VFlutter
Flight Nurse
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I think i will eventually do CRNA but i kinda thought about getting my ACNP in the mean time since the programs are fairly flexible and mostly online.
the 100% directionless thread
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I think i will eventually do CRNA but i kinda thought about getting my ACNP in the mean time since the programs are fairly flexible and mostly online.
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If you really want to do anesthesia, go for it. I like what I do and I'm glad I did it. But honestly, if I had it to do over again, I would probably keep flying for a handful more years while doing a combined FNP/ACNP program mostly online.
There are so many awesome opportunities for NP's, and it's only getting better. And the initial investment of both time and money is much smaller than becoming a CRNA.
EpiEMS
Forum Deputy Chief
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It's pretty interesting that they do mostly online programs. Do they have you doing clinical time as an NP student? They must, right?
Also...graduate school applications are *the worst thing ever*.
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RocketMedic
Californian, Lost in Texas
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I know what you mean. I met an AAF bomber pilot a while back who looked like he was 70, drove a Cobra Mustang and rocked what I thought was his dad's bomber jacket. Turned out it was his, earned the hard way.
He got a kick out of my 22.
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Minimum of 500 hours for a FNP program to be accredited, but the mean for FNP students is close to 700. A combined (FNP/ACNP, or FNP/PCP) program would require many more hours.
Chris07
Competent in Incompetence
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Just as an aside, how deep into the sciences do NP programs go. It seems to me it less science and more taking what you already know and applying it to clinical practice and management of patients. Is it really more of a quick and dirty “here’s what you need to know to function “ type thing or do they take full blown pathophys and biochem? Or is there no real science type classes?
VFlutter
Flight Nurse
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Most FNP programs do not require Biochem prior. CRNA and ACNP usually require Graduate Physics and Biochem prior to enrolling. All the MSN programs should include graduate level pharm, patho, etc.
https://www.barnesjewishcollege.edu...titioner-Concentration/Sample-Course-Sequence
He sounds like an awesome guy as well. Living the good life haha.
@Remi and @E tank. This is right up y'alls alley. Had a case of presumed hereditary angioedema today. Significant swelling to the neck and tounge, couldn't breathe well, drooling, and the works. Everything went as good as can hope during the ride, but do y'all have any little pearls of experience to share for patients like this?
Position of comfort and coaching worked for the ride, but she got a cric in the ED after declining suddenly. What y'all thresholds of passive vs aggressive managment and any little things y'all find helpful in these cases? I know where my plans and acceptable limits were and felt comfortable with them, but I want to hear y'all's thoughts pertaining to prehospital since the last time I saw something like this was literally my first ride along about 3 years ago.
Position of comfort and coaching worked for the ride, but she got a cric in the ED after declining suddenly. What y'all thresholds of passive vs aggressive managment and any little things y'all find helpful in these cases? I know where my plans and acceptable limits were and felt comfortable with them, but I want to hear y'all's thoughts pertaining to prehospital since the last time I saw something like this was literally my first ride along about 3 years ago.
EpiEMS
Forum Deputy Chief
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@Chase, you know, I always found it interesting that they split up the acute care tracks for NPs by age but have both FNP and pediatric specialties...never really make sense to me why they didn't have an acute care generalist of some kind, like a "hospitalist NP" or something.
E tank
Caution: Paralyzing Agent
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Just reading the post makes my palms sweat a little...I doubt I have anything for you that you don't already know. The back of an ambulance is a rotten place to intubate someone let alone do a surgical airway. All I would say is that you should have the most competent pair of assistant hands present in the back with you for transport. That is often an overlooked critical element in these situations. And my threshold for doing anything to the airway would be eyes rolling to the back of the head followed by unresponsiveness. Anything short that, definitely let it ride. The enemy of good is better. In that event, quick look DL, straight to surgical airway if no joy there. You might could save some time with a well lubed, smaller ETT as an NPA advanced to just above the supra glottis. Blind nasal intubation could be a possibility as well. Either way you cut it, it would be a very bloody airway when all was said and done.
I don't know what you have available to you, but as long as I was doing a cricothyrotomy, I'd try a retrograde wire. I've done it once without success, but in a crisis like that, I'd try it. If it were a nice long, skinny neck, you're golden. A fat bull neck and you may as well get the tape measure.
Sorry, Bro. Not a lot, but it's all I have...
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Jim37F
Forum Deputy Chief
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My sister took her cat to the emergency vet last night....apparently they said he had fluid in his pleural space....fortunately a new med and a night of observation he's back to his normal self
VFlutter
Flight Nurse
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Just filled out my benefits for next year. I need to go on disability then fake my own death and move to the Bahamas.
CodeBru1984
EMT
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Just got cleared to sit for the civil service exam that I applied for, which happens to be in exactly one month.
Here’s to cramming!
Here’s to cramming!
CALEMT
The Other Guy/ Paramaybe?
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@E tank, honestly intubation wasn't even an option for me personally. I don't think I have the experience to tackle that kind airway with DL even if th cords weren't swollen like they were. It was going to be 0 or 60.
They actually used one of their scopes through a nare and afterwards the doc told me even he wouldn't have been able to fit a tube through the cords due to the swelling and that she needed 1. Trach 2. Cric. Nasal wouldn't have been an option, but I wasn't aware at the time.
As far as what is available, standard DL equipment and then a scalpel, bougie, and an ET tube. I've read about retrograde intubation, but I don't have anything specific to do that. Otherwise it is just me to manage the airway. I didn't bring fire and my partner today is still relatively new, so there would be little to nothing to fall back on. It wasn't a hard neck to landmark though, swelling aside.
Sounds like the cut off you set is the same as mine. I didn't think anything in the box (racemic epi, IM epi, Benadryl, or Dex) would been helpful and from what I've read that was the case and I didn't know enough about the physiology to be sure. I think it's just such a rare thing that I am trying to brush up on the finer points of these airways, it's been a minute since I have came across this. The other problem is one I've mentioned in the past and not having a great sedatives, which is why I am trying to get a better gauge on how quickly these will progress and my limits on just how far I can stretch it. Otherwise it's go a bit rogue with a quick hit of fentanyl/versed and say sorry, not sorry after it's all said and done.
They actually used one of their scopes through a nare and afterwards the doc told me even he wouldn't have been able to fit a tube through the cords due to the swelling and that she needed 1. Trach 2. Cric. Nasal wouldn't have been an option, but I wasn't aware at the time.
As far as what is available, standard DL equipment and then a scalpel, bougie, and an ET tube. I've read about retrograde intubation, but I don't have anything specific to do that. Otherwise it is just me to manage the airway. I didn't bring fire and my partner today is still relatively new, so there would be little to nothing to fall back on. It wasn't a hard neck to landmark though, swelling aside.
Sounds like the cut off you set is the same as mine. I didn't think anything in the box (racemic epi, IM epi, Benadryl, or Dex) would been helpful and from what I've read that was the case and I didn't know enough about the physiology to be sure. I think it's just such a rare thing that I am trying to brush up on the finer points of these airways, it's been a minute since I have came across this. The other problem is one I've mentioned in the past and not having a great sedatives, which is why I am trying to get a better gauge on how quickly these will progress and my limits on just how far I can stretch it. Otherwise it's go a bit rogue with a quick hit of fentanyl/versed and say sorry, not sorry after it's all said and done.
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The way I see it, you only have two options in angioedema: You can intubate early before swelling becomes severe, or you can (possibly have to) cut the neck later. Intubating early is not necessarily ideal because from what I understand, even though the mild cases are anxiety-inducing, few cases of angioedema progress to extremis. OTOH, waiting has obvious disadvantages - if they do start to progress quickly you can be caught with your pants down. I think all things considered, keeping in mind how rare these cases are and how bad they can become, intubating early is probably the best approach, in general. Not necessarily in the field, but maybe.
Either way, once they are swollen to the point that they can't swallow their own oral secretions - or worse yet, have progressed to complete obstruction - they will almost certainly require a surgical airway. This is because at that point visualizing the glottis will be extremely difficult if not impossible, and since they'll have little physiologic reserve, you don't have time to spend trying things that are unlikely to work.
Because of that, I would probably not attempt to intubate this patient in the field under any circumstances. I would have done exactly what you did: oxygen, reassurance, as-rapid-as-is-safely-possible transport to an ED and give them as much heads up as possible so they can get all hands on deck. Have your airway stuff out and be mentally prepared to cric if things go downhill.
In the hospital, my approach would really depend on how well they were maintaining and how much / what kind of help I had. Once they start to crash, I would go straight to a surgical airway, just like I would in the ambulance. If I felt I had a little bit of time, a sitting, awake fiberoptic intubation may be an option, though I am not personally experienced with that. Maybe an awake attempt with the glide scope, but that seems like a long shot, especially if they can't lay back at all. A retrograde might be worth considering but I'd be concerned with causing coughing and gagging, which may worsen the picture.
All in all, it sounds like you did a good job. I probably wouldn't have done any different.