# ml syringe

Basic Drug Calculations: How to Survive Clinical Rotations #4

When I matriculated into clinical rotations, the thing that I probably was most terrified of was messing up a drug dosage or calculation. So much math, and when you are stressed? It can be easy to mess up! So let’s go through a basic drug calculation together!

-First things first: Unless it’s a very specific drug that states otherwise, in general, ALL OF YOUR WEIGHTS WILL NEED TO BE IN KGS (kilograms), NOT POUNDS!!!!!  How do you do this? Take your weight in pounds and divide by 2.2!! So a 14 pound dog is 6.36kgs!!!!

Okay, so you have a 14 pound dog (6.36 kg) named PooPoo that you want to give Miraclemycin to that is in a bottle. It states in your pharmacy book (Drugs R Us) that you should give 3.0 mg/kg of MIraclemycin. That means you need 3.0 mg (MILLIGRAMS) PER KILOGRAM of body weight. We just that PooPoo is 6.36 kgs, so simply multiply THE WEIGHT (IN KGS) BY THE MGS PER KILOGRAM. That is 3.0 mg/kg X 6.36 kg to get 19.08 mgs!  Whoohoo, we know how much to give!!!

…But it’s in a bottle that is liquid and it says that the bottle has 15 mg/ml… Never fear! This means there is 15 MG (milligrams) of medication per 1 ML (Milliliter) of liquid. So if we want 19.08 milligrams, we take the amount of milligrams we want divided by how many MG/ML. So 19.08 mg divided 15 mg/ml= 1.2 mls! That means we would draw up 1.2 mls in our syringe!

(Below is the calculation again in a little more streamlined fashion):

14 pounds / 2.2 = 6.36 kgs

6.36 kgs X 3.0 mg/kg = 19.08 mgs

19.08 mgs/ 15 mg/ml = 1.2 mls of Miraclemycin!

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Other useful links: Surviving clinical rotations #1 (how to be prepared for clinical rotations), #2 (Presenting a case: Signalment), #3 (How to take a history), what is a clinical rotation

Aquatic plant nutrition - An overview

Our green, red and orange photosynthesizing friends need care beyond being wet and I will elaborate what are the key points of aquatic plant nutrition.

Liebig’s law of the minimum states that the least available nutrient is the limiter of growth. Or positively put, fertilizing the scarcest nutrient(s) will improve growth, often greatly. Of the law is an gross oversimplification of the biological processes behind plant metabolism, but in the aquatic practice it makes an good estimate.

## Macronutrients:

1. Derived from air and water: Hydrogen, Oxygen and Carbon as H2O, O2 and CO2 . Water is obviously abundant underwater, Oxygen diffuses into water through the surface as well as produced by photosynthesis and thus most often abundant too. While Carbon Dioxide also diffuses into the water and is produced by the decay of organic matter, the conzentrations are rather low and in general the limiting factor of photosynthesis and plant metabolism. One can decide to artificially dissolve CO2  in one aquarium, enabling the use of high intensity lighting, leading to an much higher metabolic rate and growth but also to more demand for other nutrients, of course. Still, common aquatic plants are adapted to conzentrations found in aquaria without additional CO2 source, so you don’t have to do any work here.
2. Primary Macronutrients, Potassium, Phosphorus and Nitrogen, typically encountered as K+ , PO43-  and as parts of the Nitrogen Cycle, NH3/NH4+, NO2-, NO3-. Nitrogen and Phosphorus are generally present in large amounts from fish food and certain substrates, but very heavy planted tanks and tanks under high light need additional fertilization here. Potassium is one minor cation in natural waters and found in traces in organic matter, but it is also needed approximately as much as Nitrate (NO3-), meaning it is in high demand. Water changes are thus the most notable source in home aquaria, but are often insufficient. Thus additional Potassium fertilization is a good way to improve growth in an otherwise unfertilized tank.
3. Secondary and Tertiary Macronutrients: Calcium, Magnesium and Sulfur. Calcium and Magnesium are as Ca2+ and Mg2+ the major contributors to the General Hardness, GH. They are abundant in all but the softest waters. Sulfur is as Sulfate, SO42-, is a common anion in natural waters and only in very low demand, thus abundant. Unless you plan to never do water changes or have extremely soft waters and lots of plants under high light and additional CO2, you will have no need to fertilize them.

## Micronutrients:

Iron and the rest: They are all traces elements needed to ensure proper metabolism, and the only notable sources is organic matter, aka fish food (or certain substrates). While the demand is low, the supply is even lower. Fertilizing Micronutrients is often the best first step into fertilization and often leads to great improvements in growth and plant health.

## The Delivery, fertilizing the water column and the substrate:

Contrary to terrestrial plants, aquatic plants not only can take up nutrients from the substrate through their roots, but also from the water column. There are many aquatic plants that have roots reduced to mere tools to secure themselves in the substrate or on rocks, some even having no roots at all. No aquatic plant will choose death over having to take up nutrients through the water column, thus fertilizing the water column will be enough to ensure survival and even decent growth. For the best growth however, nutrition through the substrate is also recommended, as there are still many plants in the hobby that root quite heavily, such as Echinodorus spp. and most carpet plants. There are three major types of substrates used in the hobby:

1. Inert substrates, such as sand or gravel: They contain no available nutrients not do they anything else. Nutrients are added as detritus/mulm gets in between the grains or when the aquarists add root tabs or other substrate fertilizer to them. Sand in particular hardly allows any detritus to get into it, therefore root tabs are highly recommended. Gravel will also benefit from them, of course.
2. Clay-based substrate, such as Eco-Complete or other substrates. These substrates are themselves just as inert as sand or gravel, but have a trick to get nutritious: Replacement of silicate through ions with lower charge diffusive processes gives clay particles in small negative charge, making adsorb cations, This is called Cation-Exchange-Capability (CEC), meaning in effect clay based substrates can collect cations like a sponge, just waiting for plant to pick them up. This is a notable effect and greatly increases the fertility of the substrate, but still not the best case.
3. Substrates with organics in it, such as aquasoils or an dirted tank. An dirted tank being an tank where the substrate is organic potting soil capped with a layer sand or gravel. These substrates contain actually nutrients themselves, though it’s mostly Nitrogen and Phosphorus. Still, hummus in a dirted tank has an even higher CEC than clay, is also all-around better. Aquasoils being pellets of compressed and burned volcanic ash have also a notable CEC, making it also all around better than clay-based substrates. Aquasoils in particular also buffer the water to a lower pH and soften it too, that is beneficial for many fish in the hobby and the lowered pH in the substrate helps roots taking up nutrients. On the downside, aquasoils are expensive and sometimes leech toxic ammonia in the first few weeks.

Buying bottled fertilizer in a fish store is not very efficient, you pay mostly for water. It is up to hundert times cheaper to buy a few substances from vendors such as GLA or TNC and mix up your own fertilizer. Or for those who want it simpler, using these substances for an fertilization system such as Estimative Index (EI). EI in particular aims to supply nutrition to densely planted tanks with high light and additional CO2, but downscaling it to one fourth is also suitable for tanks without additional CO2.

Simple recipe for EI-style fertilizer, the dosage is 5 ml of each solution daily per 40 liter/10 g of water:

• Macro-Solution: Dissolve 60 g KNO3, 10 g KH2PO4 in 1 liter of reasonably pure water like RO or destilled water. If you have plants with a high potassium demand, you may dissolve 20 g KSO4 too.
• Micro-Solution: Dissolve 1.9 g of TNC Micro-nutrient mix or 2.3 g of CSM+B in 1 liter of reasonably pure water. You may add some ascorbic acid to increase the shelf time, though I found that is often not necessary.

As a tip, you measure 5 ml easily with an syringe or and dosing pump (like from a dispenser)

Feel free to ask/PM me questions if you have some.

PSA for all nurses, but especially pediatric nurses

OK, this is something I feel like everyone should know…but I have seen on more than one occasion someone has NOT known, so it may do some good to make a post about it!

It’s super important to know how many mLs are held in your tubing! Like, super super important!

The hospital I work in has tubing that hold 0.54 mLs for syringe pumps and 20 mLs for bags, but I have seen different lengths at different facilities. The volume of the tubing should be written on the packaging, so take a look at yours the next time you’re at work if you don’t know! Why it is so important?

Especially in pediatrics, we frequently give doses of medications that are smaller than the length of our tubing. In my Prostin example from the other night, the dose only runs at 0.106 ml/hr. That means it takes just over 5 hours to get from the syringe to the patient. If you primed that tubing with NS and hooked a Prostin syringe to it, your patient would be going without their medication for over 5 hours. No bueno!! You need to prime with your drip!

It’s also SO IMPORTANT TO FLUSH! I have seen this happen multiple times on the floor. Let’s say you run a 2 mL medication on your pump, but you don’t flush behind it. ¼ of their medication is left in the tubing! That can make a difference! Don’t short your patients! Even worse, say you have a dose of medication that is only 0.5 mLs. If you hook that syringe up and run it over 30 minutes……when your pump beeps, it’s only filled the tubing. Your patient has not actually received any medication at all. If you don’t run a flush, they will never get their dose! This is why if I have a medication volume that is equal to or less than my tubing volume, I will push the whole of the medication into the tubing and then run it into the patient with a flush. Obviously you wouldn’t do that if you’re running it with vasoactive drips or something….but in most situations, that is really the only way to get a patient their full dose in a timely manner.  If you do this, though, you still need to be aware of your volumes and rates. Lets say you push 0.5 mLs of medication into the tubing, then run a 1 mL flush behind it in 30 minutes….if your tubing is 0.5 mLs in length, the patient will actually be getting their medication in 15 minutes and then NS for 15 minutes. If you run a 2 mL flush in 30 minutes, the patient will get their medication in 7.5 minutes, and NS for 22.5 minutes. See where I’m going with this?

Likewise for bags, if you run a flush of only 5 mLs on a bag that was hung with 20 mL tubing…there’s still 15 mLs of medication being left in the tubing. On pediatric patients, 15 mLs is a lot!!

I used tubing lengths from my hospital in these examples, but they may be different where you work! Find out yours if you don’t already know! Make sure you’re giving your patients their entire doses!  :)

Day of the Dumb Shits: Pharmacy Follies

-I should’ve known today was going to be a shit day when I woke up to dog balls in my face.

-I actually walked into that shitter of a pharmacy in a good mood. I mean, I got paid, paid all my bills, had some trick off money left over, stopped at Dunkin Donut’s and got me an ice mocha latte with extra sugar, mocha and whipped cream and considering the Blackhawks won the night before, all was well in my world. Until I dealt with my first patient.

Asshole: “My parents are going out of the country for 3 months. They need to get these prescriptions filled and the doctor wrote them out for 3 months so it shouldn’t be a problem.”

But of course, there was a problem. The insurance would NOT pay for a 3 month supply. Here’s where the fucking party starts…

Me: “The insurance does not cover a 3 month supply.”

Asshole: “The doctor wrote the scripts for 3 months and said it shouldn’t be a problem.”

Me: “The doctor doesn’t have any control over what the insurance covers.”

Asshole: “He wrote the scripts for 3 months!”

Me: “He could write the scripts for a 2 year supply but if the insurance only covers 1 month at a time, that’s all they’re going to pay for.”

Asshole: “I don’t understand this. We go through this every year! My parents go out of the country every year for 3 months! The INSURANCE should KNOW this!”

Yep, you read correctly. The fucking INSURANCE should KNOW that his parents go out of the country every year and should pay for their medications. He was going on and on and on about this and at one point, I was ready to take out the Thor Regulation Hammer so I could beat MYSELF over the head with it and end my misery.

Idiot: “I need to get a refill on this. I know there’s no refills on it. However, I left the prescription at home. Just refill this and I’ll bring the script back, ok?”

Me: “No, it’s not ok.”

Idiot: “Excuse me”

Me: “I can’t do that. I cannot fill a prescription ahead of time without the actual prescription.”

Idiot: “I have a prescription! It’s at home!”

Me: “Ok. Bring it back and we can fill the prescription.”

Idiot: “So I have to go all the way home in order to get this filled?!

Me: "Correct.”

Idiot: “I just don’t understand why you can’t fill it ahead of time!”

Me: “I know you don’t understand. You got 2 options. I can either spend time explaining the legalities of why I cannot fill a prescription ahead of time without a valid prescription or you can go get the prescription and we can fill it. What will it be?”

Because she sensed I wasn’t in the mood to deal with her dumb fuckery, she wisely chose option 2.

-It seems whenever people lose prescriptions, it’s NEVER insulin, blood pressure medication or anti-depressants. It’s ALWAYS controlled substances and these poor people just have the shittiest luck because they’re always “losing” or having their controlled substances “stolen”. Case in point: Fuckface comes in AGAIN claiming someone stole her bag out of her car. In addition to stealing her bag, her kids C-II’s were in it. The doctor gave her new scripts and she was more than willing to pay cash price for the lost medication. Because H the Pharmacist heard that bullshit story before, she refused to do it.

H: “How many fucking times this year has this asshole had her shit stolen? I’m not filling anything early. I don’t give a fuck if her doctor gave her new scripts. I don’t give a fuck if she’s willing to pay cash price. She’s ALWAYS willing to pay cash price! She can go somewhere else.”

-Poor J got stuck with this winner. She was picking up prescriptions and J asked…

J: “Do you have insurance?”

Fucktard: “He was in an accident and the other persons insurance is going to pay for it. Here’s the information.”

And she proceeds to whip out her cell phone and show J a screen shot of some fucking car insurance company name. Naturally, J’s confused by that and asks me to look at it.

Me: “Unless you have actually insurance billing information, I can’t bill an insurance company.”

Fucktard: “This is the insurance information.”

Me: “What you’re showing me is the name of the insurance company. There’s no billing information on there.”

Then she whips out a piece of paper that turns out to be an accident report.

Me: “This is an accident report. There’s no insurance billing information on here.”

Fucktard: “The car insurance company is going to pay for it!”

Me: “Usually when a car insurance company is going to pay for something, it’s in the form of reimbursement. That means, you have to pay out of pocket for whatever you need that stems from the accident. You give those bills to the insurance company and they cut you a check back. So unless they actually gave you a prescription card to use at the pharmacy to pay for prescriptions, I have no way of billing them.”

Fucktard: “You’re going to bill it to this company.”

Me: “That’s a car insurance company. We don’t bill car insurance companies. We bill prescription insurance companies. Give them a phone call and let them know unless they give us actual billing information, I can’t bill them.”

She wanted to continue arguing about it but I walked away. I’d have better luck pulling a rabbit out of my ass than billing a fucking no name car insurance company for prescriptions.

-For some strange reason, after lunch, I lost whatever little tolerance I had for stupidity. It got to the point where I was actually looking at people like this when dealing with their spazzery….

Many cases in point…

Me: “Have you had prescriptions filled here before?”

Wank Pot: “I don’t know.”

Me: “Do you have insurance?”

WP: “I think so.”

Me: “Do you have the insurance card with you?”

WP: “No, but my wife does.”

Me: “Ok, just bring the card back when you come to pick up your prescriptions.”

WP: “I don’t have insurance.”

Me: “I thought you said your wife has the card.”

WP: “I don’t have a wife.”

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Dip Shit: “I’m picking up a prescription.”

DS: “Dip Shit”

Me: “H! There’s a consultation on DS’s prescription!”

H the Pharmacist: “Ask her if she’s pregnant.”

Me: “Are you pregnant?”

DS: “No.”

Me: “H! She’s not pregnant.”

DS: “Why do you need to know that?”

Me: “Because if you’re pregnant, you can’t take this medication.”

DS: “Oh ok. I’m not pregnant. But does it matter if prescription is not for me?”

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Moron: “I need a 10 ml syringe. Do you know where I can find one?”

Me: “Are you looking for an oral syringe or one for injection?”

Moron: “I don’t know. What’s the difference?”

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Nimrod: “I just picked up my prescription and I have a question.”

Me: “Ok?”

Nimrod: “Why didn’t the doctor give me any refills?”

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Shit Wit: “I need to drop off this prescription and I’d like to wait for it.”

Me: “Ok, what’s the date of birth?”

SW: “For me?”

Me: “Is this prescription for you?”

SW: “No.”

Me: “I need this persons date of birth.”

SW: “Even if it’s my insurance?”

Me: “Yes.”

SW: “Can you use my birthday?”

Me: “No.”

SW: “Are you serious?”

I’m telling you, I should’ve joined the fucking circus. I could be training poodles and pachyderms instead of dealing with this bullshit!