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As The Hospital Pervs-- It's Overtime Time

Ccrn

I don't want to practice test alone.
---

A 45-year-old man had a heart transplant 10 hours ago. Assessment: cold, clammy skin, jugular venous distention, bilateral rales, and tachycardia. Vital signs: 98.6° F, blood pressure 80/60 mm Hg, :heart: heart rate 120 beats/min, and respiratory rate 26 breaths/min. Mediastinal chest tube drainage is approximately 50 mL/hr. He is diagnosed with decreased cardiac contractility. Which of the following would be an appropriate treatment for this patient?

A. Beta-adrenergic stimulant (Dobutamine)

B. Diuretic (Lasix)

C. Normal saline bolus

D. Antibiotics
--------

My thinking: I first ruled out antibiotics, then I ruled out the fluid bolus because of the neck vein distention and chest tube drainage, then I was stuck between lasix and dobutamine but because the question told me decreased cardiac contractility I figured the answer must be dobutamine, even though I was concerned that the tachycardia would increase with dobutamine-- the lasix would not fix the underlying cause.


Rationale: Treatment for decreased contractility is to increase the contractility with inotropic agents such as Dobutamine. The heart failure has caused fluid to be backed up into the pulmonary circuit, causing increased interstitial fluid, increased pulmonary colloidal pressure, and a resultant increase in intraalveolar fluid as evidenced by the crackles. Additional fluid is not indicated. Diuretics may be needed to decrease preload but may decrease cardiac output further in this patient. Inotropes would be indicated first. The patient is afebrile, and there are no indications that infection is a problem.

Strategy: The clinical picture is heart failure and cardiogenic shock. To improve the contractility, give a drug that directly increases contractility. Remember that stimulation of beta1 receptors increases heart rate and contractility and that dobutamine is the drug of choice for cardiogenic shock.
 
A 19 year-old patient is admitted to the trauma intensive care unit after a motorcycle crash. He has a fractured femur. He becomes pulseless, although the monitor shows sinus tachycardia with a rate of 120 beats/min. Which of the following should be included in the patient's initial therapy?


A.Intubation, mechanical ventilation, sodium bicarbonate

B.Intubation, mechanical ventilation, atropine

C. CPR, epinephrine, intravenous fluids

D. CPR, dopamine, isoproterenol

My thinking: It's easy-- ACLS: CPR, and Epi are always given first, unless it's v-fib, v-tach with no pulse: defibrillate. The IVF will not hurt the patient, even if you don't know that long bone fractures can cause big blood loss.
 
pete said:
got 4wd?
Click to expand...
Aw no, the days of my little 4x4 are over. I drive a little red car now.
I figured if night shifters made it to work, I could make it home.
Luckily, I didn't have to work today and that saved me from sleeping over at the hospital. The nurses working back to back packed their pajamas and clean work uniforms for the morning.

There is this 'abandonment' of patient law/ethic. A nurse really can't leave the patients until handing over care to another nurse.

It's just snow! It's not a blizzard! Every nurse knows they have to come to work to relieve the next nurse, even if they are four hours late getting there. Surely, in a true emergency no nurse would leave the hospital unattended, understaffed.

Wat_Tyler said:
Dress warmly.
Click to expand...
Hahahaha! I still haven't worn a winter coat yet this year. I have a red fleece jacket and a red puffy vest, a red hat, red gloves, and a red scarf. This man nurse is always yelling at me for a few years now to put on a winter coat.
 
sweepthefloor said:
Aw no, the days of my little 4x4 are over. I drive a little red car now.
I figured if night shifters made it to work, I could make it home.
Luckily, I didn't have to work today and that saved me from sleeping over at the hospital. The nurses working back to back packed their pajamas and clean work uniforms for the morning.

There is this 'abandonment' of patient law/ethic. A nurse really can't leave the patients until handing over care to another nurse.

It's just snow! It's not a blizzard! Every nurse knows they have to come to work to relieve the next nurse, even if they are four hours late getting there. Surely, in a true emergency no nurse would leave the hospital unattended, understaffed.


Hahahaha! I still haven't worn a winter coat yet this year. I have a red fleece jacket and a red puffy vest, a red hat, red gloves, and a red scarf. This man nurse is always yelling at me for a few years now to put on a winter coat.
Click to expand...


Yeah, the good news is, it's just snow. The bad news is that it all froze not long after contact. Of course, the horrid bit is the idiots who either over-compensate or make no adjustments whatever. I've already been out for my scheduled morning run as well as an extra that I got at 0445. Breakfast is 3 greasy fried eggs and half a pound of bacon. I go back out this afternoon. I wonder which of those runs will cancel. The hospitals won't.


I have worn my winter coat exactly once this winter. This morning was just an extra sweater and the vest on top. My gloves and hat are gray. By day after tomorrow, the vest will likely just be carried under my arm for PRN use. It is amazing how quickly I get used to this cold crap.
 
Wat_Tyler said:
Yeah, the good news is, it's just snow. The bad news is that it all froze not long after contact. Of course, the horrid bit is the idiots who either over-compensate or make no adjustments whatever. I've already been out for my scheduled morning run as well as an extra that I got at 0445. Breakfast is 3 greasy fried eggs and half a pound of bacon. I go back out this afternoon. I wonder which of those runs will cancel. The hospitals won't.


I have worn my winter coat exactly once this winter. This morning was just an extra sweater and the vest on top. My gloves and hat are gray. By day after tomorrow, the vest will likely just be carried under my arm for PRN use. It is amazing how quickly I get used to this cold crap.
Click to expand...
I should go out there and shovel my car out of the driveway that I rammed it into last night, at least it's not half in the street. I don't feel like it.
 
sweepthefloor said:
I should go out there and shovel my car out of the driveway that I rammed it into last night, at least it's not half in the street. I don't feel like it.
Click to expand...


Maybe later, when the sun has made it easier.


Well, I assume you have sun. I do. It's lovely bright in here, reflecting off the ground. I forget how bright it gets . . . and how you can then see every ceiling booboo there is.
 
Wat_Tyler said:
Maybe later, when the sun has made it easier.


Well, I assume you have sun. I do. It's lovely bright in here, reflecting off the ground. I forget how bright it gets . . . and how you can then see every ceiling booboo there is.
Click to expand...
I kind of have a little driveway with a few rocks that leads to a yard. The neighbor is a church with a parking lot in the back. I watched the church paid-for-plow come and go. They usually make a path for my side, because the parking lot is my Father's property that we don't use. I guess they forgot about us this time.

I went out and shoveled the driveway, made a path to the door, made a walking path for my Father's truck if he wants to park in the yard like he usually does, and made space in case he wants to park behind me. It wasn't too bad. I live in a rural area with no sidewalks. We don't even use the front door. It still has a skeleton key in the lock hole for I don't know how many years, probably before we lived here.

The sun is shining bright. I didn't want to wait because I imagined the sun melting some snow, making it heavier with wet.
 
sweepthefloor said:
I kind of have a little driveway with a few rocks that leads to a yard. The neighbor is a church with a parking lot in the back. I watched the church paid-for-plow come and go. They usually make a path for my side, because the parking lot is my Father's property that we don't use. I guess they forgot about us this time.

I went out and shoveled the driveway, made a path to the door, made a walking path for my Father's truck if he wants to park in the yard like he usually does, and made space in case he wants to park behind me. It wasn't too bad. I live in a rural area with no sidewalks. We don't even use the front door. It still has a skeleton key in the lock hole for I don't know how many years, probably before we lived here.

The sun is shining bright. I didn't want to wait because I imagined the sun melting some snow, making it heavier with wet.
Click to expand...


If you clear the big parts and then the sun hits it, it gets rid of what's left. Usually. I swept the heavy crap off my proch and front walk and Sun took care of the residue.


I need to go out and clean the car windows. They are becoming a menace because they are so scudded over. It's 11 and the car is in the sun, so I'll give it a go shortly.
 
Wat_Tyler said:
If you clear the big parts and then the sun hits it, it gets rid of what's left. Usually. I swept the heavy crap off my proch and front walk and Sun took care of the residue.


I need to go out and clean the car windows. They are becoming a menace because they are so scudded over. It's 11 and the car is in the sun, so I'll give it a go shortly.
Click to expand...
I am staying inside watching the massive ice dicks get hard-ons hung from the pelvic roof. I should take a picture.
 
About a crush inspired by Pink's Crush Thread

I have a secret crush. He is quiet and powerful at the same time. He doesn't yell, and he doesn't show emotion in the presence of an emergency. He has a steady hand. I have watched him surgically insert a tracheostomy at the bedside in less than 8 minutes. His sutures are tight and pretty with blue knot thread.

He doesn't flirt, he is immune to our beauty. We get what we need but we don't always get what we want.

He: How are you doing, how is the patient doing?
Me: How are you?
He: I just got back from the trauma bay- stable.
Me: Yes, I am aware.

What I wanted to say--

He: I just got back from the trauma bay- stable.
Me: Yes, I am aware. I hope you are well rested and well fed for the time when the night falls, when you have no idea what will rush through the door, or fly from the heliport. When you don't know how many long hours you will stand in the operating room, when you don't know how many calls from ICU RNs that you will receive when you try to close your eyes. When you don't know how many decisions you will make. When you don't know of the bad news you may have to break.

And you won't know any of this till your sign out at 0800-- when the last note is written, and your round report is given.

What I do know is that there is coffee, empathy, understanding, crackers, and a juice box with your name on it, any time you want it.
---
Hahahahaha! Imagine that! I speak facts. I don't know another language.
How is the patient? Subjective and objective data.
How am I doing? Silence.
 
sweepthefloor said:
About a crush inspired by Pink's Crush Thread

I have a secret crush. He is quiet and powerful at the same time. He doesn't yell, and he doesn't show emotion in the presence of an emergency. He has a steady hand. I have watched him surgically insert a tracheostomy at the bedside in less than 8 minutes. His sutures are tight and pretty with blue knot thread.

He doesn't flirt, he is immune to our beauty. We get what we need but we don't always get what we want.

He: How are you doing, how is the patient doing?
Me: How are you?
He: I just got back from the trauma bay- stable.
Me: Yes, I am aware.

What I wanted to say--

He: I just got back from the trauma bay- stable.
Me: Yes, I am aware. I hope you are well rested and well fed for the time when the night falls, when you have no idea what will rush through the door, or fly from the heliport. When you don't know how many long hours you will stand in the operating room, when you don't know how many calls from ICU RNs that you will receive when you try to close your eyes. When you don't know how many decisions you will make. When you don't know of the bad news you may have to break.

And you won't know any of this till your sign out at 0800-- when the last note is written, and your round report is given.

What I do know is that there is coffee, empathy, understanding, crackers, and a juice box with your name on it, any time you want it.
---
Hahahahaha! Imagine that! I speak facts. I don't know another language.
How is the patient? Subjective and objective data.
How am I doing? Silence.
Click to expand...

aw, how cute.
its the classic romance:

girl meets surgeon, surgeon acts aloof, girl slips surgeon a roofie and has her way with him

:heart:
 
pete said:
aw, how cute.
its the classic romance:

girl meets surgeon, surgeon acts aloof, girl slips surgeon a roofie and has her way with him

:heart:
Click to expand...
hahaha! The nurses are known to sit around and evaluate our favorite trauma surgeons when it is not busy. The collective nurse assessment of him is: quiet and condescending. I have only noticed quiet.

I go against the majority. My favorite trauma surgeon is the oldest one. His leadership skills are superior to all the newer surgeons. He will tell you to leave the room if there are too many people crowding his thought process that he speaks out loud so we all know what is going on. He will tell you exactly what to do in an emergency. He will stand at the foot of the bed like this tall shadow dictating interventions and looking for outcomes. He never forgets to tell us to keep the cervical spine stable during CPR-- there better be someone at the head of the bed holding the neck.

He is blunt and brutally honest to family and staff because sometimes we all need a dose of the truth.

Anyway, he is not my crush, just my favorite surgeon---I got distracted.

I am not the flirty nurse and I am no surgeon's favorite. I am just quiet too. :heart:
 
Now I will write about the Resident crush:

My favorite Resident is now Chief Resident Attending but his year is almost up and I will miss him. It is one of those traumatic attachments, the time spent at the bedside for 12 hours trying to maintain life on a young woman, with a young child.

He never left my side. He never left the room, he pushed the HCO3 when my wrist hurt so bad from pushing, and when the night nurse arrived he gave her report for me from the past medical history to the current situation, because I could barely speak with clear speech. I kept working while he signed out to her, and I looked at him and realized that I loved him for what he does. I realized that he was good. I knew he was the best in class and ready to lead, manage and mentor the next third years.

I was so happy when he was placed at the top after his third year was over. There was a close runner up with extensive knowledge but his application fell slightly short, and his reliance on diagnostics compared to assessment was ridiculous.

My Resident crush is so different from my Surgical crush because of the bond from that day. When this new Attending walks into the ICU and sees me at the end of the unit-- I wave, I blow kisses! He smiles and blows back. :kiss: When we talk I beg him to apply for critical care fellowship anywhere he can. I want him to come back as Intensivist.

And we whisper about who will replace him, and I agree with his nominee. :heart:
 
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