Clinical Pearls: How To Work Up Hypoxia Part 1
I was recently drafting some material for a client who I am tutoring regarding hypoxia. She is in a pulmonary rotation and this is a very common reason for consult. I think when you are providing a consult service (which can receive a high volume of patients) keeping things focused on your organ system, standardizing your approach, and developing automation’s are the key to efficiency. The cool thing is that when you systematically work through the causes of hypoxia you can simplify the process of coming to the most accurate diagnosis. Then you can offer the primary team a suggested plan of action and be the hero (or maybe just uphold your reputation as a trusted colleague 😉). This article is designed to help ease the process of working through the etiology and focuses heavily on pathophysiology. If you can appreciate the pathway of oxygen delivery from the atmosphere all the way through to delivery at the tissue level you can better understand the disease states and more easily come to a diagnosis (or three, as is our common reality).
Clinical Pearls: Shock
Diagnosing the type of shock your patient is exhibiting is clutch when it comes to appropriately treating. Yes, Levophed is our quarterback when it comes to pressor selection, for good reason. But you need to have a darn good understanding of what it can and cannot do, when it is not the ideal choice and when there are better or adjunctive measures that must be undertaken quickly to save your patient. It all starts with coming to an accurate diagnosis. Often in real world practice this is hard to do as multiple states can co-exist, iatrogenic factors obfuscate, and no one piece of data is the be all end all. As with most things in medicine, you have to piece together the data to form the picture. This article reviews the pathophysiology, shares a hemodynamic chart, and overviews how to differentiate shock states.
Clinical Pearls: Ventilator Modes 101
There are a number of reasons why ventilators are confusing, and I’ll break down how to simplify these factors in this blog post. But the big takeaway is this: just because a patient seems controlled well on the vent does not mean he is; do not leave the task of interpreting the vent and the patient’s response to the vent to others. It is incumbent on you to educate yourself about what the knobs, numbers, and waveforms mean in order to better treat your patient. Let’s talk vent basics and it starts with understanding the mode.
Clinical Pearls: Is It Time To Extubate, An Objective Approach
I spent a lot of years working at the bedside in the ICU. I can tell you one thing a nurse won’t tolerate and that’s an agitated and intubated patient. IYKYK. It’s scary, it’s physically taxing for you, and it’s not good for the patient. So naturally I would immediately call the provider with the “can we extubate” query when they woke up fighting. In my mind they were awake, right? Let’s liberate them from the ventilator!
This is only one scenario in which the clarity I gained in NP school blew my mind at how naive I was as a nurse. Maybe naive isn’t the right word, uninformed perhaps? IDK, I think my point is I didn’t realize there was a systematic approach to assessing extubation readiness. I didn’t properly think through all the reasons why a person would need a vent, nor appreciate all the ways in which a person can fail an extubation attempt. One key factor I learned is that objective medical analysis of the diagnosis and current exam is crucial in predicting risk and then weighing the risk/benefit ratio to determine what is safest for the patient. In this post I’ll walk you through the step by step process of performing this assessment to eliminate as much doubt as possible and set your patient up for success. Skip to the end for a bedside checklist.
Clinical Pearls:What’s up with the lactate?
In 2001 a research article was published expounding early goal directed therapy as a treatment strategy for sepsis. Key points in the article suggest that physical exam findings are subpar for directing resuscitation and that measures such as lactate, SCVO2, base deficit, and pH are more accurate measures of adequate treatment. There were certainly other factors, and the take home message was to find the source and start antibiotics early, but volume resuscitate until tissue hypoxia improves was the practical application of this research. As a result lactic acidosis has become a bad omen to be feared by all. Several guideline updates have since been published, the most recent in 2021 with weak evidence to suggest using lactate as an end-point measurement. Practically speaking though, the word is out that a high lactate = bad bad badness. I’m not saying it isn’t bad, but there are plenty of reasons why an elevated lactate alone is not the end of the world. In this post we’ll discuss causes for lactate elevation, what should be cause for alarm and what shouldn’t, and how to manage it.
Clinical Pearls: Weird COPD Labs
I recall sitting in my ninth grade biology class and feeling awed at how perfectly our bodies are designed. It is infinitely complex at baseline - just keeping the status quo. True magic happens when badness ensues and the body begins to change it’s patterns to compensate. Must. Keep. Things. Going. It’s amazing to me. That’s the moment I knew I would go into the healthcare field.
To this day I remind myself that just because modern medicine offers the capability to tweak things, sometimes the best thing we can do is just stay out of the way. First, do no harm. It’s tough though, because when things are hitting the fan, the instinct is to look at a set of patient problems and try to optimize them. If you fail to recognize when an abnormal finding is actual a new normal in a chronically abnormal person you may jump to fix things, unintentionally worsening things. That’s a heavy use of the noun things, but you get what I’m putting down right?
COPD is a perfect example of this phenomenon so in this post I will discuss the normally abnormal derangement’s that can occur in a patient with COPD. Why they occur, how to interpret them, when to intervene, and when to leave them alone.
Clinical Pearls: Is it DKA or HHS?
Should be pretty straight forward, but even amongst seasoned providers this can sometimes be debatable. Especially when you don’t have all the labs back. Often we are called to admit a patient for DKA because they do not seem appropriate for a routine floor or even step-down ICU admission. The Internal Medicine/Hospitalist team may not feel comfortable taking a patient but on your evaluation they do not seem to be on the severe end of the spectrum. You aren’t alone, my friend. Let’s talk about admitting a DKA vs HHS patient and how you make a diagnosis.
Clinical Pearls: DIC
One of the rare and weird things in medicine that combine a dramatic constellation of opposites. Caring for someone in the throes of badness from two dichotomous problems leaves one in a state of floundering. Do I treat the clotting or do I treat the bleeding? What will kill them first? It’s universally known that getting the diagnosis of disseminated intravascular coagulation is a dreaded event. DIC is a downstream complication that arises late in the game with several diagnoses that we see in the ICU, and unfortunately in our maternal population. Every time an OB calls our team to see or transfer a patient to ICU my shoulders instantly feel tense. Let’s talk about the pathophysiology behind this dreaded state and what our treatment options really are.
Clinical Pearls: Liver Failure
Oh the ways the liver can fail. As a new nurse practitioner this one was hard to get down. Cardiology is generally seen as the bee all end all when it comes to keeping our bodies running, but I’d like to talk about the under appreciated liver. Hepatology is fascinating because the normal function of the liver is supremely multi-faceted. Throw in a little pathology and any number of pathways can be deranged and within those any degree of severity can be seen. From acute to chronic to acute-on-chronic, severity can run the gamut. Decompensated cirrhosis is a common killer in most ICU’s. Given how poorly understood this disease state is, I’d like to talk about the complexity, progression, prognosis, and management of liver failure in the intensive care unit.
Mistakes To Avoid On Your Resume
I’ve seen a fair number of nurse practitioner resumes in my day. Seems like my large group is always cycling through new hires. In addition to that I look at all the resumes that come through for my consultation/interview prep business. It’s interesting to me the variety of what folks are doing across the nation. When I wrote my first NP resume I assumed we all heard the same HR lecture and wrote them the same. Most people have professional looking resumes but there are some industry specific issues that I find am repeatedly addressing with clients. In this post I’ll discuss the most common mistakes I see on the nurse practitioner resume.
Clinical Pearls: Evaluating For Intubation
When is it time to say it’s time? I think back on the really bad days of the pandemic when I walked from room to room asking myself this question repeatedly. Honestly, for intensive care unit level covid that’s what it felt like - a few random meds that typically didn’t help, supportive care, and careful vigilance for when it was time to go on the dreaded vent. Our patients feared it, our families feared it; it was the elephant in the room every time you walked in. Outside of covid pneumonia, there are a million reasons why a patient needs mechanical vent support and failing lungs are just one component. This is a very common question I get asked when I am training a nurse practitioner student Here’s how I approach evaluating a patient for intubation need.
Clinical Pearl: Status Asthmaticus
Not a common problem in most ICU’s, but you do get the occasional severe case of asthma. When you do, it can get a little hairy. Mostly because these are generally young people and there’s only so much you can do. Sort of like Covid when it gets bad, there’s not much to offer. You provide the medicine, the supportive devices and wait for their bodies to heal themselves. Same with asthma, you order the standard treatment and then pray it doesn’t get to a point where you have to intubate. In large part, our primary goal in ICU asthma is to not make them worse with counter-intuitive ventilator strategies. Let’s talk asthma.
Clinical Pearls: Pleural Effusions
Pleural effusions can be a big barrier to improving respiratory status in the ICU. Deciding how and when to treat them becomes easier once you break down how to diagnose and treat.
Clinical Pearls: How To Handle The Rapid Response Call
As a nurse practitioner I approach the rapid response call by quickly absorbing information to formulate a list of differentials and a plan of care starting with stabilization. The secret is threefold: experience, honoring the team approach, and offering redundancy.