wathe
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Posts posted by wathe
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"DNR" can mean different things. One must specify some details.
My hospital had a lovely tool that divided resusc decisions into 4 broad categories:
- Full resus. Do everything.
- Limited resus. NO CPR, but would accept bipap, pressors, cardioversion, ICU level care. (Do everything except CPR)
- DNR supportive. No CPR, no pressers, no ICU. But yes to antbiotics, IV fluids, and other non-ICU interventions to reverse reversible causes and extend life
- DNR comfort care. End of life care. No CPR. Comfort measures/symptom management only. No antiobiotics, blood work, IV's, or other interventions meant to reverse reversable causes or extend life.
It was very helpful for walking SDU's through goals of care.
(These categories are not fixed in stone; interventions would be tailored to the unique circumstances of each pt, but medical interventions tend to be a package deal and SDU's sometimes want to choose a la carte in ways that do not make medical sense - having broad categories helps guide decisions.)
We got rid of it because it was not supported by the almighty new EMR. What we have now is much worse. I am mad about it.
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10 minutes ago, Pawz4me said:
Having BTDT as a decision maker I feel like the word "extremely" is woefully inadequate. You want someone who can make very, very difficult decisions if the need arises. You also want someone whose mental health can withstand the consequences of having to make those decisions. It's a lot to ask of someone.
Agreed. Traumatic, futile CPR and the emotional tension between HCW and unprepared SDU's is a significant contributor to HCW burnout and PTSD.
ETA: of course it's terrible for families too. For HCW, it happens over and over and over and over --- cumulative trauma.
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8 minutes ago, cjzimmer1 said:
As a family we decided that being suffocated was not what she had in mind when she asked for no medical interventions and overrode that and had her placed on oxygen.
This is very common. SDU's override AD's, so long as it is clear that they are making decisions based on what they feel the pt would have wanted in the specific circumstances that actually happen.
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11 minutes ago, WildflowerMom said:
How can I figure out the most likely scenarios and “what ifs”? I need to do some googling. Sorry for so many questions. Just a little overwhelmed thinking of all of it.
Go through the workbook from the page I linked in a previous post.
I will argue that it's more important to document your over-arching goals of care. Once that's known, you SDU and care team can tailor care depending on specific, unique circumstances. It is , thought, important specifically document interventions that will never be acceptable to you under any circumstances (ie blood products for JW's).
Advanced directives that are too specific often don't actually make medical sense.
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Also, it's important to make sure that your substitute decision makers know what your goals of care are. In a crisis situation where resuscitation is imminent, there isn't time to fetch documents from the lawyer or safety deposit box etc or review documents. Please make sure that your SDM is empowered to make immediate emergency decisions that are consistent with your wishes.
We do a lot of CPR that we really shouldn't because SDM wasn't prepared to make resusc decisions. It's extremely traumatic for everyone: patient, SDM, family, and care team.
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Advance Care Planning Canada website has tons of into and tools. The workbook is very good. It's Canadian (obvi), but the principles will be the same.
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FYI,
My Father's Dragon is public domain
Also, there is a free audio version on librivox read by a child, which is really very good.
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On 1/24/2023 at 12:23 PM, TCB said:
I am so frustrated and angry at our complete lack of ability, as a community/society, to realize, that in order to get out of this intact with good health, we must do everything we can to improve ventilation and air quality in our public areas!
There is so much information available now, about the possible medium term, and long term affects of Covid. If we think longer term, even if some of these things turn out not to be correct, we can only improve our health anyway, by improving shared air.
My frustration is increased right now because my dd is working in a preschool as part of her SLP grad course, and she tells me that almost all the kids there are sick. The students can’t wear masks because of the therapy they have to do with the kids.
I should put a JAWM on this post because I am really not in the mood to hear a bunch of minimizing crap. How we can think that it is ok for small children to be virtually continuously sick I don’t know.100%
Here's my prediction: Clean indoor air will eventually become standard in public indoor spaces - a kind of expected public good. Just like clean water, toilet facilities, fire suppression systems, food safety practices, etc. There is momentum already: Belgium and France have already passed legislation.
It will start with government spaces (schools, libraries, city hall, government offices etc). Then be pushed to privately-owned publicly accessible spaces (stores, gyms, movie theatres, restaurants). There will be government subsidies to help cover the cost of re-fitting ventilation systems. Occupancy permits and capacity will be tied ventilation capacity. Inspections (like current fire or food safety inspections). Mandated real-time display of clean air metrics (CO2, and maybe also PM2.5, PM10) to keep businesses honest (to ensure the ventilations system is turned on). New ventilation standards for new construction.
I really believe that all of this will come to pass. More socialist countries will get it done first. Capitalist countries will have to follow in order to keep up -- the economic cost of a constantly sick population will be too high.
It's only a matter of time. More time than I'd like, but inevitable, I think.
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Psychiatrists are 100% state funded in my province, and cannot legally charge privately for services covered by the state.
Access to PCP mental health care and, with referral, psychiatrist care that is 100% funded care, with no out-of-pocket cost is a big deal.
Canadians love to complain about their healthcare (and it's not perfect!), but 100% state funded primary and specialist care and hospital care is actually a very big deal that our nation tends to take for granted.
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3 hours ago, maize said:
Do people have access to treatments like TMS? If primary care providers are mostly just dispensing SSRI's and calling it good I'd see that as a major concern.
PCP's here do not dispense. They assess, diagnose, formulate treatment plans, manage, and prescribe. Treatment plans often include meds, but not always. Some PCP's do psychotherapy (state funded 100%).
TMS is not (yet!) covered by the provincial plan in my province, but is available through teaching hospitals (funded, ie UHN in Toronto.). Would require referral to a psychiatrist to access this way. In Canada, IIRC, it is approved only for treatment-resistant depression and OCD. It is covered in some other provinces. I think that state funding for TMS in my province will happen in time, but we are not there yet. (There are private TMS clinics, though, based on their websites, the ones I've seen seem very commercial/profit driven and shady to me.)
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I'll be contrary and suggest that medical mental health care in Canada is actually pretty good -- at least in my part of the country. (I acknowledge that access to care is not the same everywhere, and that rural and remote communities are under-serviced). Managing social determinants of health s more challenging.
Most medical mental health care is provided by primary care physicians (and sometimes NP's). They are well trained and can competently manage most cases. Funded by the state. Out-of-pocket for PCP care is $0 - no co-pays, no deductibles, nothing. The biggest benefit of primary care mental health delivery model is excellent accessibility.
Complex cases get referred to psychiatrists, who mostly use a consulting model: assessment and recommendations back to the PCP. Some complex cases will be followed by a psychiatrist long-term. Funded by the state. Out-of-pocket cost $0
Emergency assessments (generally in emergency departments) in mod-large hospitals are usually multidiscplinary. Crisis intervention team (social work, mental health nurse) and ED MD both available 24/7/365. Psychiatrist consultation at EDMD discretion. Involuntary admissions are assessed by a psychiatrist. All voluntary admits in my hospital are also seen by a psychiatrist. Very small hospitals would tend to transfer care to a larger centre with a multidisc team. Funded by the state, out-of-pocket cost 0$. Cases that are not admitted are discharged to some sort of followup - multidisc crisis team, urgent outpt psychiatrist, community orgs or family doctor. all of these are funded by the state, out-of-pocket cost $0.
Talk-therapy and other therapies with non-MD's is not as easily available, and generally not funded by the state. This is generally where private insurance provided by employers comes in.
There are no private psychiatrists or family doctors in my province. In my province, It is illegal for MD's to bill privately for services that are covered by the state, or to extra-bill (charge an extra fee beyond state funding) for these same services.
We do not have universal pharmacare. Pharmacare varies by province. In by province, those under-25, over-65, those on state disability benefits and welfare benefits, and first nations people with status cards have meds paid for by the state.
Part of judging how good a country delivers mental health care depends on how we define mental health and what we mean by mental health care --- western medicine cannot fix social determinants of health. Homelessness, poverty, abuse, addiction, food insecurity... the list is endless. Sometimes, when I hear people complain about access to mental health care, what they actually seem to be doing is medicalizing social issues --- seeking medical solutions to problems that are not solvable by western medicine. Canada does pretty well with the medical aspects of mental health delivery. Managing social determinants of health, on the other hand, not nearly as well as we should.
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9 hours ago, cintinative said:
ETA: I am trying to prop them on the heat vent using chopsticks. LOL
a couple of empty toilet paper rolls might work better than chopsticks?
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We finish drying ours on a forced air vent with one of these mitt/boot racks
We also put them on the rack when damp after wearing.
Waterproof gloves are also dryer-proof. The waterproofing works both ways, and it's hard to get the moisture out. The stink loves moisture. Forcing warm air into the gloves (rack on vent) works really well.
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10 hours ago, Corraleno said:
The only person who should have the right to decide how "open and honest" they want to be about their personal history, and with whom, is the adoptee. It is their story to tell or not.
The legal function of a birth certificate isn't to tell a child who his or her biological parents are, it's a government document confirming date and place of birth, along with the names of the legal parents, which also generally serves as proof of citizenship. Adopted children have two birth certificates, even when a child is immediately relinquished at birth; the birth mother signs the original birth certificate and then when the adoption is completed a second certificate is issued with the adoptive parents names. What possible justification can there be for insisting, against the wishes of many adoptees, that their birth certificate and proof of citizenship must inform everyone who reads it that this person's legal parents are not their biological parents? What purpose does that serve, other than to embarrass adoptees who may not feel like discussing their personal (often painful) history with some random DMV employee?
It's a sad fact of life that people ask incredibly rude and inappropriate questions about adoption. DD has been asked why her mother "just threw her away," and how she feels about never knowing who her "real" parents are. I've been asked "where I got her from" and "how much I paid for her." People are stupid.
Imagine if marriage certificates were required to list prior marriages, and any time you wanted to apply for a joint mortgage or bank account or something, you had to show a marriage certificate that listed your ex-husband and listen to some nosy bank manager quiz you about your divorce. If your gut reaction is "that's none of their damn business," then you understand why adoptees should not be forced to include more than the names of their legal parents, just like your marriage certificate only needs to show the name of your current, legal spouse.
Agree that BC is not about biology.
If it were, then paternity is wrong on BC quite often - the BC names the person who claims paternity, which may have nothing to do with biological paternity. Not a rare thing.(a bit of a tangent, since this nothing to do with adoption, but still a relevant point, I think)
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One of the dorms I stayed in had one of these. It had 2 modes: Microwave mode and convection oven mode. In convection oven mode, it was a real oven with a heating element (not microwaves). Used regular bakeware. I made muffins in metal pans IIRC. This was in the days long before "air-fryers" existed. Air-fryers are really just convection ovens.
So you don't have to buy an air-fryer, because you already have one!
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I think the bunny-ear method is totally fine. It's structurally the same knot as the "adult method" (double slipped square knot).
The trick is to make sure to tie a double slipped square knot and not a double slipped granny knot.
My kids are fine with shoetying (always square!), but I really wish that they had better table-manners.
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I've used mason jars in the past. And just drilled a hole (sized to match my reusable straws) into regular canning lids. It works well. And it was stuff zi already had in the house, so I didn't to buy anything new.
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1 hour ago, lewelma said:
When I was in public high school in 1987 in Richmond VA, our mascot was a confederate soldier and our school flag was the rebel flag. So like 1000 waving at every football game and big ones hung throughout the school.
There was a highschool in the region that I grew up in that was similar at about the same time.. I remember a track and field meet where this team had a confederate flag flying. Team name "Rebels". THIS WAS IN CANADA. There was literally no defensible historical reason for it. I looks like they dropped the flag a few years later.
There was a kid in my highschool who wore a Nazi armband. Not someone I really knew, and I have no idea what was done about it (presumably something), but I do remember it caused a bit of a stir.
At summer camp a group of girls did the Nylon's "The Lion Sleeps Tonight" in black face for a talent show. I was much younger for that, maybe 10 or 11. I don't think anyone thought anything of it at the time. (All I remember about it was wondering how they'd pulled it off at a camp where make-up was not allowed --- a mixture of noxzema and tempera paint, apparently). Of course, now, looking back, it was horrifying.
These were all from my middle-class childhood in a very white area. Not wealthy.
Norms have changed. I think we sometimes forget by just how much.
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7 hours ago, Terabith said:
I have questions about this. It became a controlled substance (but at a lower classification than a lot of other drugs) in my state. I’ve been taking it for like 23 years, and like I said it was miraculous for me. But I can’t figure out how it could be abused. It’s not fast acting. I have certainly never felt high or anything from it. It just, over the course of several weeks, took my depression from crippling and life threatening to “wow, is this what normal people feel like?” (And I know it isn’t considered effective for depression or bipolar disorder, but 23 years ago it was considered possibly one and I had had no response to several classes of drugs. And my long term psychiatrist says that while he knows the studies say it’s not effective at a population level, he has a number of patients for whom it clearly is effective.)
How is it abused? Or rather, why?
Euphoria similar to an opiate high for some people.
It also potentiates opiates, and there is increased mortality when gabapentin is mis-used concurrently with opiates. CDC report.
Brief report from CMAJ, and another paper from Scotland
Very recent article in JAMA is worth reading, but it's paywalled (and not gift-able)
It's a good drug that's perfect for some people. But, like many other controlled substances, there is also risk and abuse potential. Which is why it's important to have a regular prescriber with whom one has an ongoing therapeutic relationship and appropriate followup. We won't refill it from the ED, because the required risk assessment and followup is impossible in an episodic care environment.
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Another thing to consider:
Gabapentin is a drug with abuse potential, and is a controlled substance in some states. Many walk-in clinics and ED's will not refill it.
That's obviously not a reason to not take it if you will benefit. But good to be aware of.
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Handled bristle brush. I've stitched up too many hands from dishcloth dishwashing accidents (from using hand and cloth to wash the inside of a glass, glass breaks, ouch; it happens a lot, or hand and cloth on knife blade).
I don't specially wash the brush. The bristles and brush aren't porous - there aren't any moist crevices for germs to hide, like there are in a sponge or cloths. It's gets washed by being in hot soapy water while being used to wash dishes.
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Adding that the vitalight has an annoying alarm when CO2 exceeds 1000ppm.
It can be turned off. But it defaults to alarm-on when turning on the unit, so you have to remember to disable the alarm every time you turn the thing on. It's little bit annoying. (though, we leave ours on all the time. The only time I have to turn it on is if I've let the battery run down completey and had to recharge from nothing. so not terrible either)
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My parents also bought a vitalight.
My dad has breakfast with a few buddies at a not-crowded restaurant occasionally.
He showed it to the restaurant staff (who overheard him talking to buddies about it, I think - he wasn't purposely trying to complain or anything) . Shortly afterward, the numbers at the table improved by quite a lot. He's pretty sure that him showing numbers to the staff caused them to turn on or turn up the ventilation system. If you know better, you can do better etc.
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Just now, mommyoffive said:
Yes, that's the one.
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Living will, advance directive, regular will, etc.
in The Chat Board
Posted
Resuscitation/code status has to be re-ordered by MD with each new admission - the orders (just like orders for meds or anything else) do not carry. over from one admission to the next. The history of resusc orders from past admissions is available in the EMR, but they are not active until re-ordered.
As for what happens when pts who can't speak for themselves arrive in ED requiring resuscitation with no SDU immediately available: The ED MD has to make the decision in the moment (and take responsibility for it)
Sometimes patients come with clear, formal DNR orders (my province has a DNR confirmation form especially meant to direct EMS and fire; ED MDs also use them to to make resusc decisions. Pt's are instructed to leave them on the fridge.) Sometimes it's very clear in the EMR of a recent past visit that the pt has a terminal diagnosis and that the plan is strictly palliative. Sometimes it's clear that resusc is futile.
Otherwise, though, ED MD's are going to err on the side of resuscitation.