated heart failure, post cardiac arrest, COPD exacerbation, ARDS, drug overdose, and the post-ops of every discipline (except the open hearts who have their own CVICU).  We manage treatment modalities like CRRT (continuous dialysis), hypothermia protocol, and LV assist devices like the Impella and balloon pump. Highly technical and lots of variety, which is what attracted me here.

I originally was going to write about an entire shift in the ICU but found that the first hour of a recent shift gave a decent representation of what we do. Not terribly eventful or comprehensive, just typical. 

Hour One went as follows:

I walk on the unit for the first of my three 12 hours shifts.  Check the board for my two assigned patients, find the nurse who had them for the day and plop down next to her.  Yes, only three shifts, and yes, only two patients.  Trust me, it’s enough.   

The “Day Babe,” as we night shift nurses affectionately call day nurses (do they have a name for us?  The walking dead……) fills me in on each patient: history, hospital course, treatments, status of each body system.  I fill out all the little boxes on my report sheet in an attempt to grasp an entire patient’s health and plan of care in less than five minutes in a way that somehow qualifies me to be responsible for them.  It’s always astounded me how short, random, and unregulated this process is.

Hemodynamic monitors placed around the unit display heart rhythms and vital signs on each patient. They alarm and flash with increasing levels of dismay when something is out of range. This varies from little peeps and flashes for something minor (O2 sat probe is off) to the From Hell noise that awakens your hindbrain to mortal danger (your patient’s heart has stopped beating.) 

Both of my patients have heart rhythms that are compatible with life and no alarms.  Yay. I fill out a quick little schedule for myself for each patient and then go to see the sicker one first.

Originally posted by otakutreasure

Patient One:  Small bowel obstruction status post Exploratory Lap, went into respiratory failure on the hospital floor after developing pneumonia. Came up to us to be intubated, diuresed, and get IV antibiotics until the invading organisms are killed to death.  She’s in septic shock on several pressors, Cardizem and heparin drips for AFib, fentanyl for sedation.

I assess her, making the million little observations that tell me if she is really doing as well as the monitor might lead me to believe. Vital signs can be very deceiving, nowhere more than ICU.  Lung/heart/bowel sounds, ET/OG tubes, pupils, hand grips, pulses, skin integrity, IV access.

She’s severely edematous. Her flesh puckers under my finger like that green brick material flowers are arranged in.   I wonder what she does for a living, if she has kids, pets, if she’s married?  Read any good books lately? Details of personal life are UTA (Unable to Assess) when the person is I&S (Intubated and Sedated) and there’s no family around.

I ensure all her drips are running correctly and calibrate the arterial line, which tells me her MAP is 68.  Beautiful. Only as much Levophed as she needs, no necrotic fingers and toes for her. She looks good. Stable-ly unstable, we call them, when their vitals are normalized on medicated drips.

Patient Two:  Older gentlemen, VFib arrest, visited the Cath lab for a variety of stents then hypothermia protocol.   He’s past all that now and has just been extubated.  The day nurse told me he looked good respiratory-wise.  I don’t agree. 

He’s tachypnic taking shallow breaths. Weak cough that isn’t getting the job done.  He’ll be reintubated within 12 hours if he keeps this up.  I call my friends in Respiratory Therapy for ENT suction.  It helps, but he HATES it. He asks me why I like to torture him.  I tell him that I don’t, that I’m trying to get him better.  He scowls. He’s over it.  I don’t blame him.

The rest of his assessment is WNL, and that’s not “We Never Looked,”  it’s “Within Normal Limits.” Because I looked.   Except…….I can’t help but notice that he doesn’t move his left side as much as his right, and his hand grip on that side is just a tiny bit weaker.  Am I imagining it?  His pupils both react to light but don’t look exactly the same…..and he’s not really answering my questions. He’s probably just being difficult….right?

Come on man, don’t do that.  Let’s not take an emergent trip to CT and do TPA protocol right now.  Fast as I can, track down the NP.  He has a history of right CVA with residual left-sided weakness.  The day nurse didn’t tell me that in report. 

I push some IV hydralazine for his BP of 180/70.  He asks for a beer.  I feel foolish for worrying about him so much a few minutes ago. 

The hydralazine helps for only a few minutes so I chase it with 5mg of metoprolol, pushed over two minutes because I don’t want to stop his heart, just slow it down.  I make peace with the fact that I’m going to be chasing his BP with IV meds all night long.

I set the bed alarm.  Dude’s awake now and I don’t trust him, even as weak as he looks.  You know how 100 lb. moms can lift cars when their kids are in danger?  Elderly patients can do astounding things when the delerium sets in.

Overall a pretty easy ICU assignment.

I leave his room and hear a plea for help from a nurse at the end of the hall.

I know this patient, Heroin OD.  Tattoos everywhere.   When I say everywhere I mean it.  Many of the nurses had speculated about whether or not certain tattoos look differently when certain body parts were in certain anatomical configurations. If you know what I mean.  If you don’t, don’t think about it too much.  

We don’t mean to belittle people or treat them as objects.  We can’t help but think these things.

The nurse called for help because he’s been on tube feeding for over a week and his Dignicare fell out.  You can imagine the consequences.  If you can’t imagine them because you don’t know what a Dignicare is don’t worry about it, innocence being bliss and all.  I help her get things straightened out. She grateful.  I promise to help her with his bath later. He’s a big dude.

Quick stop at the Accudose, grab my meds and waste Versed and Fentanyl for another nurse.  We chat and make fun of the NP who’s working on the other side of the glass, not noticing us.  We’ll tell him about it later.

I give Patient One’s meds after deciding that they’re all safe and appropriate for her.  A few IV pushes, hang an IV antibiotic, crush up the pills, mix them in some water, flush down the OG tube. 

I most definitely never pretend I’m a wizard making a magic healing potion when I do this. That would be childish and I’m a professional.

Originally posted by geekhistorylesson

Her MAP is 64.  Borderline but I’ll ride that out another 10 minutes before titrating her Levophed; you learn after a while not to micromanage your pressors……

Then the monitor starts alarming THAT alarm, the hindbrain one.  Bed 24, and judging from the trace on the monitor it’s legit VTach.  I start to run to the room but two steps in the alarm stops.  Just a run of VT, not sustained, 20 beats or so. 

I grab the rhythm strip that’s printing out and go to the room to give it to the nurse, a friend of mine who just got back from maternity leave.  She turns to me and takes the strip. 

I don’t know this patient.  Septic on CRRT, came in yesterday.

  “She looks like shit, ” my friend says.  She does indeed.

Now that’s not some random or insensitive insult.  It’s a thing we ICU nurses say when we get that vague unsettling feeling in our perceptive gut that even though this patient looks okay on paper or computer screen they’re going to go downhill, soon. And now here she comes with the increasingly-long runs of VT.

“I told them,” she says, shaking her head.  I tell her to let me know if she needs anything, I have my unit phone. 

Then I go get a unit phone and sign into it since I forgot to do it earlier. My manager runs a report every week that tells her when we forget to sign into a phone within five minutes of starting our shift. I’ll get a strongly-worded email.

Check the monitor, Patient One, MAP 72. Hah!  Peek in on Patient Two.  Still in bed.  BP 200/103.  Awesome.  Bust out the IV labetalol.  Take THAT.   Back down to around 180/70. Sigh. NP says to give it a half hour. 

Grab the aide, both patients get repositioned.  Sit down to chart.  Barely get logged on.

Good buddy nurse sticks her head outside the curtain and gives me The Smile. She’s helped me so many times, she knows I’ll do anything for her. Not that I want to go into that patient’s room.  I do not. But we’re nurses, and we do what needs to be done.

I enter the room of the patient who solidified my belief that ultimately ICU nursing is not for me.

Now, I love intensive care.  I love helping someone right in the moment they need it most. I’m good at my job and I love using my head and my heart to do it.  But I can’t stay here.  I’m willing to walk with a patient through difficult and painful treatments to get them better but I didn’t sacrifice my time with my family and go to nursing school to put people through hell for no meaningful recovery.  I have an ethical aversion to a good 40% of what I do at my job now and that percentage only seems to be growing.

Her history is too long to recount.  Her body had lost the ability to heal a long time ago.  Every organ failing, even her skin. Her skin would break under our hands no matter how gently we would move her.

Her BKA stump has been infected for months.  The flavor of this month was Pseudomonas.  The nurse was asking for help changing the dressing. We remove the old dressing to find her stump disintegrating into the telltale light green of raging Pseudomonas infection.  It looked like pea soup.  We were keeping this woman alive so she could turn into pea soup before our eyes.

I couldn’t look at her face anymore.  When I had first taken care of her I had paid very close attention to her face, trying to read her expression for anything I was doing that she found painful since she was nonverbal at baseline after massive stroke.  Eventually I figured out everything we did caused her pain. 

We still warned her of what we were going to do, still apologized.  The family had instructed that no pain medicine be given “because it makes her less interactive with us.”   The family wasn’t even here. Sorry she can’t entertain you like you want because of the tremendous pain she’s in. I try so hard no to judge them as I’m sure they’re are suffering too.  But I fail every time and every time I get angry. 

Ethics consult was “pending.”  Meaningless, we have no teeth, no real influence. If the family says treat, we treat.  What does “treat” even mean, then?  If all we do is…..

I stop myself from going down that mental road, again. It simply isn’t up to me. What is in my power to do for this woman, right now, that will help her?  I can think of nothing but to treat her gently and say a prayer for her relief.

I don’t know if it helped.

Dressing done, I leave the room with ice in my gut and go back to charting.

A few clicks done before Bed 24 alarms again.

VTach, really fast and not stopping this time.  Everybody runs for the room.  I’m first so I go to grab the cart with the Resus meds and Life Pack but it’s not there because my friend with the bad feeling already has it in the room.  She’s been feeling for a pulse while we ran to her.

“No pulse,” she says as I walk in.  I start CPR while she digs out the defibrillator pads.  She puts them on around my hands and starts charging the Life Pack.  “Clear!,“ I back off, she discharges the shock.

(Ahhhhh sorry. I can’t help it, it’s exactly what we’re doing when we shock someone.)

Sinus rhythm restored.

“Maternity leave didn’t slow you down, did it?” I say to her.  She shrugs.  Intensivist walks in and starts barking orders about STAT labs and electrolyte replacements.  “Need something, call me,” I say as I walk out.

Check the monitor.  Patient Two’s BP is 190/90.  *sigh*

All things considered, not a bad hour. My scrubs aren’t covered in anything.  I didn’t get any indecent proposals. Nobody tried that hard to die.

Eleven hours to go.

Croup vs. Epiglottitis (Peds.)

Pediatrics (neonates to school age; adolescence is another topic) is probably my least favorite specialty to deal with and they are one of the hardest to help at times with all the elements that go with the patient. Whether it is dealing with the sick child or the distraught parents, we must sift through the physical findings and the information from the parents to understand what is going on. This gets especially sticky when it comes to some upper airway complications in the younger group.

Two very common upper airway problems in the younger populations include Croup and Epiglottitis. Both can be dangerous, but require different management when treatment is concerned. This article will give you a brief overview of the pathophysiology, signs and symptoms, treatments, and key points to remember.

Croup

Pathophysiology: Commonly a viral infection (RSV, adenovirus, influenza A and B, etc.) of the upper respiratory system for ages 6 to 36 months. Major inflammation has occurred in the larynx, trachea, bronchi, bronchioles, and lung parenchyma; causing obstruction of the airway. As the swelling progresses supraglottic the patients with begin show signs of respiratory distress. Further along, the patient’s lower airway may begin to begin having atelectasis, due to the lack of air keeping the alveoli open.

Croup is a slow progression of inflammation. Noticing early that the patient has upper respiratory issue is key in the management. Due to the smaller airway of children, we must not hesitate to seat

Signs and Symptoms: The most common sign of croup will be the seal like bark with inspiratory stridor. With this means that the patient is in respiratory distress and quickly heading to failure. If you hear the seal like bark, check the lower lung fields for crackles, because possible atelectasis may have begun.

Commonly more serious during night, awakening them from sleep. Other signs to know include:

  • Tachypnea
  • Retractions
  • Cyanosis
  • Shallow respirations
  • Fever

Treatment: Emergency treatment for croup is a humidified air and a dose of corticosteroids. If in further destress, racemic epinephrine will assist with edema. ETCO2 and O2 readings will help determine if there is retention of gasses, which may lead to acidosis. ABGs will be needed to confirm this as well.

Usually, patients will be able to return home to be monitored. Family should watch for difficulty breath and be using humified air. Antipyretics will assist in keeping fevers down as well.

Epiglottitis

Pathophysiology: Influenza type B, streptococcus pneumoniae or aureus may cause epiglottitis. The epiglottis is a small flap above the glottic opening, which is used to prevent foreign objects entering the trachea. When the epiglottis is infected, with will swell, narrowing the airway for the patient. Increased work of breathing may occur and soon my might have a patient in respiratory failure.

Epiglottitis is a more acute problem, with sudden onset and quick changes to mentation form the restriction of airflow.

Signs and symptoms: As the epiglottis swells, the child may begin to develop stridor. When stridor occurs, we must ask the question is this an object or is this medical. Other signs that might point you towards epiglottitis will be:

  • Sore throat
  • fever
  • Odynophagia
  • Drooling
  • Irritability
  • Cyanosis
  • Tripoding or nasal flaring

Treatment: The most important thing with these patients is to ensure they have an airway. Do not try and examine the patient, especially if you are a paramedic on scene (Load and go). When gathering a medical history, it is especially important to ask for vaccination in the pediatric population. Today, Influenza vaccinations are given to children, but we do have a set population now that do not vaccinate their children. X-rays of neck will be done and a visual examination may be performed. Keep the patient calm at this time, further agitation may cause the airway to swell more.

Patient will commonly receive an antibiotic, such as ceftriaxone, to help with the bacteria. ET tubes may be places in severe cases and usually remain for 24 to 48 hours. Trachostomes may be required, if a ET tube cannot pass the glottic opening.

Key Points

  • Both Croup and Epiglottitis can be dangerous to pediatric patients. If you have a child that has stridor and any signs of distress, they will need immediate attention.
  • Out of hospital, assume epiglottitis and rule it out when you can. This load and go for you
  • Croup X rays may show steeple sign, but epiglottitis won’t

Written by: MEDDAILY

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anonymous asked:

My character's soul left their body (it's magic) right after a brain injury and didn't warn anyone they were going. Their doctor isn't very familiar with magic and THINKS it's a coma. For a week, they're a 3 on the Glasgow scale except one couple-minute waking. Then the soul and body reunite. What would be a reasonable response to a formerly unresponsive patient suddenly getting up, getting work done and being mostly lucid and coherent (minor impairment from the brain injury but only minor)?

Shock. Confusion. Puzzlement. Tests. Lots and lots of tests.

It’s worth mentioning that your character will be very very medicalized. They’ll wake up in the neurollogical ICU, they’ll have a feeding tube in their nose, a breathing tube down their throat, and at least one IV in place.

So they’ll wake up, likely with some discomfort in their mouth and throat, and immediately try to pull out the breathing tube. They might succeed, but they might also damage their vocal cords doing so; there’s a balloon that inflates beyond the vocal cords to keep the tube in place. (The tube will also have a device to keep it where it belongs, which goes around the head like so:

As soon as your character starts fighting with that holder and that tube, their ventilator is going to start to alarm, so staff will come rushing in to make sure they’re okay. (A displaced ET tube can kill someone, so they’re not exactly lax about checking on them.) They will then find out your character is awake and wants a snack.

Their case would likely have been a mystery, since it sounds like their brain is mostly healthy, it’s just that their personality/consciousness has vanished temporarily. So their CTs, MRIs, etc would likely have come back normal, with the reason for their unconsciousness a mystery. Them waking up out of nowhere almost 100% fine would be another mystery, but a happy one.

Good luck!

xoxo, Aunt Scripty

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How we organize our ET tubes now.

I recently read that they should be kept in a drawer or cabinet to lessen contamination, and stole the idea to use empty paper towel tubes cut into sections and labelled with sharpie to keep everything orderly from a Facebook post. (The ones in the FB post were also decorated all pretty, but I don’t have time for that, unfortunately) Much easier than trying to find one on our wall holder, which always seemed to be in a state of chaos no matter how often I tried to straighten it!

a rant about nursing

It upsets me that nurses are notorious for “eating their young.” There is NO REASON for a nurse to be like that. I don’t care if your assignment sucks and you don’t want to work with a student. I don’t care if you think the student shadowing you is too quiet or doesn’t have the “right personality” for your certain setting: chances are they are quiet because they can sense the disdain oozing from you, and they probably don’t want to specialize in whatever area you’re in anyway!

I have been a registered nurse now for seven years. I have mentored new grads, I have worked with students going through their clinical rotations, and I have worked closely with students in their final year as their preceptor. I have not been rude to a student or made them feel insignificant or talked down to them. 

You know what I do when I see a student in our PICU looking like a frightened fly on the wall? I walk up to them, smiling! I tell them my name, I ask theirs, and ask them if they have questions, what things would they like to see, and ask them if they would like to come see one of my patients later (if it’s okay with the family members) because I am caring for a child with a rare genetic disorder or taking care of an infant on a high frequency ventilator that they may not ever see again in their career. Later in the shift I like to show them the resources we have both online and as reference guides on the unit, or ask them about medications my patients are on to boost their self confidence, because hey, they know what that medication does and why the patient would be on it!

The same goes for any of our new hires. I like to try to mentor those who are open to it, and grab them when I can to help them practice their skills (central line dressing changes, helping to turn an intubated patient or retape an ET tube, etc). If the older / experienced nurses aren’t passing on their knowledge to the new people, how can they expect them to know about things? It irritates me when I hear someone talking badly about a new hire or a student because they didn’t know about X Y or Z. Like NO KIDDING?!? they’re new!! TEACH THEM. HELP THEM. Luckily, the unit I work on has a team of amazing people who all try to teach one another and not be complete dickwads.

I hope that in 10, 15, 20, and maybe 30 years from now I still approach new hires or students in this same manner. The last thing I want in my career as a nurse is to become one of those nurses that treats the new generation of nurses as a burden and doesn’t “have time” for students or for teaching new skills,

To all you nursing students out there right now who are experiencing the feeling of being “in the way” or are being looked down upon by other nurses, I’m sorry. All I can ask is that you forgive them for their lack of compassion. They don’t appreciate all the sleep-deprived nights you have as you spend 10 hours on your care plans, and the sacrifices you made with your social lives, and the anxiety you have over next week’s midterms. They must have forgotten what it was like to be in your shoes.

When you student nurses become seasoned nurses, please remember what it was like to be a frightened student and do your best to mentor and teach the new generation.

Endotracheal intubation

Endo - Prefixes indicating within, inner, absorbing, or containing

Tracheal - Anatomical area of the human body, the trachea. also called the windpipe.

You have a patient with a GCS of 7, their respirations are agonal and oxygen saturation is 84%. First rule for anyone in the medical field is to get oxygen back into the is person’s body and fast. One of the common ways in the field and the Emergency room are to place what they call an Endotracheal tube.

The cartilage in your neck, more predominant on men as the “Adams apple,” this is called the thyroid cartilage. It houses your vocal cords and is the immediate opening of the airway. When you look down into a patient’s throat, using a MAC or MIL blade, you will be looking for the epiglottis (the little flap that covers the airway when you swallow food. Then you’ll look for the vocal cords.

The ET tube will have to slide past this to be able to work properly. Once you are confident in your placement and have followed your steps to secure it, you will test it. Some people forget that to auscultate the stomach, listening for gurgling sounds is the first thing you do when pushing air. This means you put it in the esophagus and that is BAD! If that happens, You can pull back tube and try again.

Auscultation of lung sounds bilaterally will be important, to make sure you haven’t slipped the tube past the carina and into one of the bronchioles. Secure the airway and maintain. Remember to always document.

This is just a brief overview. I have place advanced airway techniques video under as a better reference. Remember though, airway is one of the top priorities in the medical field. Without air, it only takes about 4 minutes to cause severe brain damage.

Written by: Meddaily

anonymous asked:

So I have a fantasy society with very roughly 1830s technology. I'm fine with that, and I know how their medicine works. The thing is they're in contact with a much more modern society that's convinced them to start trials runs of aseptic technique and anesthesia instead of relying on the will of the gods to keep surgery patients alive. I need to know what can be done without an electrical grid, and what equipment can and can't fit through a five foot diameter magical portal.

This is VERY cool. I like this ask. You get a star.

Originally posted by imnotcoolenough4you

So there are a few ways you could run some anesthesia between worlds.

Things that require no power, ever, except possibly to make:

  • Disposable materials including scalpels
  • Antiseptics
  • Drapes
  • Actual literal doctors to do the training
  • Concepts like germ theory, surgical time-outs, etc.
  • Diagrams, textbooks, charts, journals, data
  • Airway equipment (laryngoscopes, ET tubes, etc.)
  • IV supplies
  • Medications (not those that need refrigerated though)
  • Non-powered beds for positioning

Things that require power but can be run on batteries:

  • Cardiac monitors / defibrillators
  • Ventilators
  • IV Pumps

Things that can power things that require power but can be run on batteries:

  • Batteries

Things that would be nice but require power:

  • Anesthesia machine
  • Powered beds

They’ll want to do surgery in a room with a high window that faces the sun (light is a Big Deal™ during surgery). They’ll also want that room to be clean (and easy-TO-clean), equipment for washing hands, and more.

Also remember that it’s not just tools and technology that your advanced society brings with them. Surgical techniques have improved A LOT. They’ll have a great deal to teach.

Just don’t forget that this kind of thing can breed some significant arrogance in the more modern side, too, and not everyone is willing to meet people where they are. I can see a HUGE fight going on over something as simple as handwashing.

Best of luck withy our story!!

xoxo, Aunt Scripty

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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!

I'm gonna get myself in trouble
  • Patient, post-op female of 23 yrs: When I woke up there was something in my mouth, I couldn't talk.
  • Me: Yup, that was ET tube to help you breath during surgery. It was actually in your windpipe.
  • P: Will they have to put it back?
  • Me: Not unless you stop breathing. But you should be good.
  • P: Good, because my throat couldn't take it.
  • Me, absent-mindedly: Your throat could take much more.
  • P: 😐
  • Me: 😐
  • Me: Crap, I didn't mean it like that.
  • P: *giggling*
Ugh

Today was thanksgiving. I worked a paramedic fly car. Thanksgiving was slow… Quiet even. Until 15:09 hours when I got a job to back up an EMT unit calling for a medic. It was a respiratory distress call. I won’t get into the medicine behind it because I don’t want to bore anyone but I had to intubate her. Intubation is an advanced level of airway management that is only performed by doctors and paramedics. This was an 87 year old female alone on thanksgiving. When I got there she was in bad shape. But I couldn’t help but notice all the pictures on her wall and family and her husband and loved ones. She seemed to have lived a full life. She was a nun for a period of time. She seemed like a good person who at one time had a life full of love and family. Today however she was alone on thanksgiving struggling to breath. The EMTs did all that they could and did the right thing by calling for a paramedic. I arrived and tried everything I possibly could to not intubate her. Nothing worked. So I had to sedate, paralyze and intubate her. And the last thing this woman saw was my face as she went unconscious from the medication I gave her to sedate her ready with a giant mac blade and ET tube to shove into her trachea. Shes alive right now and doing ok intubated in the ER… Still alone without family sedated and intubated with a machine breathing for her. What I’m trying to say is that life goes fast and tomorrow is never promised. Live well. Love hard. And be a good person.

#PARAMEDIC

Cellules apparentées aux fibroblastes dans le stroma des gonades

Dans le stroma des gonades, on peut trouver chez les deux sexes des cellules apparentées aux fibroblastes (violet). Dans les testicules on retrouve les cellules de Leydig entre les tubes séminifères, et dans les ovaires on les trouve au niveau de la thèque interne autours de l'ovocyte au stade de de Graaf par exemple. Dans les deux cas ces cellules sont impliquées dans la sécrétion d'hormones stéroïdiennes comme la luteinizing hormone (LH).

Ces schémas ont été faits pour mes ED du Tutorat à partir des cours que j'ai retranscrit quand j'étais en première année de médecine. Ma seule source est le professeur de l'époque, et je peux avoir mal compris certaines choses, faire des approximations fausses, etc même si je fais de mon mieux. Croiser les sources permet d'avoir des informations plus fiables. N'hésitez pas à commenter pour discuter des sujets abordés ! Schémas et explications faits entre 2015 et 2016.

ET Tube fun! When to extubate?

In dogs:

When recovering from an anaesthetic dogs are left on oxygen for 5-10 minutes. Extubation should occur when the dog regains its ability to swallow, this can be indicated by their first cough. It is vital the cuff of the ET tube is allowed to deflate before the dog is extubated.

Cats:

Cats differ from dogs as they need to be extubated BEFORE they regain the ability to swallow to prevent laryngeal spasm. Therefore it is important to play close attention to increased jaw tone and look for an ear twitch when the hair on the ears is gently stroked. 

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.

Tongue Piercings And Emergency Intubation

Urgent and emergent intubation is challenging enough, but what if your patient is sporting some type of tongue piercing? Does it make a difference? Do you need to do anything differently?

Obviously, the jewelry may physically impede the process of intubating the patient, impairing visualization of structures or getting in the way of inserting the tube. It can also cause complications later down the road, such as pressure necrosis from the tube coming into contact with it.

The anesthesia literature recommends removing all oral jewelry prior to elective intubation, or declining to do the case if the patient refuses. Unfortunately, trauma professionals do not have that option when the patient needs an emergency airway.

Here are some pointers for dealing with oral jewlry:

  • Is the item going to impede insertion of the airway? Is it large, or obstructing the usual tube pathway? If so, remove it quickly (see below). 
  • Sweep the tongue well to the side during tube insertion to avoid the jewelry. You may need an assistant to grasp it with gauze to keep it out of the way.
  • Once the airway is secured, remove the item. This takes two people! The ET tube should be moved to the side, and one person will grasp the tongue with a gauze pad and extend it. The other person can then grasp the jewelry with gloved fingers, and unscrew the ball on one side. It can then be removed and saved in an envelope.

Note: both hands must always be in contact with the jewelry at all times! It is slippery, and if the pieces are not controlled, this can happen!

Image source: internet