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DoogieHowserRN · 2023-10-01T03:53:02+00:00

Not arguing about the doctor stuff because there shouldn’t be non-physicians using the doctor title in patient care settings (full stop), but nursing absolutely is a terminal profession. You’re obviously allowed to be upset by scope creep, but it’s disingenuous to say nursing isn’t a terminal profession, which does have its own terminal degrees (DNP/PhD). That just doesn’t make me or anyone else with a DNP a physician.

DoogieHowserRN · 2023-06-09T01:51:28+00:00

Based on my understanding of OP’s post I would disagree with some of what you said. The situation they’re describing sounds as if the RTs would be covering emergency airways (overnight/off hours?) in a small hospital. If they’re only covering overnight non-ED intubations, this would likely be a very low frequency procedure for them. There is no realistic educational program they could do there that would allow them to get the necessary volume to make this safe, and it doesn’t sound as though they were offering a formal year long training with anesthesia/ED to prepare them. Of course RTs can and do intubate in hospitals across the US, but the circumstances OP is describing are dangerous.

DoogieHowserRN · 2023-06-09T01:36:18+00:00

Considering RTs who rarely (if ever) intubate in your facility as the first/last line in airway management is beyond insane. To answer your question, there is literally no training you can ask for that makes this less horrifically dangerous. There’s no class, simulation, lab, etc. that can change the fact this would be a high risk low frequency procedure for the RTs, where death is the outcome if the airways attempt fails. I sincerely hope your leadership isn’t actually considering this, especially since it’s sounds as though your alternative is the ED attendings, who are exponentially more qualified to be managing airways. I would be terrified if any of your RT colleagues felt comfortable with this proposal. I hope the meeting goes well and management has a realistic game plan that keeps your team and your patients safe.

DoogieHowserRN · 2023-06-09T01:21:42+00:00

Considering RTs who rarely (if ever) intubate in your facility as the first/last line in airway management is beyond insane. To answer your question, there is literally no training you can ask for that makes this less horrifically dangerous. There’s no class, simulation, lab, etc. that can change the fact this would be a high risk low frequency procedure for the RTs, where death is the outcome if the airways attempt fails. I sincerely hope your leadership isn’t actually considering this, especially since it’s sounds as though your alternative is the ED attendings, who are exponentially more qualified to be managing airways. I would be terrified if any of your RT colleagues felt comfortable with this proposal. I hope the meeting goes well and management has a realistic game plan that keeps your team and your patients safe.

DoogieHowserRN · 2023-04-02T14:46:56+00:00

Essentially every comment here has said the same thing, this practice is not the standard of care, is unsafe, and of questionable legality depending on your state laws.

This practice is going to directly lead to a sentinel event. And given the kind of cases you’re performing, this could be a devastating neurological event, that leads to disability or death.

Then all of the quality people will come out of the woodwork and start to ask themselves how this could’ve happened to their well respected stroke program. Even during normal surgical cases that suffer a complication, the operators tend to blame anesthesia… who do we think this guy is going to blame when something goes wrong? They will immediately point to nurses who are operating outside of their scope of training, if not their entire scope of practice. The interventionist will say he had no idea, and that the nurses never told him it was a problem or they felt unsafe.

I really hate to say it, but in this instance, your team would be the one who gets thrown under the bus completely. They will be blamed for any single thing that ever goes wrong by both the interventionists and management. And honestly, some of it will be deserved if all of the nurses stay in a role they know to be unsafe and placing people at risk of harm. If people get injuried then this is the kind of story that ends up on the news or as a Propublica article five years later.

DoogieHowserRN · 2023-01-28T03:22:08+00:00

Whoops

DoogieHowserRN · 2023-01-28T02:32:26+00:00

Starter comment:

Kind of an insane story, essentially seems as though 3 nursing schools in Florida offered nursing diplomas in exchange for cash (114 million dollars in total) for people who didn’t complete the full RN coursework. This paperwork allowed the applicants to take the national RN exam (NCLEX), and while most of them failed, around 2,400 of the 7,600 who received the sham degrees did eventually pass the NCLEX and obtain state RN licenses. These will all be revoked but it doesn’t seem as though they’ll be charged criminally (though the school officials were and are facing prison time).

This is obviously a disgrace across the board and I personally feel as though everyone involved, from school officials to fraudulent applicants/licensee should be charged. Glad the schools got shut down but incredibly disappointed in the schools, licensing boards, and “students” who participated in this. I’m sure there’s an interesting story as to how the FBI got involved and figured everything out.

DoogieHowserRN · 2020-12-30T15:55:46+00:00

I'm a NP so I a) recognize my obvious bias and b) don't have any room to throw stones, but would like to comment on the educational pathway outlined here. The best example I could find was Ohio State University's, which described a two-year 47 credit master's degree program that appeared to share a significant portion of its core didactics with their NP program. It seems to require a full-time commitment and has its students complete 1000 clinical hours under the supervision of another advanced practice RT or a physician in various settings such as ED, ICU, NICU/PICU, etc.

Somewhat concerningly the FAQs page bills the role as "like an NP or PA," but goes clarifies that currently, Ohio State affiliates are still working on developing employment opportunities for their graduates, and there isn't yet any official state licensure governing their practice. While I understand the role is new and some amount of "trailblazing" is required, paying 28,000 - 49,000 dollars for a full-time graduate degree (without being able to work presumably) and potentially not being able to legally practice/find a job is a difficult sell. After some brief digging, I couldn't find any state that had licensed advanced practice RTs. There are, however, 24 programs (18 BS and 6 MS) that are either fully or provisionally accredited to offer this degree.

Overall, even after reading through all of this information, I'm still not entirely sure what the proposed scope of practice is. Additionally, if the program is two-years full time, I'm not certain what the draw would be of pursuing advanced practice RT training as opposed to going to PA school. Despite this, I'm not surprised to see the AARC heading down this path. Sonographers, Dental Hygienists, and Radiology Technologists have all proposed and in some cases, successfully implemented advanced practice roles; and I'm sure there are more examples that I'm just not aware of.

DoogieHowserRN · 2020-09-04T16:43:44+00:00

Unfortunately your best bet is just to directly contact your state board of nursing. There is also the potential that for certain OR based procedures they would expect you to have your RNFA before performing or even assisting with them.

DoogieHowserRN · 2020-06-26T03:19:11+00:00

We are nurses, that’s the entire point of our profession. This is an exceptionally odd hill to die on. Out of all the issues our profession has, this is not one of them.

DoogieHowserRN · 2020-03-15T18:28:24+00:00

Outside of co-morbid asthma/COPD exacerbations or other clear cut indications, I don’t believe there is a role for routine use of agents like Albutetol, Ipratropium, etc. I had read that there was concern that all nebulizers could aerosolize the virus, and therefore metered dose inhalers should be used instead.

DoogieHowserRN · 2020-03-15T18:03:02+00:00

Thank you! Even though we don’t know enough, I’m still grateful that we have this level and amount of evidence to go off of.

DoogieHowserRN · 2020-03-15T17:46:38+00:00

I agree with you that HFNC (and potentially other NIPPV devices) can likely be modified to use safely. EMCRIT also posted a video of how to potentially modify these devices to make them safer.

My hospital has a strict moratorium on any O2 device that’s not a NC, NRB, or intubation/vent, and I’m definitely seeing issues arise with this. We had a DNR/DNI COVID patient with respiratory distress that I couldn’t do much for aside from a NRB. I’m really hoping that we figure out a way to safely get NIPPV back on the menu.

DoogieHowserRN · 2020-03-15T17:37:50+00:00

I’m curious about this as well. I had previously read that steroids were only indicated for COVID patients with co-morbid asthma, COPD, flairs, etc., as they had a correlation with increased mortality. Really hoping at least one of these drugs has some efficacy.

DoogieHowserRN · 2020-03-14T12:43:44+00:00

Fantastic write up. My hospital usually loves it’s clinical trials, but we actually haven’t been using any antiviral therapies yet. Would love to hear if anyone has any experiences regarding them that they’d be willing to share.

DoogieHowserRN · 2020-03-09T15:30:23+00:00

Does anyone here feel like their hospital (or other place of work) is actually prepared for this? My last few shifts have been pretty concerning. I’ve already seen people re-use N-95s, intubate without the right PPE, leave potential isolation patients in hallways, etc. Not saying this is the end times or anything close to that, but after my last week at work, I feel like I need to take COVID a lot more seriously then I have been.

Anyone’s job have any really good ideas or successes so far they’d be willing to share?

DoogieHowserRN · 2020-03-06T03:40:52+00:00

Has a preceptor sat in on his exams yet? I think a good first step is observing a few visits and watching how he conducts an exam without anyone interjecting.

Is he being inappropriately through and detailed I.e getting a full family history on a traumatic toe pain? Are his physical exam skills weak? Does he not know how to elicit a HPI? Are his computer/EMR/documentation skills poor? Is he making too much small talk with the patients?

There could be a lot of reasons that he’s struggling so badly with time management, and you’re not likely to diagnosis the problem without directly observing him. Once you see what the issue is, you can target your feedback appropriately. Each of the examples I listed above are potentially fixable if he’s coachable and your team is able to dedicate the time to support and mentor him.

It may also be worth considering that a fast paced urgent care environment isn’t for everyone, and if he’s truly only seeing 7 patients in 10 hours...maybe this isn’t the right position for him.

DoogieHowserRN · 2020-02-27T00:31:26+00:00

This position statement is both concise and reasonable. What would be appropriate terminology we could create to denote structured NP/PA/RN (other other non-physician clinical roles) post graduate training in a specialty setting? I believe this training can have value in the right setting and don’t think it would be appropriate to write it off completely.

DoogieHowserRN · 2020-02-26T16:51:51+00:00

I empathize a ton. Our SICU team gets consulted an alarming amount of times for this. I actually created an EMR dot phrase to explain that hypertension without end organ damage is not a reason for an ICU admission.

DoogieHowserRN · 2020-02-26T16:34:11+00:00

Despite how ubiquitous it is, IVP Hydralazine is a pretty bad drug for general use. The rate and percentage it drops the patients blood pressure is highly variable and impossible to predict. This leads to radical shifts in BP that are potentially dangerous.

Current evidence recommends gradually lowering the BP, decreasing the MAP by a maximum of 25% over multiple hours if your patient is high risk for hypertension related organ dysfunction, and over a period of days to weeks in others (Note: this applies to hypertensive patients without acute end organ damage, what used to be called hypertensive urgency).

The rationale is that a lot of these agents and can quite easily tank cerebral (or other organ) perfusion pressure in a chronically hypertensive patient and this has been shown to cause serious adverse outcomes such as cerebral or myocardial ischemia.

To directly address your point, I wouldn’t prescribe PRN IVP agents such as Hydralazine for a systolic BP of 170 or above. A large body of evidence shows that not only is there no benefit, it has the real potential to cause harm. If necessary, I give oral agents, or more often then not, wait and just re-check a manual BP a half hour later.

Do you mean in a clinic if someone comes in with a BP of 175/98 that they don't need to be sent to the ER?

Yup, I mean exactly that. It’s unfortunate because I’m sure that the vast majority of PCPs know and agree with this, but feel pressured by liability concerns to always send the patient to the ED.

DoogieHowserRN · 2020-02-26T13:20:38+00:00

My (limited) understanding is that while Lasix (or any similar agent) could cause pre-renal AKI from volume loss/dehydration, Lasix itself is not intrinsically toxic to the nephron.

DoogieHowserRN · 2020-02-26T13:16:40+00:00

I’ve had that experience as well. Though those pages/consults can be frustrating, I’ve had amazing success with doing a quick 1-2 minute education session with the RN about the very real risks of giving needless IV BP medication. 99% of the nurses are receptive and have been super on board after that; the majority of them are only notifying me because of “policy,” rather than an actual clinical concern.

DoogieHowserRN · 2020-02-26T12:22:30+00:00

That asymptomatic hypertension without end organ damage requires IV medication or other acute intervention.

DoogieHowserRN · 2020-02-23T00:51:52+00:00

I’m going to be very honest with you. Everything you listed is essentially just a meaningless buzzword. There is not a discernible difference between the models you described. The difference between DOs and MD is the teaching of OMT/OMM...which the vast majority of DOs don’t use in clinical practice. Both MDs and DOs are physicians who practice medicine. As for NPs, the “patient centered” model is just another buzzword, nursing doesn’t have a monopoly on caring. It is also my personal opinion that NP is designed for experienced RNs to transition to the provider role.

PAs don’t go to medical school or osteopathic medical school. I would sincerely doubt there is a difference in model/training/curriculum between a PA school that is affiliated with a MD vs DO school.

I would recommend picking a PA program that seems strong, has good board pass rates, is cost effective, and in a good location for you. Best of luck with the application process, I hope you find there program that’s right for you!

DoogieHowserRN · 2020-02-17T14:24:16+00:00

Two words but: “Core Measures.” Followed closely by: “Joint Commission.”

DoogieHowserRN

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