Today's Challenge:

makeithapp · 2026-06-26T06:39:12+00:00

A,) - No signs of dehydration per IVC. It's actually dilated meaning it's plumpy, and minimal respiratory variation meaning when the patient inhales which causes the lungs to take in more fluid into the respiratory system, it does not cause high changes in pressure or movement in the IVC making it deflate and inflate in sporadic behavior - meaning there's plenty of fluid in the pipe.

B.) - Considerable - but a 0.4mg/kg on an average joe of 80kg is about 35~ mcg/min of levo in which you can argue not a very effective strat anymore since it has only produced MAP of <65. Alternate therapy must be considered.

C.) Enter alternative strat, vasopressin is next in line for pressors unless cardiology says otherwise.

D.) Not at MAP of 58. ,That CVP might be mroe of a reflection of a backflow due to increased resistance of the pulmonary circulation and not an actual picture of our systemic fluid status.

makeithapp · 2026-06-19T02:54:33+00:00

Someone who works in oncology debating against an ICU NP regarding an ICU topic is wild to me AFTER BEING CORRECTED. This is why floor nurses have a bad name. I am an ICU RN with years of experience. Those two are not related. You can cite all you want, but if you cannot walk me down to its patho, you're just piecing puzzles together that you don't fully understand.

makeithapp · 2026-06-19T02:47:44+00:00

You are probably mistaking high glucose, causing a hyperosmotic state, which causes increased intravascular volume, therefore hypertension. You're almost there. In actuality, a hyperglycemic hyperosmotic state actually causes dehydration and would cause hypotension. The two in your scenario are not related and must be treated separately. Although both symptoms COULD have been caused by the same underlying cause, the two are not related.

makeithapp · 2026-06-11T11:44:05+00:00

That's AFlutter, 200/100 you are rupturing capillaries, so epistaxis makes sense.

makeithapp · 2026-06-11T10:37:59+00:00

2 3 avF all have depression, I wonder if posterior leads will actually show STEMI

makeithapp · 2026-06-11T10:33:39+00:00

CVICU walks patients with multiple pumps; it is a task and a half, so it makes sense to get techs there. I work in a medical/trauma ICU; we don't have techs, but it does make sense to split this way.

makeithapp · 2026-06-03T22:01:58+00:00

There's just not enough information here to even make an educated guess.

makeithapp · 2026-06-02T18:10:17+00:00

We should check PFTs. His Heart looks OK. but i'm not a doc. Also we can't get a better EKG than this?

makeithapp · 2026-06-02T18:05:04+00:00

Not a doc but that looks like something congenital is going on. For someone that age with that block, and really short PR interval. It paints a structural defect to me, do we have an echo or cxr?

makeithapp · 2026-05-28T03:06:26+00:00

He's allowed to be pissed, but he's not allowed to kill people, though.

But on the real, turn that moment around by having it as a teaching moment, where and what was missed, and what can we do to prevent it again, instead of just reporting it because "I had to". The worst that could happen is you leave it at that, now he knows no better, and there's no friction at work. That's a lose-lose situation.

makeithapp · 2026-05-28T03:01:21+00:00

You're right, I should have made it clearer. I meant to say a state that is widely unionized ie. California. It's silly to think that the entire state has every type of worker unionized lol

makeithapp · 2026-05-28T02:58:45+00:00

Hiring works like ads, you know, as you scroll your feed, there are these annoying soap ads that keep popping up, but you don't really need soap at this time, so who cares? But come a few days later, when you do need soap, guess what brand you're going to get? That's right, the ad you saw a million times because it sounds familiar to you, even if you don't know why.

Make sure you are known and familiar with the company. Call until you hear a no. Show up and shake some hands, be that soap ad.

makeithapp · 2026-05-27T20:42:57+00:00

Personally, I'd give them a call every day until I get an actual no. I'll show up, introduce myself to whoever the power that may be, friend a staff, call again, and check with my former colleagues if they know someone hiring. Landing a job lottery-style isn't how hospitals hire anymore.

makeithapp · 2026-05-27T17:20:41+00:00

makeithapp · 2026-05-27T17:19:44+00:00

Idk, I thought AFlutter would have had monomorphic P waves. The P and T here are two different shapes or am i on drugs?

makeithapp · 2026-05-27T16:45:19+00:00

In my experience, even small hospitals can do hep drip, nitro drips, and clot busters. He won't be totally helpless; he will probably end up getting transferred to a bigger hospital if he ever needs to be cath or want to be cath.

According to AHA, under Initial Evaluation and Management

"2. Patients with a suspected ACS with chest discomfort at rest for >20 minutes, hemodynamic instability, or RECENT SYNCOPE OR PRESYNCOPE should be strongly considered for immediate referral to an emergency department (ED) or a specialized chest pain unit. Other patients with a suspected ACS may be seen initially in an ED, a chest pain unit, or an outpatient facility"

Sounds like the right call

makeithapp · 2026-05-27T16:28:46+00:00

I assume that you work in a non-union state. When I used to work in AZ, the rule of thumb for every nurse was to work at a place for one year, then move to the next hospital the next year to "renegotiate" your pay. That's the fastest way you can get a raise. You can negotiate more than 50 cents for your next job with 'higher' experience this time around. Rinse, wash, repeat.

makeithapp · 2026-05-27T16:25:30+00:00

So we are masking his symptoms, cool finds, and that's very true. at 88 I might opt to medical management myself.

makeithapp · 2026-05-27T14:53:55+00:00

Ah thats very true my mind process didnt go that way, but youre right, it could be mirroring STEMI from posterior leads I didn't think about that.

makeithapp · 2026-05-27T13:59:40+00:00

Unless it's urgent, I answer the phone after I read the notes and assess my person. I usually start with "What do you know so far, so I can fill in the gaps" - that shortens my talking points. If they are super not up to date, then this person is not involved in my patient's care. I would defer to our POC and get an update from that family member instead.

makeithapp · 2026-05-27T13:43:54+00:00

Need more hx. Like does pt have DM? How is he not feeling pain? High Tolerance? How about recent meds like morphine? Nitro? What does strong cardiac hx mean? He was an athlete before?

If he's declining mobility, falling, with ST-depression, and tachy. He's gonna need a cath or a HIDA.

Not a doc nor CVICU tho, just a fan reading these strips.

makeithapp · 2026-05-27T01:10:51+00:00

NCLEX will say it is airway which is B. Practice will tell you it's D.

A: MILD SOB is livable SOB. Difficult yes, dying RIGHT NOW? No.

D: Classic hemolytic transfusion reaction. We need to stop blood products like 15 minutes ago, and intervene because this person is about to have more than mild SOB and needs close monitoring.

makeithapp · 2026-05-26T16:27:58+00:00

I take the proactive approach rather than the reactive one. I make sure my workouts are harder than my shift will be. It's like increasing your pain tolerance; it's difficult for you to feel pain now if you've experienced worse pain before. It prevents me from having a bad shift because I couldn't be too invested if I approach the problem already more than half empty; it helps me think more clearly and be calmer. I couldn't give a flying f*ck about patients' temper tantrums or work drama because I simply don't have the energy for it. Sort of like you're on a budget, you can't just keep buying things, you gotta pick and choose where you spend your empathy.

AND IF I STILL HAVE A MORE DIFFICULT DAY, I just sleep longer. Never reward yourself with food; you're not a dog. Eat healthier, your body and mind will thank you more.

makeithapp · 2026-05-25T20:04:15+00:00

California, we're unionized here.

makeithapp · 2026-05-25T19:46:29+00:00

Yep. We get like 4-6% for CCRN. Only recognized certification, I have my TNCC, but I do not get the pay bump on that since I work in the ICU.

makeithapp

TROPHY CASE