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)

Updates: good and bad

So, 2016 has been a rough year filled with loss, death, illness with the random pinches of happy times and celebrations.

2016, I have learned of almost ten deaths. All from different causes. Car, cancer, cardiac – what my ex-surgeon dad says describing the top three causes of death in the US. And, it is very true. All of those people died from one of those causes.

You’d think that knowing this information one would be more careful. You know, look both sides before you cross the street, never drive intoxicated, don’t smoke or drink or live near a power plant (all carcinogenic), and the biggest ones eat healthier and move more. My dad recently got hospitalized for chest pains. To his luck, the weekend after Thanksgiving. The notorious weekend where everyone gets sick somehow. My brother’s gf PGY3 in medical school described her family medicine weekend rotation as an group of people admitted for all of these rashes, colds, all from thanksgiving day and on. So, there we were in the ED, describing the weekend statistic perfectly. They did an EKG, did a CXR, drew cardiac enzymes, and we sat there for 14 hours, waiting for a room on the floor. His EKG showed some ST elevations bit T wave inversions. Thankfully, it was unchanged from his prior EKG and all cardiac enzyme labs resulted normally. Finally, Sunday comes and nothing happens. Nothing ever happens on a Sunday unless you’re dying. Then Monday, he got a stress echo done. The results would indicate if one vessel was occluded they would need to send him to the cath lab to have a stent placed. If more, then a CABG. Open heart surgery. They also sent him to get a chest xray with conrast to rule out a PE.

Finally, today he got discharged. Good, because he is traveling with my mom in two days to the Philippines for the next two months. They totally need the break.

So, you’re probably wondering what the good news is. Well, two weeks ago Columbia University accepted me to their CRNA program. My dream school. I was sad that I decided to forgo my California apps, but honestly, I can’t imagine myself besides NYC. Here’s to a great 2017 and 6 more months of freedom! I can’t believe how quickly time flies.

work perks

You know what makes my day?

A simple phone call or interaction with patients or the family…

Today, a husband called me wary about his wife (my patient) when hanging up the phone pauses and says “you are taking care of a very special lady right there, take very good care of her.” Just like that, I assume the responsibility of being their gatekeeper.

When I was helping her recline her chair, in hopes of preventing post operative atelectasis and muscle atrophy, she whispers be careful honey, you should wear a back brace for all that you have been doing for me.

Then, later I keep checking in on her to see how she was doing and she says “I am okay, I know I am in good hands”

These are the moments I live for. Forget the surgery – the mitral valve repair, her pressor requirements which we had a hard time weaning – hypokinetic biventricular function needed epinephrine and norepinephrine which help your heart’s contractility, the complications, I am in this because nursing is what makes me human. I did not start off loving nursing, I grow to love it more and more each day.

What do you understand the role of CRNA to be and how prepared are you to pursue this role?

As a Certified Registered Nurse anesthetist we perform a dual responsibility to our patients and their families. A nurse and an advanced practitioner. 

Our patients are at a vulnerable state where they are undergoing a tough time. In an instance of a pediatric patient, the CRNA has the opportunity to meet families before their children goes to sleep with general anesthesia. Often times patients are kept NPO and the time of the procedure gets pushed back to compensate for the teeming amount of patients in our hospitals. As the CRNA we are not only performing anesthesia we are both the nurse and the anesthetist. It is our duty to alleviate anxiety physically and emotionally.
We have the nursing touch of comforting patients through a tough time in their lives, for this one procedure or two. It is our duty as a CRNA to educate patients on how they will feel and to hold their hand and provide them the voice of comfort and smiling face ensuring that they have made it through this.

It is our duty to assess and find out their history. What pain regimen or sedation have worked in the past to provide optimal comfort. It is important that we as the CRNA are the listeners and often learn from our patients and family as they do in fact know themselves the best.

In the field we are our patients advocates and always keep patient safety as our top priority. As a CRNA we do not forget nursing basics, we build up on them. We are CRNAs also promote lifelong learning and enforce evidence based practice in our routines.

In addition, CRNAs give back to the community and provide our services to third world and disaster relief areas.

Describe your critical care nursing experience and career goals

My brother drops me off at the Fifth avenue entrance of the Mount Sinai Hospital, conveniently located on the border of Spanish Harlem and the Upper East Side. I hear a good morning from the security guard and I make sure to look up from my coffee cup to greet him back. After all, who knows if I’ll see him again. Pray some duas, (prayer in Arabic) and exhale on completion as I approach my unit. I started in the Cardiothoracic ICU a year ago. Prior to that, I was a med surg nurse with six ambulatory patients but now as I enter the automatic doors I am greeted with one and sometimes two bed bound patients, often attached to the trumpet of the ventilator and din of the cardiac monitors. As their ICU nurse I begin to make their problems my own.

When 7am hits, bedside handoff is given, I check my drips, ventilator and my patients intact sacrum, get an initial ABG, and make my voice heard during AM rounds. I am amazed at that the next time I look at the clock that often three hours have passed. The pace is very fast, clinical judgment and critical thinking are at its peak. I am in my element. The constant monitoring of the patient’s physiological changes, hemodynamic status,  titrating vasoactive drips, and preventing barotrauma from high ventilator settings keep me driven to stay ahead of the patient. To envision the worst possible scenario and being able to tackle it long before it surfaces. Working in the CTICU i have developed meticulous attention to detail and being able to keep my composure through tough times, whether it be an open chest or dealing with a family of a patient with a total artificial heart who is now deciding to withdraw care.

The ICU has prepared me to look much further than hemodynamics and to understand patient suffering internally understanding their histories, lab values, CVP, PAP, and putting it all together. Similarly, externally we look at their psychosocial status, did anyone come to visit? How can I effectively teach the families to care for their loved one LVAD when they get home?

After shadowing a CRNA, I knew that this is where my worlds would converge. Not only would I keep my nursing skills but I would be able to do much more. Being able to be an advanced practitioner to under my patient’s physiological status to adequately help alleviate suffering internally and also being able to explain it to their families thereafter externally that their family did well and was up and talking again. Furthermore, after CRNA school, I hope to take my degree further than the walls of American institutions. I hope to  take my skills as an anesthetist to aid in relief efforts around the world. To educate others on proper techniques of anesthesia and nursing practice so they can be empowered to do it on their own.

As the day ends, I say goodnight to the security guard and run past the revolving doors accepting that the day does not end there.  I get to into the subway and sit there and — people watch, often seeing my patients faces on them. These people can all be my patients one day. I wish i can tell them to stop smoking or eating that bag of chips. I don’t want you to have a heart attack dear, I think in my head. 

oxygenation and seizures

OK I promise to write here more often… I meant to start this blog as a way to keep myself sharp and continuously learning. Also, for those who are looking to get into the ICU or in the the health field. I will write random things I learn everyday. Enjoy!

 

is a face mask the same thing as an aerosol mask?

Is a venturi mask a face mask?

What about a non rebreather?

 

Remember all those days in nursing school learning all about the different ways to properly oxygenate someone. Rolling out of bed to make it to lab? My teachers were all intensive care nurses … I should have probably paid attention.

 

So a nonrebreather mask, is 100% oxygen.

A venturi mask is partial nonrebreather mask, the patient gets what percentage of oxygen you give them

An aerosol mask is indeed a face mask. You connect it to a nebulizer set up for humidification.

Oh, and a seizure?

There are absent seizures… where the patient dazes off and becomes unresponsive.

“An absence seizure is the term given to a type of seizure involving staring spells. This type of seizure is a brief (usually less than 15 seconds) disturbance of brain function due to abnormal electrical activity in the brain.”

(https://www.nlm.nih.gov/medlineplus/ency/article/000696.htm)

Tonic- clonic seizures is what you imagine a seizure to look like. An older term for it is “grand mal”

Here the whole brain is affected from the beginning. In (a) there is a cry and loss of consciousness, arms flex up then extend in (b) and remain rigid (the tonic phase) for a few seconds. A series of jerking movements take place (the clonic phase) as muscles contract and relax together. In (c) the jerking is slowing down and will eventually stop.