It's 6:30 am. I'm sitting next to a patient who is having trouble breathing. She's on oxygen, 7 CRIs (two of which are pressors), and her surgical site is coming apart.
The criticalist walks over and quietly assesses the situation:
Criticalist: "So...how's it going?"
Alacrity: "Ha! So, so badly!"
Showing posts with label ECC. Show all posts
Showing posts with label ECC. Show all posts
on securing a temporary tracheostomy tube:
Criticalist: "You're gonna want to wrap it like this and then reinforce the vetwrap with a piece of tape. Be sure you make an anti-buddy-fucker tab on the end of the tape."
so, reading the treatment sheet is good:
(Technician pokes her head into rounds)
Technician: "Hey Alacrity, can I have the fentanyl and lidocaine so I can start setting up your patient's CRIs while you finish rounds?"
Alacrity: "Oh thank you! That would be awesome. I would like the CRIs diluted in saline please, but I wrote recipes on the treatment sheet. If it's confusing, just leave it for me and I'll set them up in a few minutes."
Tech: "Okay, will do."
A few minutes later, in ICU:
Tech: "Why are you giving this dog so much fentanyl?"
Alacrity: "I'm not-wait, is that straight fentanyl in the syringe?"
Tech: "Yes, that's how we do fentanyl CRIs."
Alacrity: "It's supposed to be diluted in saline! Did you read the recipe that I told you about on the treatment sheet?"
Tech: "No."
Alacrity:
Technician: "Hey Alacrity, can I have the fentanyl and lidocaine so I can start setting up your patient's CRIs while you finish rounds?"
Alacrity: "Oh thank you! That would be awesome. I would like the CRIs diluted in saline please, but I wrote recipes on the treatment sheet. If it's confusing, just leave it for me and I'll set them up in a few minutes."
Tech: "Okay, will do."
A few minutes later, in ICU:
Tech: "Why are you giving this dog so much fentanyl?"
Alacrity: "I'm not-wait, is that straight fentanyl in the syringe?"
Tech: "Yes, that's how we do fentanyl CRIs."
Alacrity: "It's supposed to be diluted in saline! Did you read the recipe that I told you about on the treatment sheet?"
Tech: "No."
Alacrity:
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| thanks memegenerator.net |
in the ICU:
Alacrity, to criticalist: "Okay, so what are your feelings about-"
Criticalist: "I'm a man. I don't have feelings."
Alacrity: "-so, what are your man-feelings about giving contrast if the patient is azotemic?"
Criticalist: "I'm a man. I don't have feelings."
Alacrity: "-so, what are your man-feelings about giving contrast if the patient is azotemic?"
this does not bode well:
Dr. Raeqe (criticalist): "I really hate the summer. There's far too much crying. The clients are crying because their pets are sick. We're crying because there's never enough doctors and we're all here until midnight. It's just bad."
weird emergency room skills:
1. Guessing weight.
Hey, that big dog is having a seizure! No time to get it on the scale. Instead, you guess, as in:
That looks like a 45 kilogram dog = 4.5 ml Valium (0.5 mg/kg, 5 mg/ml).
Also useful when you're tapping the sweet Golden's pericardial effusion and she goes into vtach:
That looks like a 30 kilogram Golden = 3 ml lidocaine slowly until she converts (2 mg/kg, 20 mg/ml).
You can also guess weight in multiples of cats. A medium-sized cat is 5 kilograms (12 pounds), so you go:
That dog looks like about the size of 7 cats = 35 kilograms.
2. The ghettecho.
Let's say it's the middle of the night, you have a patient with shitty cardiac output, and an ultrasound. With a little bit of knowledge, you can get yourself a lot of information:
- First, make sure your patient can breathe! Oxygen and sedation are your buddies.
- Once you've sort of stabilized and administered oxygen, Lasix, torb, or other drugs as needed, do a physical. Think about mucous membrane color, lung sounds (are there crackles? wheezes? are they...suspiciously dull or absent?), heart sounds (murmur? arrhythmia? can't hear the heart?), pulse quality (weak? thready? waterhammer? pulsus paradox?), etc.
- Chest x-rays would be pretty great, but your patient might not be stable enough for those yet. You can usually ghettecho while your patient sits or stands in a comfortable position, and you can totally do it through the oxygen cage porthole if needed.
- If your ultrasound has a cardiac preset or probe, use that.
- Figure out how to adjust your depth and gain settings.
- Find the heart with the ultrasound. Sometimes (especially if your patient is hypovolemic) this is harder than you think.
- Is the heart surrounded by a bag of fluid? Heeeey, pericardial effusion! Tap that! (caveat - sometimes you can be faked out by pleural effusion, which looks more like it has sharp corners on flash).
- Okay, next check out left atrial size. You don't need to actually measure it, but is it way bigger than the aorta? Lasix!
- Finally, find the short axis view, and look at ventricular function. The big muscular one is the left ventricle - does it look like it's adequately contracting to move the fluid inside it? If it looks like the walls move towards the center just a little bit, your patient's fractional shortening may be sub-optimal. If the right ventricle (the smaller, curved-around-the-big-muscular-ventricle one) looks really full, think about right heart failure.
- While you're there (if the patient is stable enough), check out the pleural space and the abdomen for free fluid.
The ghettecho is not as useful as a legitimate cardiologist or radiologist echo in any sense of the word, but it does have its place as a middle-of-the-night rough gander at heart function.
3. Euthanizing a wide variety of wildlife.
Ever done an intracardiac stick on a severely injured baby bunny or a tiny bird with a broken leg? It'll make you feel like a terrible person.
4. Standing high jump.
If your patient is larger than a medium-sized cat (see above) or if you are shorter than ~5'10'', you're gonna need to get on the table to do good chest compressions during CPR.
The fastest/least awkward way to do this (the CPR stool is never actually with the crash cart) is to put your hands on the table (while someone else is doing the compressions), vault onto the table in one jump, land (gently) on your knees, and take over.
5. Hitting a moving, challenging target.
You know what's fun? Intubating a healthy dog in sternal recumbency who has just gently drifted to sleep after receiving modest amounts of pre-meds and propofol.
You know what's less fun? Intubating a dog who has arrested in lateral recumbency while wedged between the crash cart and the technician placing the catheter whose head is moving because of the chest compressions while hemorrhagic fluid pours out of his mouth.
Hey, that big dog is having a seizure! No time to get it on the scale. Instead, you guess, as in:
That looks like a 45 kilogram dog = 4.5 ml Valium (0.5 mg/kg, 5 mg/ml).
Also useful when you're tapping the sweet Golden's pericardial effusion and she goes into vtach:
That looks like a 30 kilogram Golden = 3 ml lidocaine slowly until she converts (2 mg/kg, 20 mg/ml).
You can also guess weight in multiples of cats. A medium-sized cat is 5 kilograms (12 pounds), so you go:
That dog looks like about the size of 7 cats = 35 kilograms.
2. The ghettecho.
Let's say it's the middle of the night, you have a patient with shitty cardiac output, and an ultrasound. With a little bit of knowledge, you can get yourself a lot of information:
- First, make sure your patient can breathe! Oxygen and sedation are your buddies.
- Once you've sort of stabilized and administered oxygen, Lasix, torb, or other drugs as needed, do a physical. Think about mucous membrane color, lung sounds (are there crackles? wheezes? are they...suspiciously dull or absent?), heart sounds (murmur? arrhythmia? can't hear the heart?), pulse quality (weak? thready? waterhammer? pulsus paradox?), etc.
- Chest x-rays would be pretty great, but your patient might not be stable enough for those yet. You can usually ghettecho while your patient sits or stands in a comfortable position, and you can totally do it through the oxygen cage porthole if needed.
- If your ultrasound has a cardiac preset or probe, use that.
- Figure out how to adjust your depth and gain settings.
- Find the heart with the ultrasound. Sometimes (especially if your patient is hypovolemic) this is harder than you think.
- Is the heart surrounded by a bag of fluid? Heeeey, pericardial effusion! Tap that! (caveat - sometimes you can be faked out by pleural effusion, which looks more like it has sharp corners on flash).
- Okay, next check out left atrial size. You don't need to actually measure it, but is it way bigger than the aorta? Lasix!
- Finally, find the short axis view, and look at ventricular function. The big muscular one is the left ventricle - does it look like it's adequately contracting to move the fluid inside it? If it looks like the walls move towards the center just a little bit, your patient's fractional shortening may be sub-optimal. If the right ventricle (the smaller, curved-around-the-big-muscular-ventricle one) looks really full, think about right heart failure.
- While you're there (if the patient is stable enough), check out the pleural space and the abdomen for free fluid.
The ghettecho is not as useful as a legitimate cardiologist or radiologist echo in any sense of the word, but it does have its place as a middle-of-the-night rough gander at heart function.
3. Euthanizing a wide variety of wildlife.
Ever done an intracardiac stick on a severely injured baby bunny or a tiny bird with a broken leg? It'll make you feel like a terrible person.
4. Standing high jump.
If your patient is larger than a medium-sized cat (see above) or if you are shorter than ~5'10'', you're gonna need to get on the table to do good chest compressions during CPR.
The fastest/least awkward way to do this (the CPR stool is never actually with the crash cart) is to put your hands on the table (while someone else is doing the compressions), vault onto the table in one jump, land (gently) on your knees, and take over.
5. Hitting a moving, challenging target.
You know what's fun? Intubating a healthy dog in sternal recumbency who has just gently drifted to sleep after receiving modest amounts of pre-meds and propofol.
You know what's less fun? Intubating a dog who has arrested in lateral recumbency while wedged between the crash cart and the technician placing the catheter whose head is moving because of the chest compressions while hemorrhagic fluid pours out of his mouth.
mental blocks:
Okay, so you know how there are some things that you should be able to remember, but for whatever reason you always forget/are bad at them? Yup, you know. Here are (some of) mine:
1) Neurolocalization/most of neurology, actually.
Sometimes I try to chalk this up to never having a neuro rotation in vet school, but that's not it. I mean, I can generally sort out "brain problem" from "neck dog" from "back dog" from "lower lumbar dog", but most of the time the rounds-pimping by the neurologist goes like this:
Neurologist: "Okay, so what else could cause [these signs]?"
(silence)
(neurologist kicks me under the table)
Alacrity: "Neoplasia."
Neurologist: "Yes. What else?"
(silence)
Alacrity: "Inflammatory disease."
Neurologist: "EEEHHHH wrong. What else?"
Haaaa fun times! Also, if we're in vestibular-land, I have a bugger of a time sorting out central vestibular (unless the dog has other central signs) from peripheral vestibular (unless the dog has gross ears) +/- paradoxical vestibular (what even is this really).
2) Acid/base.
THIS SUCKS. You know, I've read my vet school acid-base notes an embarrassingly large number of times (and worked through this handy acid/base practice simulator developed by the University of Awesome's engineer-turned-criticalist) and I still internally panic every time I go to read a blood gas.
3) Reading thoracic x-rays.
I'm starting to get better at this one. Dr. Nell (radiologist) has taught the intern herd some quick tricks to help get through the overnights, and I'm hopeful that (with practice and epic mistakes along the way) I'm improving.
I secretly want to be better at this, not only because it's an important workplace skill but also because queers are supposed to be good pattern-recognizers. Think about it! If your dating life depends on good pattern-recognition skills (read: gaydar), you'll get good at it. And radiology is exactly that.
1) Neurolocalization/most of neurology, actually.
Sometimes I try to chalk this up to never having a neuro rotation in vet school, but that's not it. I mean, I can generally sort out "brain problem" from "neck dog" from "back dog" from "lower lumbar dog", but most of the time the rounds-pimping by the neurologist goes like this:
Neurologist: "Okay, so what else could cause [these signs]?"
(silence)
(neurologist kicks me under the table)
Alacrity: "Neoplasia."
Neurologist: "Yes. What else?"
(silence)
Alacrity: "Inflammatory disease."
Neurologist: "EEEHHHH wrong. What else?"
Haaaa fun times! Also, if we're in vestibular-land, I have a bugger of a time sorting out central vestibular (unless the dog has other central signs) from peripheral vestibular (unless the dog has gross ears) +/- paradoxical vestibular (what even is this really).
2) Acid/base.
THIS SUCKS. You know, I've read my vet school acid-base notes an embarrassingly large number of times (and worked through this handy acid/base practice simulator developed by the University of Awesome's engineer-turned-criticalist) and I still internally panic every time I go to read a blood gas.
3) Reading thoracic x-rays.
I'm starting to get better at this one. Dr. Nell (radiologist) has taught the intern herd some quick tricks to help get through the overnights, and I'm hopeful that (with practice and epic mistakes along the way) I'm improving.
I secretly want to be better at this, not only because it's an important workplace skill but also because queers are supposed to be good pattern-recognizers. Think about it! If your dating life depends on good pattern-recognition skills (read: gaydar), you'll get good at it. And radiology is exactly that.
that's a fantastic image:
ECC resident: "So [this cat] projectile vomited overnight."
Day ER doctor: "Okay."
ECC resident: "This was not a normal projectile vomit. It was a non-stop horrendous torrent of foul, brown liquid that gushed forth from the cat's mouth like a fire hose."
Day ER doctor: "Huh."
ECC resident: "I kept expecting it to stop, but it just continued. It shot right through the front of the cage. I was amazed at how much liquid came out of that cat."
Day ER doctor: "Okay."
ECC resident: "This was not a normal projectile vomit. It was a non-stop horrendous torrent of foul, brown liquid that gushed forth from the cat's mouth like a fire hose."
Day ER doctor: "Huh."
ECC resident: "I kept expecting it to stop, but it just continued. It shot right through the front of the cage. I was amazed at how much liquid came out of that cat."
pericardial tap instructions:
Alacrity: "Hey, [ECC resident], would you be able to help me tap this dog's pericardial fluid please? I've never done it before."
ECC resident: "Sure. Do you know where you're going to stick your needle?"
Alacrity: "Nope."
ECC resident: "Take the elbow. Bend it. There."
ECC resident: "Sure. Do you know where you're going to stick your needle?"
Alacrity: "Nope."
ECC resident: "Take the elbow. Bend it. There."
learning!
1st year ECC resident (frantic): "Is Dr. Raeqe placing the chest tubes in that cat? Is she doing it now?"
3rd year ECC resident (glances over): "It would appear that she is."
1st year ECC resident: "Augghh! I told her to page me when she was starting! I will fight for this education!"
3rd year ECC resident (calmly): "You will fail."
3rd year ECC resident (glances over): "It would appear that she is."
1st year ECC resident: "Augghh! I told her to page me when she was starting! I will fight for this education!"
3rd year ECC resident (calmly): "You will fail."
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