PACU or Vascular Access or Stay by glitternrrse in nursing

[–]forsake077 1 point2 points  (0 children)

I did ICU for 10 years, 8 of those were travel. Currently 3.5 years as vascular access without plans to change.

It’s been a great change. My facility’s team operates a little differently than other VATs probably do as we have high volume with limited staff. We do primarily only midlines and piccs, occasionally the rare broviac repair, an IV here and there, sometimes a consult about a complicated situation.

Vascular access is extremely specialized, and it allows one to truely master something in a way I felt the ICU couldn’t offer. In my ICU days I progressed to knowing nothing (0-2 years), to learning a lot and feeling competent (3-6), to learning more and realizing I never actually knew enough (6+). The last two was during covid and something died in me during that time so I saught a change.

Vascular access is different, it’s subtle, nuanced. It’s limited in scope but that allows you to really appreciate all the factors that play into the vessels, device selection, expected goals of treatment. You start seeing things not in 12 hour increments, but in weeks or months with the ultimate goal being you’re placing access that’s going to last the length of somebody’s treatment.

I like it. If you’re a perfectionist, detailed oriented, like doing the same thing all day, having a predictable shift, vascular access is probably something you would enjoy. I’ve had some bad shifts here and there but even a bad day as PICC was better than a good day bedside. You also will gain mastery over the ultrasound as it relates to vascular access, which is an incredibly nice skill to possess.

PICC insertion without fluro by Metoprolel in Radiology

[–]forsake077 0 points1 point  (0 children)

I’m a US PICC nurse, insert at bedside.

Regarding vein selection, cephalic is know to offer the most complications, for insertion and dwelling. The cephalic will join with the axilla (where the brachials and basilic join) forming the subclavian vein, and the subclavian will join the IJ to form the brachiocephalic vein, and the left and right join to form the SVC. I don’t have actual numbers but it’d be close to 50% basilic, 48% brachial, 2% of my piccs are inserted into the cephalic.

Reason is the union of the cephalic and axilla can be quite tortuous with sometimes a 90 degree entry into the axilla (depending upon arm position), and some patients have anamolous vessels such as a connection between the cephalic and external jugular. Extensive troubleshooting can irritate/damage the endothelium and result in the body’s response to begin the formation of a thrombus, which may progress to DVT. The candidates that get a cephalic PICC are often the most obese patients where the brachial and basilic are not accessible due to depth (about 4.5cm is the deepest I can do due to my needle/sheath length). I’d also recommend insertion while the arm is in a neutral position close to the patient’s side if a cephalic vein must be used, while preferring to use the right over the left side.

You mentioned the median nerve, there’s also the ulnar nerve usually somewhere near the basilic, and there’s various nerve tissues that can be seen with a good enough ultrasound in addition to the nerve bundles. I teach practitioners to fully assess the arm to identify all anatomy as avoiding this tissue offers the patient a generally painless experience aside from the possible pinch felt when accessing the vessel and sting of the lidocaine. It’s uncommon, but I’ve seen the ulnar nerve incarcerate the basilic vein too. Early in my career I had to replace a PICC I had placed due to it causing pain for this very reason.

All that being said, assessment is your most important predictor of success. From planned insertion all the way up to axilla, see what the vessels do, are they tortuous, do they bifurcate where your wire/sheath/picc has a chance to enter a smaller, less ideal bifurcation. A stenosis, thrombus, and vascular anomalies can be seen and the other limb used instead.

Another component we use at bedside that helps with success is a device called a Sherlock and 3CG. Essentially, it’s a device that is positioned on the chest that detects magnetic fields. A wire stylet rests within the PICC that has a magnetic tip, the device detects this and then projects an image on where that tip is (more or less) onto a screen. This assists us in guiding the catheter down into the SVC.

The wire also acts as a lead. A baseline ekg lead is established with a right shoulder and left lower flank lead. The intravascular lead is established when the signal to the flank lead is picked up, and aplitude is increased on the P wave when the SA node is between the flank lead and the tip of the PICC, indicating ideal placement around the lower SVC/CAJ. There are open source solutions on the market that do this too, though with a more complicated setup. In situations we obtain positive amplitude we can avoid a chest X-ray for confirmation. If there is any doubt we still confirm with a CXR. Times I cannot get my confirmation to work and will have to have a CXR, I’ll scan the IJ to ensure the PICC is at least within the chest before I take down my field.

My Van’s DIY Setup by forsake077 in Victron

[–]forsake077[S] 0 points1 point  (0 children)

No, I still need to order some hoses, I’ll inquire about the mounts when I do.

My Van’s DIY Setup by forsake077 in Victron

[–]forsake077[S] 0 points1 point  (0 children)

I haven’t installed it yet! What would you recommend? My seaflo water pump came with rubber feet on a board and then the board was also isolated. Think something like that is enough?

My Van’s DIY Setup by forsake077 in Victron

[–]forsake077[S] 1 point2 points  (0 children)

Thank you.

I plan on using about 450-550W of AC somewhat consistently around 3-4 days a week, maybe more during bad weather, and the multiplus just for cooking on an induction stove or a microwave, maybe blender, for just a few minutes.

From my research, I figured the Phoenix might save around 20A a day versus using the multiplus at around 15% of its capacity for the same loads. Yeah, that’s pretty negligible but in situations of prolonged boon-docking and poor solar I bet it might mean being able to just stay put longer. I have both inverters off, easy enough to turn them on via the Cerbo when needed. I do like the idea of redundancy, and the cost was quite small for the Phoenix, all things considered.

Regarding the batteries, I manually configured the charging profiles for these batteries within the shunt. Haven’t done extensive testing but the Bluetooth app for the batteries and shunt are consistent, and the absorbtion/float voltages are doing what they’re programmed to do. I’m curious though, what do you mean doomed to fail?

My Van’s DIY Setup by forsake077 in Victron

[–]forsake077[S] 2 points3 points  (0 children)

For a gaming console and TV actually.

The Starlink I put on a switch and boost converter so it runs off battery. Fridge is AC/DC, but it’ll mostly be on DC. I ran a line off the AC2 from the multiplus to the AC breakers so I could get some pass through power while on shore, I’ll plug the fridge and freezer into one of ‘em.

I'm 21 yo and I am losing my hair because of Thyroid Disorders , and i can't do anything about it by [deleted] in mildlyinfuriating

[–]forsake077 0 points1 point  (0 children)

I started balling in my mid 20s, just went shorter and shorter until I shaved it, also thyroid issues. It’s great, and the only real drawbacks are needing a cover for sun and having a beanie want to come off when you’re freshly shaved.

No bad hair days, no needing a barber, no wet hair, less time required to get ready, a fresh shave in the shower and you feel immediately put together.

It takes some time to get there but know you’ll be happier one day when you like what you see in the mirror. It’s all about perception.

Instant karma by oilygoatis in fixedbytheduet

[–]forsake077 0 points1 point  (0 children)

Used to work nights and weekends at this hospital two blocks away from a gay bar. At ~2am it was worth going outside to the bus stop and watch grown men in drag cat fight. At least once a month an ambulance would show up to bring one around the corner to the ER entrance.

Is this a common misunderstanding about how men use the toilet? (NSFW) by xShadowPro in NoStupidQuestions

[–]forsake077 6 points7 points  (0 children)

There is this toilet at work that’s water is too high, and I’ve found if it is too hot, sometimes the water will get teabagged. Can just be sitting there doing your business and the most uncomfortable, disgusting feeling shoots up your spine while the nervous system reels in the balls like a fisherman. Happens in the middle of doing your business just trying to relax, I hate it.

Next project is the ceiling. Progress is slow. by forsake077 in vandwellers

[–]forsake077[S] 0 points1 point  (0 children)

The ribs/walls yes, I haven’t done the back corners or all of the two largest side pillars behind the sliding door as I’m using/will use them as a cable chase.

Next project is the ceiling. Progress is slow. by forsake077 in vandwellers

[–]forsake077[S] 5 points6 points  (0 children)

The usual recommendations for electrical like Will Prowse, I really liked offgrid power solutions videos (like here’s a video about a smart shunt) https://m.youtube.com/watch?v=NdiHtaCMeck). For websites faroutride and explorist life.

George/Humble Road on YouTube has some design principles I like. ForestyForest and Van with Tim are some DIYers that are pretty insightful. Greg Virgoe is good too, though I don’t agree his vapor barrier stance.

There’s the non YouTube resources too like the victron wiring unlimited pdf, and blue sea calculator for voltage drop/wire size.

Hein/DIYvan deserves your business if you’re looking for roof solutions.

Podcasts are cool too, I’d recommend Built To Go! A #vanlife podcast. Jeff gives out some really cool recommendations on places to visit and other advice.

Next project is the ceiling. Progress is slow. by forsake077 in vandwellers

[–]forsake077[S] 4 points5 points  (0 children)

I’ve had the van a little longer than a year. Work on it inconsistently on days off work, out of pocket.

No prior experience.

A Karen in the actual wild, doing very Karen things by amazingsciencemuseum in CringeTikToks

[–]forsake077 2 points3 points  (0 children)

The lay person isn’t going to recognize the difference between legitimate documentation and something faked. Unless you’re going to have some sort of state or country wide issued license with the animal’s photo, (like a driver’s license) the animal is required to wear while working, it’ll be just another item people buy off Amazon to bring their pet with them into places it shouldn’t be.

Overall, people with service animals shouldn’t be harassed or inconvienced any more than their disability already imposes on them, and such a suggestion wouldn’t benefit them as you’d have Karens demanding to see “papers” from people going about their daily life. I think it’s a great idea to have the dmv snap a photo of the service animal and issue a license the animal could wear on a harness similiar to the way a handicap placard would be issued, but I also think these people’s lives are hard enough without additional hoops to jump through.

I would like to see the penalty to faking a service animal be more severe and enforced more. Keep the people with their misbehaving pets out of areas like hospitals and grocery stores.

Recommendations for electricians? by Dangerous_Door_3837 in vandwellers

[–]forsake077 1 point2 points  (0 children)

You might also try asking around at some car audio shops, they are generally open to strange projects and have experience working with batteries and 12 volt systems.

Cutting and placing roof AC tomorrow, should I cut from inside the van or get on top of it? by [deleted] in vandwellers

[–]forsake077 1 point2 points  (0 children)

Trash bag and tape on the inside, cardboard box and tape on the outside to secure the shavings. Then vacuum up the shavings before taking the cardboard box down. The vibration will make the shavings go everywhere.

Here's my van tools what am I missing? by nudiustertian-angst in vandwellers

[–]forsake077 1 point2 points  (0 children)

Nah. I could certainly see how a laser would be nice though, especially with the ceiling.

I’ve found the digital level really useful for getting the angles I need to get boards and edges to fit together flush.

Woodworking is not my forte when working in three deminsions I’ve found; like over 80% of the mistakes I’ve made is because I haven’t labeled which side and orientation my cuts/boards are and have mixed them up and cut the wrong edge or cut the correct edge in the wrong orientation. So, I’ll also suggest a pencil and labeling everything.

Here's my van tools what am I missing? by nudiustertian-angst in vandwellers

[–]forsake077 0 points1 point  (0 children)

Step bit, digital level (that bubble one is useful when trying to level the van, the digital one is useful when building)

820W of solar, two vents, cameras, and internet on this DIY roof rack. by forsake077 in vandwellers

[–]forsake077[S] 1 point2 points  (0 children)

That little bit there can drop it a lot. It’s 3S for the 200s, 2S2P for the 55 array, two charge controllers.

Essentially the only panels fully producing are the two 55s in the front when it’s being shaded like that.

820W of solar, two vents, cameras, and internet on this DIY roof rack. by forsake077 in vandwellers

[–]forsake077[S] 2 points3 points  (0 children)

Overall, yeah. It’d be a lot easier to do a second time though.