CCC Class Wake Med - Day 1 Report

What a day!
Just finished day 1 of a 2 day CFRN/FP-C course here in Raleigh NC at Wake Med. This was a 2-day certification review course produced by Critical Care Concepts and Rick Patterson. I was assisting Rick in teaching for his company during this class.

Their conference facility was THE BOMB. Rick even compared it to some conference hall. He said "man this is like JEMS" the EMS today national conference. Wake Med (WM) has this AWESOME conference center across from the main hospital. It's got several multi-size rooms with sweet A/V setups in each. Nice central lobby, reception areas and a juice/soda/coffe bar (self serve)....it's freakin sweet! Just being in such a nice place, made us feel like some special guest speakers and such!

Class went pretty well on day 1. We ran long and didn't cover as much as we wanted. We hit most of the big topics, but probably ran a little long winded for most of the audience.

After course introductions and "settng the stage". We kicked it off with me doing the cardio lecture. This cardio lecture is always a tiring one. The one we do for Rick's classes is a bit longer (about 80-90 minutes) than the stand alone one I do for my "CEN-only" classes. I think it's a good starting point however, and it DOES lend itself to some minor alterations depending on class prior expeience and knowledge level. Today's version we cut a bit short due to time and we dropped off the 15 or so, ACLS review slides. Instead of slides we closed out the ACLS with a 20 minute "core" ACLS review and Rick went impromptu as he finished the cardiovascular by hitting on the main ACLS bullet points. And, as always, reminded the students that if they hadn't attended an ACLS provider class within the last 6-8 months, that it's probably a good idea to hit that before taking the cert exams (CEN, CFRN, FP-C).

Then we jumped over to the flight portion of the class. Rick jumped right in and ran through the flight principles and concepts (gas laws, stressors of flight etc)..and as always, while I was sitting back watching/listening - I once again was quite engaged when Rick "does his thing"! Shortly later, we went to aircrew safety, survival and regulation to complete most of the dedicated flight content. And once again, Rick gets right into his "zone" and runs through this, lecturing effectively while inserting his anecdotes and war-stories as appropriate. Pretty cool this time working through the survival/shelter part using the big graphics on the LARGE screen; cool to see the "big picture".

Due to time concerns we carried the neuro lecture on into and through lunch this time. I was giving this one and probably where we started to see the early signs of the diverse audience starting to loose their learning thread. You start to see it when we start talking about some more "general" neuro stuff like Multiple Sclerosis or Lyme disease -- the people there for flight certifications are probably starting to think like "why do I need to know this"... So it's always a challenge to try to deliver it and at least make some relevancy to the entire audience. Interesting, at the beginning of the neuro lecture we review the cranial nerves (Nursing 101 right?)....well when I threw up the "Old Olympus Towering Tops" slide, I got so many blank stares...? Kind of made me stop and think. However as this was not a "teaching class" but rather a "review class" - I just referenced it and pointed out that some people may want to spend some time reviewing this on their own before sitting for their exams. So I knocked out the neuro lecture and then we took a break for fresh air and a leg stretch.

We proceeded to head across the parking lot to the helipad. We all posed around the Wake Med hel0; a beautiful machine -- the EC 135 with their appealing crimson and white paint scheme. It really is an appealing piece of equipment - I hope the class photos came out okay!

Afterwards we headed back in for another lecture. This time it was back to Rick for his ABG lecture. Now since I've known Rick, and since the first time I've seen him do this lecture; I am continually amazed and blown away how he does this. The first 15 min or so arethe groundwork for the topic; looking at some basic ABG concepts, pulmonary function/gas laws etc. Once that's done, the "show" begins. Rick starts to run through these ABG "problems" on the board. He starts off like a kindergarten teacher, holding the student's hand through the first few examples, prompting them along the way. Then he backs off a bit and starts letting the class work through the problems more independently.

Towards the end, the students are engaged and interacting. There were a few people however that just "didn't get it" completly and a few who were aking the time honored "calculus question: but what will I do with this in the real world?"... We had to try to explain to them that it's not so much that you'll be doing calculations like this bedside or stretcher side, rather it was a learning curve to start to drive home the relationships between the components and the principles there which lent themselves to overally pt management.

There wasn't a person who told us they had looked at the whole ABG/respiratory function like we just did here - I'm sure there were SEVERAL seasoned people who left that room feeling like they actually LEARNED something!

That pretty much wound it up for the day, it was close to 5pm and people were tired.

We'll be back hitting it early Sunday morning...bright and early at 0800!
Gonna have to step it up and get in our "zone" to keep this puppy on track.

Full day tomorrow, topics include...
1)Airway/respiratory/vents
2)Toxicology
3)Burns
4)Thoracic/abdominal trauma
5)OB/Neonatal
6)Peds
7)General medical

Gonna sign off for now, it's late and I gotta review some notes!
http://www.bemetweb.com
"...KMG-365, Clear..."

Getting Blood Out of a "turnip"...

So... the coroner comes in with a body. Tells us he needs an order and a requisition for a carboxyhemoglobin level. Apparently there was concern on scene that this deceased had quite a few kerosene heaters running in the house and the concern is for carbon monoxide poisoning.

Well we wrote up the blood gas lab slip and gave it to him (the coroner) with the appropriate specimen labels. I was standing right there, with a little free time on my hands (imagine that- free time in an ER! yikes~!)...and I told my attending MD, "I'll go do it if you're busy" (cool!).

So I went with the coroner and set about to draw this "arterial" sample...!!!
Then I got to thinking....
1) Does it have to be arterial? Isn't the COhb level the same arterial vs. venous?
2) If it has to be arterial, how do you palpate the artery on a corpse?????
...hmmmm

Anyways, after consulting with the respiratory therapist on duty (who I trust) they explain that it really won't matter at all but to try for arterial if possible.

So I set about to do a radial artery stick. First I thought about doing Allen's Test (yeah right), then I proceeded to do it just by "feel" in the same place I've always done it into the radial artery.

Got a good flash in the ABG syringe, but it was a S-L-O-W draw. Usually I'm quite used to this brisk, bright red flow from the artery; you could definitely tell this was different. It took a few seconds, but we got it done and sent it off.

Something you don't get to do every day that's for sure!
http://www.bemetweb.com
"...KMG-365, Clear..."

ABG Basics

ABG's can be one of the more difficult concepts to grasp when reviewing Emergency Nursing or Critical Care. The whole ABG interpretation process has caused many people lost/sleepless nights trying to decipher and understand the concepts. I can relate. Every time I prep for a lecture that includes ABG's I have to review myself the night before. Over time I've come up with a couple of rules for working with ABG's:

1) Don't do "ranges" (IE: 7.34-7.45), use a mid-point cut off.
For EXAMPLE: I don't consider if my pH is "towards" the low end or "towards" the high end, rather I pick 7.40 as my cut point. If it's above 7.40 even just a 0.01 above, then it's alkalotic and vice versa. Do this for your PaCO2 and HCO3 also - use mid points.

2) I like to draw a 4x3 box and fill in the values starting with the ones I KNOW FOR SURE
For EXAMPLE: My prototype Resp. Alkalosis pt is that hyperventilating-anxiety-stricken-20-something-female that comes into triage. I can easily remember that she has "blown off too much CO2" thus her PaCO2 is LOW. I know it's a respiratory problem because she's hyperventilating. I know that CO2 is a weak ACID so if she's blown off too much of it her pH is HIGH - given that information I can fill in those boxes.

3) Now I look for OPPOSITES. If the above patient is Resp. Alkalosis, then by default, the Resp. Acidosis pt MUST have a LOW pH. Now the prototype pt I use for this is my CARDIAC ARREST pt. We know that they have STOPPED breathing, so too much CO2 is built up (it's a weak acid remember, so that pH MUST be down). So I can now fill in the boxes for that one.

4) Now I move to the Metabolic syndromes. The rules for acidosis and alkalosis pertaining to the pH being HIGH or LOW still hold true - so plug those in under pH.

5) Now look at the HCO3. I KNOW that HCO3 buffers CO2 so if CO2 is an acid, then HCO3 is a base. If my pt is in an acidotic state, then the HCO3 is NOT ENOUGH to compensate and therefore HCO3 is LOW, and thus vice versa. If my pt is alkalotic then the HCO3 is TOO HIGH.

So basically it's a process of elimination and fill in the blanks. When you're done your little table should look a little something like this....

Good Luck!
-KMG-365, Clear...