Tuesday, October 15, 2013

Spidey-sense

I was having an interesting conversation with a resident earlier (and actually, gasp, enjoyed it) about how to know when to intubate a patient that looks like poop, but has a relatively normal blood gas. It was interesting in the sense that he really was looking for my opinion/experience on the matter. We bounced ideas back and forth and came to a few major points to look over. 


1. What does the patient look like? Labored, sweaty, pale, jaundiced, only awake when aroused, old/young? 
2. Are they oriented to time/place (sans hypercapnia)? (ie could they anticipate vomiting and warn someone about it?) 
3. What disease process(es)/history is causing this? Someone with ESRD can usually be fixed with bridge bipap/dialysis, whereas a stage 4 met lung CA patient is terminally ill and will succumb to the disease eventually.
4. What are the other vital signs/labs? Basically, are they about to code b/c their BP is labile and HR is jumping from 120's to 180's with a few pvcs thrown in there? 
5. Does the patient/family want aggressive care? Code status and the patient's wishes should always be respected if they are of sound mind (medical power of attorney plays a role, too)
6. Spidey-sense? This one is just something I've acquired over time. Call it intuition, my experiences in the ED, ICU or pre-coding patients on the floor... I just can tell when a patient is coming up close to needing life support. 

Those are just some good starting points (no particular order) in making a call on those borderline patients. I feel like one of the most obvious green lights for intubation on airway protection is status epilepticus that won't respond to benzos/barbituates (also taking into account respiratory drive depression from those drugs as well). Flash pulmonary edema in extreme cases, epiglottis (this is an absolute), hemoptisis, unstable NSTEMI going to cath lab, drug overdose, and history of very difficult airway in resp distress are the other big ones that I would push for intubation. 

Personally, I tend to go with that if the patient is exhibiting at least 3 of the 6 points I brought up, I will voice my opinion. Now, most of the time I don't make that call, but at least I can put forth my two cents (whether it's taken seriously depends on the boss man in charge). I do find it hard to swallow some days when I can see an intubation coming from a mile away, but no one will listen to my plea because abcdefg reasons.

I know I have more to elaborate on this subject, but it's late and I have another long long shift coming forth tomorrow. 

I hope you are all enjoying the lovely fall weather :) 

Tuesday, October 1, 2013

feeling feelings

So. Lots to discuss, but not enough desire to bore you with all of it. Just enough to keep up with the changing tides.

Work is a constant evolution of face palms. 1. work load. 2. computer systems changing at the same time as 3. annual check offs that are convoluted and weird 4. the suits and their obvious  and completely horrific displays of favoritism 5. being sick, triggered from work load 6. breaking bad is over and I no longer have something to small-talk my manager about 7. i dont like the new set of residents because one of them ordered an abg & electrolytes on a dnr/dni patient just to check a k+ level that should have been tacked on in morning labs that THIS RESIDENT FORGOT TO ORDER. And wanted me to help them put in the a-line. At 10:30 at night. Noooooope.

Anyway. Perfect segue into reasoning behind going back to school...

Apparently... a university system hospital that is of a "public service" entity,such as the finest university system hospital I am currently employed (hopefully to stay thus), reaches the bracket of loan exemption. Listen up kids, this is important. So, if I make 170 qualifying payments to my stafford loans (about 10 yrs give or take with some wiggle room), I can qualify for student loan forgiveness. Breaking it down...

Let's just say I have less than 20K in loans now. If I keep paying, go back to school and finish up prereqs for PA school, keep paying on loans through the PA program (which would be optional), exit said program with a price tag of 140K, and meet the criteria for loan forgiveness upon graduation and re-hire from current hospital employed....

Deep breath. Sigh. Could it be? Education that doesn't completely rape your bank account for the rest of your life? This all seemed too good to be true. Maybe it will all change someday soon, but for now I would suggest peeking into the current gov loan forgiveness program. I've let student loans deter me from going back to school for 2+ years, and I'm no longer letting the fear of repayment keep me from achieving my goals.

So the decision has been made. I'll start chipping away at classes over the next few years with the over-all goal in mind. Deep breaths again. It all begins in January.

I have felt kind of nostalgic tonight. Whether it's just been from writing on this blog, getting out there and having my adventure fun times, or just relationships (friendships and relationships alike), that are keeping me on edge...slightly. I feel like I've let some good people slip through the cracks. I wish some of my exs had just been friends, and nothing more. I can see now that I should never have held such amazing characters up to my fine-tip comb of my inadequacies.

As far as the ever-stimulating game of dating is concerned, I met someone. A person that's pretty important, and sees the bigger picture. We shall see how it evolves.