Forbes Article

 This article in Forbes magazine is a must read.  Do it. Read it now-- and then come back to my blog. 


With the ever growing patient population as a result of ObamaCare the demand for competent health care providers will continue to increase.  My goal is not to begin the debate MD vs. NP or NP vs. PA-- no way-- not going there.  What I will say and I am only sharing my opinions is that there is a place for everyone in health care.  As the article points out, nurse practitioners, nurse anesthetists, nurse midwives, physician assistants, pharmacists and psychologists all have a place in medicine.

When it comes to incredibly complex medical issues I feel that an experienced physician is the most qualified person to provide medical care (of course there are exceptions, as with everything).  But, nurse practitioners provide competent and safe health care in a variety of settings: outpatient, inpatient, ICU, minute clinics, long-term care and the list goes on. 

The much larger issue that is a topic of heated debate is whether or not to allow nurse practitioners to practice independently.  This would mean that a nurse practitioner could open his/her own practice without the need of a collaborating physician.  Each state currently places their own laws and restrictions on who is allowed to practice medicine independently of a physician.  Some states already allow this independence.  Independent practice is the core issue.

The state of California is already working to pass legislation that will expand health care access not only to nurse practitioners but to physician assistants, optometrists and pharmacists.  

As a future nurse practitioner you might think that I would be a proponent of independent practice but I see both sides of the argument and am still on the fence.  As a new NP, I do not feel comfortable or confident opening a solo practice, seeing my own patients and essentially running a small business.  I don't want that kind of responsibility and stress.  Perhaps in the future, this would be an appealing option and something I would consider so yes, I am glad that the NP profession is making strides in this direction.  

Dr. Adalja is a proponent of independent practice:

"Expanded scopes of practice, in which a non-physician renders care independent of a physician, not only expand access to health care and have the potential to decrease the cost of healthcare, but also reflect a respect for the free market system."

What are your thoughts on the topic?  Is independent practice for NP's the way of the future?


(the photo above is of a favorite spot in Costa Rica.  It reminds me of warmer days- a great reminder in the middle of February)

Wernicke's Aphasia

My preceptor and I took a trip to the ED last week to examine and admit a patient to the Neuro ICU.  I love going to the ED because you never know exactly what you're going to get.  Plus, it's usually chaotic and incredibly busy.

The patient was in the hospital 3 weeks earlier for an ischemic stroke of her temporal lobe and had since been discharged home.  She was sitting at the table when her son noticed that she was having difficulty speaking correctly.  The CT scan of her brain showed a hemorrhage into her old infarct.  Her blood pressure was sky high when she presented to the ED. 

What I found most interesting about this patient when I assessed her was her receptive aphasia.  In my experience, expressive aphasia is what I have seen most often.  Patients have an inability to express oneself or a lack of verbal expression.  Instead, this patient was talking a mile a minute with full facial expression and verbal inflection.  She was laughing after her sentences and seemed to just be enjoying every minute of our conversation.  The only problem was that she wasn't making any sense.  You could understand the words she said but none of the words together made sense.  Our conversation went something like this:

Me:"Can you tell me your name?"
Patient: "Oh, famous tell candy young did soccer eating horses in."  She would go on and on like this.  She was smiling, laughing and appeared to be having fun.

I had only ever read about Wernicke's aphasia in a textbooks or heard about it in class. Seeing a patient present with this type of receptive aphasia is something I won't forget for a very long time.

"Patients who recover from Wernicke’s aphasia report that, while aphasic, they found the speech of others to be unintelligible. And, despite being cognizant of the fact that they were speaking, they could neither stop themselves nor understand their own words." -citation unknown. 

It isn't rocket science-- it's brain surgery

Clinical was interesting and challenging this week.  I really enjoyed it.  I was even able to take a trip to the operating room with my patient to observe her neurosurgery.  In an effort to maintain patient privacy, I'm leaving out all of the interesting details but here is the gist:

My patient came to the ED where they found an right cerebellar intraparencymal hemorrhage on her head CT.  When I assessed her at 0600, there was a change in her neuro exam.  She was more lethargic and unable to follow commands upon exam.  Mannitol IV was given and then she was taken for a follow up head CT.  The head CT showed worsening edema and obstructive hydrocephalus.  She was then planned for a R cerebellar craniectomy w/evacuation of her hemorrhage.  I asked if I could accompany her to the OR to observe the surgery and my preceptor made it happen.

Ok guys-- brain surgery is crazy. The patient was placed in the prone position (on her belly) and the neurosurgeon got to work.  He reviewed her two previous CT exams prior to starting the procedure.  After the skull was removed and the dura cut away, the cerebellum was easily visible.  It was huge and bulging.  He then opened a hole into cerebellum and then next thing I see is a huge gush of dark, dark red blood.  It was the hemorrhage- it was cool to see it just gush out of the cerebellum.  He cleaned it out nicely and by the end of the procedure, the cerebellum was normal in size.  Instead of replacing the skull, he placed a plate over the cerebellum to protect the brain and then closed her up.  She was taken back to the ICU.

I was thrilled to be able to observe the procedure and hope that when I go back to clinical next week that she will be back to baseline.  Neurosurgery is pretty cool, although I hope that I never have to be the one on the table getting my brain operated on. 

NP school: the interview

If you are thinking about a career as a nurse practitioner, you probably wonder if you'll be accepted after going through the process of applying. 

I thought I'd share a few inside tips about my own interview at Penn. 

I was admittedly nervous for the interview but felt confident about my interviewing capabilities.  I dressed for the occasion in a black skirt and light blue button down shirt.  It was the middle of the summer and I definitely worked up a sweat before I arrived.  I brought along a copy of my resume and essay, just in case.  

I sat down with the Associate Program Director for a one-on-one interview.  The interview lasted approximately 45 minutes and in my opinion, was incredibly thorough.  She started off asking general questions about my work experience and then followed up with scenario related questions.  You know-- the ones where you're asked to give an example of a time you showed leadership capabilities as a bedside nurse?  Or, tell me about a time that you advocated for your patient in a difficult situation?  Also, if I were to ask your co-workers and managers, what would they say about your strengths and your weaknesses?  Gotta love that question.

Then, we talked about the NP role in general and I used this opportunity to tell her why I wanted to become a nurse practitioner.  I also asked specific questions about the program at Penn.  Do not forget that even though you are the person being interviewed that this is also your chance to ask your own questions about the program.  It's important to know if a specific program is the right fit for you.  I wanted to know their board pass rate and which clinical settings/locations do they use, among a few others. 

I do remember the last question she asked which I was not expecting-- it went something like this:
"Do you read nursing or medical research?"  Me:  Oh, yes, definitely. It's important to stay updated on the latest practices because as you know, medicine changes so quickly.
"Ok- can you tell me about the research that you've read recently?" Oh, wow-- did she really just asked me that. (Think, think, think,- sweating again) Luckily, I did recently read a research article about robotic prostatecomy- don't ask me why- but it saved me, thank you, prostate.

 A few take home points from the NP interview:

1. Think through the scenario questions before the interview.  Be prepared to sell yourself.
2. Don't forget to 'interview the program' 
3. Understand the role of the NP and current legislative issues. 
3. Read up on some latest nursing/medical research.


So, there you have it- my interview experience.  I hope this helps you if you're thinking about applying or are preparing for an upcoming interview. 

Neuro ICU Clinical: a typical day

Hi there!  Wow-- it's been quite some time since my last post.  Well, that's because I've barely been able to keep up with all of the demands- school, work and clinical but I'm trying my best.

Here is a typical clinical day in the Neuro ICU:

0600-0730:  I arrive on the unit and am given 3 patient assignments.  I assess my patients, look up their recent labs, talk with the night nurse about any events and record the info on the ICU flowsheet that is then used for rounds that morning.
0800-0900:  Attend morning report.  Morning report consists of the trauma/surgical/neuro attendings, residents and students.  Each patient is discussed- the new patients in detail and a quick update is given about the existing patients.  I did present a new patient the other morning and it went well-- although you could hear the nervousness in my voice-- ugh!
0900-1230:  Morning rounds with the neuro attending, the NP, PA, bedside nurse and respiratory therapist.  Rounds are incredibly thorough and a complete neuro exam is performed on each patient.  We discuss each patient head to to toe, new orders are written and any issues are discussed.
1300-1400:  I usually follow up with my patients if there were new labs that were ordered, etc.
1400-1430:  Lunch
1430-1600:  I assess my patients again in preparation for sign-out.  My NP preceptor will usually select a topic that we discuss ie: ventriculostomies, head CT's, etc.  On several occasions I've gone to the ED with the NP or attending to assess a new stroke patient.
1630:  Sign out

I've enjoyed the Neuro ICU but over time I can see how difficult it would be to manage this patient population day in and day out.  I've only been there for a total of 8 days but almost that many patients have died or have become severely disabled as a result of their brain infarct/injury/hemorrhage.

Chest Tubes or Bacon?

The trauma surgeon was doing an excellent job lecturing to us about chest tube insertion but as soon as the pig rolled in-- all eyes were on the bacon.

He demonstrated to the class how to insert a chest tube and then we went to the lab and tried it ourselves.  Let's just say that inserting a chest tube is not as easy as it looks.  If I ever have to do this on a real human being-- help me.

Technology in medicine

Tomorrow is our panel presentation in 'Advanced Technology & Clinical Decisions in Acute Care.'  Why must the course names be so long, really?  Anyway, this presentation is kind of a big deal-- as in 40% of our grade.

The assignment is to select a controversial therapy that is currently offered to patients- select a pro side and a con side, find the latest research on the topic and creatively present on this topic for 30 minutes.  Our topic is standard radiation therapy vs. proton therapy in cancer patients.  I won't bore you with the details but instead, have posted this TED talk for your viewing pleasure.

Sometimes, we rely too heavily on technology to provide us with assessment information that we can obtain from a good old fashioned physical exam-- let's not forget that.