MSN vs. DNP?

Hi Everyone!

Long time no post, as you know I recently started in the MSN CRNA program at Columbia University in New York. Its been a smooth first two weeks so far, although I’ve already taken one exam to place out of a 3 credit Evidence- Based Practice class (would have cost me $4k, vs. the $375 I took to the test). Instead, I removed a class (Genetics) from my fall courses & decided to take it now to lighten my load later.

“The Nurse Anesthesia program is a 27-month, full-time, front-loaded program that includes a clinical anesthesia residency. The first year curriculum is devoted to advanced science courses, graduate core courses and specialty courses which form the basis for advanced specialty concepts later in the program.”

(http://nursing.columbia.edu/academics/academic-programs/master-s-and-post-master-s-programs/nurse-anesthesia-program-anes)

Basically, after the 27 months and taking the anesthesia boards you will have earned a Master’s (2.5yrs) degree in Nurse Anesthesia and can begin working and earn the same amount as someone with a DNP in nurse anesthesia like a lot of schools are offering. HOWEVER, by 2025 all advanced nurse practitioners are going to be required to get a DNP (~36months). So, the perk about getting your Master’s now is that you can start working right away, pay off your loans, and then get your institution to pay for the school you will need to get back into for your DNP. IF you do your DNP now, you just don’t have to worry about the additional schooling later on in your practice, for example, when you have a family and children. But, would have to take upon the burden of paying for it on your own.

 

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Traveled into new beginnings

Just came back from one of the longest trips I have ever taken. Well, not actually the longest in duration but more the number of things we were able to do in 16 days. Let me tell you about it!

So we took a red-eye flight Friday night May 5, 2016, out of NYC. In the midst of settling into the unease of knowing that I will no longer have a full-time job when I get back and trying to do some clean cleaning, with trying to submit pre-registration new student forms, its safe to say that the day was pretty hectic. You see, anesthesia school starts the week after I get back and I opted out of working full-time and going to school as well. This would be my last hurrah!

May 6, 2017 Casablanca to Marrakesh 

Landed in Casablanca, Morocco. Luckily we landed in the morning so it was easy to maneuver through the city. What we didn’t know was that our T-mobile phones notorious for having worldwide LTE exempted Morroco from the list. So, we were stuck with no wifi but luckily had offline downloaded maps where we starred the places we wanted to see on Google Maps. We took their version of an air train out of Casablanca airport into the city center. Oasis. From here, we were connected to a fast train going to Marrakesh. Mind you, when you buy this ticket please please please mark first class and pay extra. We were cramped, extremely hot, fatigued and the smell of BO did not help.

Finally arrived in Marrakesh to find out the Bahia Palace was closed. They closed at 4 pm. Also, pro-tip: ladies do not travel without a man by your side. My girlfriend and I were literally covered from head to toe but still catcalled and harassed to buying things and trying to lead us to wandering allies. SAM_1226.JPG

We explored the Koutoubia Mosque and ended up walking through the souks during sunset.

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Must go to restaurants: Cafe Arabe, and Nomad (try their Amylou icecream!).

 

(Cafe Arabe)

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(Nomad)

 

May 7-9 Marrakesh to Merzouga Tour

We were picked up by a tour bus that accommodated 17 people. We bought tickets online in the Merzouga Tour website, don’t get ripped off! We paid about ~80euros for the 3 -day, 2 nights deal. We stopped in multiple towns along the way. Including a Berber village. Berber meaning the natives who lives in Morroco before the Arabs came.Here we were cajoled into buying a Berber blanket and drank some tea with the locals.

On Sunday we explored kasbahs on our way to the desert and slept at a kasbah hotel. There they fed us dinner which was of course tagine and couscous!

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Monday we drove further in and made it in time for the sunset in the Sahara desert. They arranged a camel for each of us to ride into the sunset. The ride was about 1.5 hours. Our guide also gave us a complimentary ride through the sand dunes. I thought I was going to die. Then, we laid out in the desert and looked at stars and told stories around a fireplace. We slept in the tents they set up for us.

 

On the morning of May 9, we woke up at 4 am to ride into the sunrise. Not as thrilling as the sunset. We arranged for a grand taxi to Fes, Morocco. Luckily we had 4 other Americans that also wanted to go to Fez instead of Marrakesh. We paid about ~25USD for an 8hr ride. On our way we were greeted by a sandstorm. Unreal. We arrived in Fes at about ~4pm.

 

May 9-10 Fes, Morroco 

We only spent less than 24 hours here. Mainly because there wasn’t much to do in the old Arab city and we wanted to hurry up and get to Spain. The markets all close at 6pm. Fez is known for their leather tanneries where they hand make their leather goods. We went and bought leather jackets and literally, bounced the next morning!

May 11 Chefchouen, Morroco to Tangier Port, Morroco; Tangier Port- Tarifa, Spain

From Fes we luckily found a grand taxi that was charging us 1000 dirhams (~100USD) to Chefchouen. This is a steal from taking the CTM bus (which gets booked days in advanced apparently ~14USD) as you pay 16USD if split between 6 people. CHefchouen is known for its aesthetically pleasing town thats literally painted blue. We took some snaps here and then carried on.SAM_1828.JPG

From Chef, we took a local bus which cost us about 3euro to take us to the port of Tangier. This took about 3hours. From Tangier, we took a fast ferry FRS or intershipping ~35min to get into Spain. I recommend taking the 6 or 7pm to catch the sunset!We took their free shuttle bus to Algeciras and spent a night in Algeciras as there was no late night transportation to Seville.

May 12 Algeciras, Spain – Seville, Spain

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We used the app called blabla car sharing ride feature to go to Seville. It took ~2hrs and paid 10euros. The ride was pleasant and our driver was a girl our age. We are in Plaza de Espana above. Must go to the Alcazaar! This is where Dorne in Game of Thrones takes place.

May 12-14 Seville, Spain –  Pisa, Italy; Pisa, Italy – Florence, Italy

May 14 On our way to Florence, we took a flight out of Seville into Pisa with Ryanair. Print your boarding passes ahead of time! 50euro charge at the counter FYI. This was the cheapest option as direct flights from Seville to Florence was hundreds of dollars more. In Pisa, we ran to take pics with the tower, grabbed some pizza, and ran to catch a fast train that took about an hour to come into Firenze SMN.

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May 14-19 Florence, Italy — Duomo! Gelato! Hot chocolate! Oh and panini toscani and Ali’s kebabs.

May 17 Chianti Tuscan Wine Tour 6 hrs. We were taken to 3 vineyards. Got our deal from groupon for about ~70USD.

May 18 Cinque Terre (The Five Towns in Italian). Caught a train from SMN to La Spezia (train outside of Cinque Terre). Bought an all day train pass to ride from town to town. There is a hike from Town 3 to 5 which is apparently beautiful but we opted out for the sake of time.

May 19 Florence, Italy – Bologna, Italy; Bologna Italy – Ibiza, Spain

We took a train out of Firenze SMN into Bologna. From Bologna train station we took an airport bus to Bologna airport. You have to buy your ticket to the airport bus with the guy that sells magazines! Be careful of the gypsies, they will try to rob you. We have videos!! we caught a cheap flight to Ibiza.

May 20 Ibiza- Barcelona, Spain

As our returning flight was leaving from Barcelona. WE left Ibiza Saturday evening and spent a night in Barcelona in time for our flight back home the next day. Also, who doesn’t love Barcelona and it’s nightlife. Opium and Shoko for the win! Get there before 130am to avoid lines and 20euro cover. Other must dos: Park Guell, Sagrada Familia, Casa Batllo, Casa Mila, Magic Fountain of Montjuic (light show on Friday and Saturday nights)

May 21 Barcelona, Spain – Casablanca, Morroco; Casablanca – New York City

We were able to check our luggage and only have a small purse. We had an 8-hour layover in Casablanca and decided to use the time to check out Hassan II mosque. Once again, took an airport train out to the city center and took a cab there. Must do! It’s a mosque on the beach. Apparently, it’s helpful to just hire a guide while you are there. But, in our case we planned everything on a whim so did not have that luxury.

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My roundtrip flight was ~375USD. Luckily, with Chase Sapphire Reserved I booked it with my points. Overall, I would describe my trip to be rushed, unreal, and amazing!!!!

 

just a nurse.

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“I raised a doctor. You only raised a nurse.”

This phrase honestly doesn’t even phase me anymore. It makes me chuckle actually. It’s a clear source of ignorance of the different roles that healthcare has. I, for one, am comfortable in my role in the healthcare system. And we should all be, and go into it for the right reasons. God knows, with our evolving healthcare system, we all need each other. Our roles are all so precious and sometimes stretched so thin we may need more roles to work together efficiently for better patient outcomes. In an ideal world, we should get rid of the silos and come up with plans that start with “we” will do this for the patient.

As “just a nurse,” the role translates to being the 24/7 eyes, ears, hands, voice for patients who can’t do it for themselves. The nursing process is as such that we treat the patient not just as a disease, but as a whole- incorporating their social and spiritual belief to come up with a plan that best suits the individual patient.

 

(http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/Thenursingprocess.html)

The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care.
Assessment
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and lifestyle factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain medication.

Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.

Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses, as well as other health professionals caring for the patient, have access to it.

Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.

Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

 

 

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Imagine a day in the ICU per se without nurses. 

That aortic graft would have blown out because of a hypertensive episode and lack of monitoring and titrating of vasoactive medications. The patient would die.

Room 1 who is waking on the ventilator, would probably self- extubate, bleed go into respiratory insufficiency and climb himself to the floor. The patient would die.

That ECMO would have already clotted off. The patient would die.

Every chronic patient would have a pressure ulcer and die from it.

Every surgical patient besides one or two that PT can get to first will have atelectasis and catch pneumonia. The patient could prolong his hospital stay and run his medical bills through the roof.

That low flow alarm on the LVAD would go unaddressed, clot off, and the patient who waited so long for a potential heart transplant would… die.

That complaint of shortness of breath would go unwarranted as the patient turns blue.

That pulseless vtach would be dismissed as another alarm fatigue. The patient would die.

The absent bowel sounds with hardening and distension would only contribute more to his creeping lactate levels. Anaerobic metabolism. The patient would need emergent surgery, if at all possible.

Long story short, you need a nurse to save your life. There is a science behind our practice. You need the nurse’s assessments to relay your concerns to the team. To help during such a vulnerable time. To build that relationship for the next 12 hours. So we can help fix you. Doctors are important, yes, but they cannot be with you at the beside all the time or ever really if you’re a regular floor. Be kind to nurses, they will help you I promise.

 

 

 

 

What you need to know to apply for CRNA school

  1. You need to be an RN.
  2. Are you ready to be broke for at least 27 months? Yes, broke because unless you wanna pull all your hair out working full time, only a per diem job is realistic for a grueling program like the CRNA one. Well, I’ve only heard so don’t quote me on it.
  3. Did you take your CCRN? Everyone who applies for CRNA school are all ICU- experienced nurses. For at least 2 years. You can start the program when your two years is up, meaning you can apply ater the end of your first year in the ICU. Everyone from the ICU’s is CCRN certified. I know, it’s almost like whatever to them, because EVERYONE has it. I recommend Laura Gisparis’s question book and her videos as study materials! 100%.
  4. What kind of ICU experience you ask? I am biased and say CTICU. When I interviewed at Columbia I would say 80% of the people who interviewed had CTICU experience. Well, because we are creme of le crop.
  5. Do you have to take a test? Duh…. it’s grad school. Can’t get off the hook that easy. Most schools require the GRE or the MAT. I recommend the Magoosh GRE prep program! They give you a nice qbank and video explanations. As well as practice tests that are much harder than the actual exam. Magoosh verbal flashcards on your mobile devices are extremely useful for knowing the frequently used words. Especially while you’re on the train or on the go. I also took all of the practice tests on Kaplan and the 5lb book of practice problems (SO HARD FOR NO REASON). I got a 70% on verbal and 60% on math. There is also a writing section. Anything above a 50% on each subject is considered competitive. So anything above a score of 350.
  6. GPA of atleast 3.0 if your experience isn’t all that great.
  7. Certain pre-reqs that vary with each school.
  8. Recommendations- atleast 3. I got mine from my first nursing manager, hi Nicole! I love you!, our ICU medical director, and a charge nurse. Just make sure it’s someone who can vouch and say nice things about you and mean it! Not something generic that they write for everyone else…
  9. Essays – why you want to be a CRNA etc.
  10. Interview! Some schools require you to have extensive clinical knowledge and others just want to get to know you as a person.

 

I think that summarizes it enough.  If you have any questions please comment below! 🙂

hyper “k” or nah?

Hyperkalemia: tall, peaked T-waves on your heart monitor (EKG reading). Deadly. Arrythmias. cardiac arrest.

Hyperkalemia is the medical term that describes a potassium level in your blood that’s higher than normal. Potassium is a nutrient that is critical to the function of nerve and muscle cells, including those in your heart. Your blood potassium level is normally 3.6 to 5.2 millimoles per liter (mmol/L).

Right?  (Atleast that’s what the textbook says…or Laura Gisparis in her CCRN videos)

WRONG.

My patient was in normal sinus rhythm, no EKG issues. No PVCs (premature ventricular contractions, which usually means an electrolyte deficit), electrolytes on her blood gas was totally normal. But what I did notice is she did have a change in her mental status and complaining of nausea persistently throughout the morning unrelieved by the anti-emetics.

A casual ABG check reads : K 6.9, pt was basically obtunded, lethargic in her stupor, word- salading, and complaining of being extremely fatigued. Ding ding!

So, we treated it.

10u regular insulin 

1/2 amp of dextrose (to prevent hypoglycemia)

Insulin administered with glucose facilitates the uptake of glucose into the cell, which brings potassium with it

Calcium gluconate 

Furesomide (Lasix) – loop diuretic 

albuterol nebulizer

Medications such as calcium, insulin, glucose, and sodium bicarbonate are temporizing measures.

LVAD

Yesterday I had an LVAD patient… LVAD meaning a left ventricular assist device.

(http://www.medicinenet.com/left_ventricular_assist_device_lvad/article.htm)

The left ventricular assist device, or LVAD, is a mechanical pump that is implanted inside a person’s chest to help a weakened heart ventricle pump blood throughout the body.

Unlike a total artificial heart, the LVAD doesn’t replace the heart. It just helps it do its job. This can mean the difference between life and death for a person whose heart needs a rest after open-heart surgery, or for some patients waiting for a heart transplant (called “bridge to transplant”).

LVADs may also be used as destination therapy, which is an alternative to transplant. Destination therapy is used for long-term support in some terminally ill patients whose condition makes them ineligible for heart transplantation.

 

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Welcome to the ICU. This is not an atypical picture of what you can expect here. This patient is on multiple drips (intravenous infusions seen on the IV pumps behind this lovely machine) and having renal insufficiency. This device is called the CVVH or CVVHD machine meant to act as your kidneys and provide slow dialysis at the bedside for patients who are not hemodynamically ( meaning if their vital signs like blood pressure, heart rate, breathing etc) stable.

Treat the person, not the disease – c’est nursing

Living the good life and getting to meet interesting people everyday.

Our director had a 30 minute huddle with us the other morning reminding us not to forget about how to be nurses. You know, paying attention to the details and tailoring & individualizing each patient’s care plan.

As a nurse you meet all sorts of personalities from your coworkers to the patients you bond with for the next 12 hours, whether it works or not. I often tell my patients, (the A&Ox3 ones that I meet when they’re already OOBTC) that we are going to be best friends considering 12 hours is such a big chunk of time.

I realized I do get attached. I give my patient’s nicknames and talk to them like how I would speak to my child… In a cutsey you’ll be okay voice. And sometimes they don’t make it and you realize this is why you can’t get attached.
Like pop pop with the balloon pump. Le sigh.

Tumor Lysis Syndrome

My patient the other day was recently diagnosed with AML and ALL, woah haven’t even seen those terms since nursing school… in word documents trying to summarize the chapters we would be tested on. I remember our professor saying this was important because the nursing care for someone going through it was vital. I think the ke word is: nursing care. As nurses, we often forget that.

Here is what you need to know:

Leukemia may affect red blood cells, white blood cells, and platelets.

Normally, the bone marrow makes blood stem cells (immature cells) that become mature blood cells over time. A blood stem cell may become a myeloid stem cell or a lymphoid stem cell.

A myeloid stem cell becomes one of three types of mature blood cells:

  • Red blood cells that carry oxygen and other substances to all tissues of the body.
  • Platelets that form blood clots to stop bleeding.
  • Granulocytes (white blood cells) that fight infection and disease.

A lymphoid stem cell becomes a lymphoblast cell and then one of three types of lymphocytes (white blood cells):

  • B lymphocytes that make antibodies to help fight infection.
  • T lymphocytes that help B lymphocytes make the antibodies that help fight infection.
  • Natural killer cells that attack cancer cells and viruses.

Blood cell development; drawing shows the steps a blood stem cell goes through to become a red blood cell, platelet, or white blood cell. A myeloid stem cell becomes a red blood cell, a platelet, or a myeloblast, which then becomes a granulocyte (the types of granulocytes are eosinophils, basophils, and neutrophils). A lymphoid stem cell becomes a lymphoblast and then becomes a B-lymphocyte, T-lymphocyte, or natural killer cell.

Adult acute lymphoblastic leukemia (ALL) is a type of cancer in which the bone marrow makes too many lymphocytes (a type of white blood cell). This type of cancer usually gets worse quickly if it is not treated.

Renal System

– Kidneys can be damaged because:

1. Of the chemo’s direct effects during excretion

2. Accumulation of end products after cell lysis. (Remember, the chemo is killing cells

so lots of junk is going to be left over from that. Kidney has to get rid of it.)

– Cell lysis after chemo yields uric acid which can lead to renal damage

– Also, cell contents are released into the circulation once they die. This can result in

hyperkalemia, hyperphosphatemia, and hypocalcemia – Tumor Lysis Syndrome

– Monitor BUN, creatinine (serum & clearance), and electrolytes. IT’S ESSENTIAL.

– Prevention: hydration,dieresis, alkalinization of urine to prevent formation of uric acid

crystals, and allopurinol.

….

he was being treated for aspiration, cancer metastasis, tumor lysis syndrome and sepsis.

and all I could do as a nurse was perform the tasks that would save his life like titrate his pressor requirements, keep his lactate levels low (sign of anaerobic metabolism), give him abx. But as you see, these are all medical interventions. As a nurse, I prayed for him to get better and for his wife to understand his prognosis. Also, to make sure his course isn’t complicated by pneumonia or pressure ulcers. I also wanted his sedated body to remain clean… You know just like how he would want it to be if he was still talking. He was later transferred to the MICU. I hope he makes it for just a little longer.

New Year; Better Me

This is my generic 2016 growth post.

Career-wise: the countdown to CRNA school begins.I’ll link my video essays I sent to Columbia University. I continue to grow as a young ICU nurse. My coworkers and management have entrusted the role of being a preceptor to newcomers. As well, as covering charge nurse duties.

Family-wise: I think that my parents have finally tasted some freedom. They are enjoying their time in the Philippines. I am eternally grateful that they have reached that stage in their lives that they don’t have to worry about the kids anymore.

Significant other: n/a haha. I have trust in Him that everything will work out like it’s supposed to. That’s actually one of my goals, to find myself spiritually first.

Personally: For one, I finally learned how to swim. Told myself I would pick up a hobby and master it. And, this skill I have been procrastinating on since I was able to make my own money to pay for swim lessons.

This year, I have traveled more than I ever did before. Here they are, locally and internationally. 14 countries later, I love the idea of traveling more than ever. You understand so much about what you want from life. I learned that no matter where I am in life, I want to have the time to keep my desire of connecting and understanding people that are different from me. Because actually we are all quite similar. I guess, we all just want to be happy?

  1. Cancun, Mexico
  2. Washington DC, USA
  3. London, UK
  4. Paris, France
  5. Amsterdam, Netherlands
  6. Vienna, Austria
  7. Prague, Czech Republic
  8. Budapest, Hungary
  9. Montego Bay, Jamaica
  10. Montreal, Canada
  11. Poconos Mountains, Pennsylvania, USA
  12. Hong Kong, China
  13. Bangkok, Thailand ( then Chiang Mai, Phuket, and Phi phi)
  14. Singapore, Singapore
  15. Ubud Bali, Indonesia
  16. Madrid, Spain ( but the best city was Barcelona)

This year:

  • I hope to travel deeply in one place.
  • Be more connected with my inner self and Him
  • Pick up hobbies like pottery and dance
  • Start school and be good at what I do
  • Continue to be a good character to those around me (connect better with people not just social media but actually on a personal level)