"Peritoneal Vein"

[mgriffiths]

Note: this is a different NP than the one I wrote about before (see thread regarding "Personal Assistant")

 

I was covering UC at the ortho practice I work in and was working with an NP.  Had a total hip post-op patient come in because he was having pain with swelling in his post-op leg.  He knew this was normal, but his pain was much worse than when he had his other hip replaced 2 years ago and he was worried.  He had a negative homan's but I wasn't convinced as his pulses seemed somewhat diminished compared to his other leg.  I wanted to send the patient for a doppler US, but the NP disagreed.  Unfortunately it was her call as I am not actually credentialed for billing.  Thankfully one of the docs overheard our conversation and said to just send the patient!

 

About an hour later the NP gets a call for the dopper US report and tells me I was right, that there was a complete blockage of the "peritoneal vein."  I asked if she meant peroneal, she was adamant it was the peritoneal vein.  I reminded her what the peritoneum was and she told me she had never heard of it and that I must be wrong. WHAT!!!

 

It's a wonderful thing that you can look up anatomy on google these days - her face was priceless.

 

Same NP that missed a femur fracture that I thankfully caught while walking by her computer and mentioned the abnormality.

 

And I'm supposed to be learning from this girl until my credentialing comes through (hopefully soon!).

 

P.S. I usually work exclusively with my supervising doc, but she is on vacation which is why I was working with this NP at all.  That is not the norm, and once I'm credentialed I will not have to "answer" to her.

 

[LKPAC]

PAs like you make us all look good.  Keep up the good work!

[ort890]

Nice! Coming from a fellow ortho PA. Good job. 

[Reality Check 2]

In the ER at a teaching hospital - we got calls from the Children's Hospital next door and other services in the hospital.

No digital xrays then.

 

Get a call about a humerus fracture in a 10 yr old. 

Ask the Peds resident and crew - is it proximal or distal?

 

silence.......................

 

IS IT CLOSER TO THE ELBOW OR THE SHOULDER?

 

Yep, supracondylar fracture - several hours out - they can't tell me about Volkman's signs.

We haul butt over hill and through the tunnels to get to peds hospital.

Kid is ok but we do an impromptu 10 pm teaching in the Peds ER about fractures and proximal and distal and HOW to describe fractures.

Actually had to explain that a fracture is a break is a fracture is a break and there isn't any difference.

 

Lack of knowledge comes in all flavors.........

[Ridiculopathy]

Woohoo! U go mgriffiths!

[Kaepora]

Again, we can all sit around and share similar stories for all types of providers.  Like the "provider" who asked the interventional radiologist what the difference between an ESI and a transforaminal/nerve root injection is.  Should have been obvious for this person.

 

Now, I will say, this is the downfall of NPs.  They generally do not have a grad level anatomy, relying on their undergrad A&P.  This is why PAs prevail in procedural/surgical areas.  I had to go out of my way to take medical anatomy as a NP student.  So no, most NPs won't know the peroneal from the ant tib from the post tib, or similar (basic) anatomy principles.  

 

But after practicing in a certain area for some time they do catch up (typically) and are able to fill in these missing anatomical gaps.

[UpRegulated]

Note: this is a different NP than the one I wrote about before (see thread regarding "Personal Assistant")

 

I was covering UC at the ortho practice I work in and was working with an NP.  Had a total hip post-op patient come in because he was having pain with swelling in his post-op leg.  He knew this was normal, but his pain was much worse than when he had his other hip replaced 2 years ago and he was worried.  He had a negative homan's but I wasn't convinced as his pulses seemed somewhat diminished compared to his other leg.  I wanted to send the patient for a doppler US, but the NP disagreed.  Unfortunately it was her call as I am not actually credentialed for billing.  Thankfully one of the docs overheard our conversation and said to just send the patient!

 

About an hour later the NP gets a call for the dopper US report and tells me I was right, that there was a complete blockage of the "peritoneal vein."  I asked if she meant peroneal, she was adamant it was the peritoneal vein.  I reminded her what the peritoneum was and she told me she had never heard of it and that I must be wrong. WHAT!!!

 

It's a wonderful thing that you can look up anatomy on google these days - her face was priceless.

 

Same NP that missed a femur fracture that I thankfully caught while walking by her computer and mentioned the abnormality.

 

And I'm supposed to be learning from this girl until my credentialing comes through (hopefully soon!).

 

P.S. I usually work exclusively with my supervising doc, but she is on vacation which is why I was working with this NP at all.  That is not the norm, and once I'm credentialed I will not have to "answer" to her.

 

Dude, you seem really smart.  And you seem to love anecdotes. I could probably own you own those.  But let's no go there.  Instead, let's do this:

 

(1) As an ortho PA, how would you manage/treat a resistant HTN patient on a beta blocker, a CCB, and an ACEI who is allergic to several diuretics (who has normal renal function)?

 

(2) As an ortho PA, how would you manage/treat the recurrent intermittent rash on the bottom of one's foot x 3 years that has not responded to topical or oral antifungals? And what is your ddx?

 

(3) As an ortho  PA, how would you manage/treat the otherwise healthy young URI patient whose had symptoms x 14 days that suddenly worsened, has no cough, normal pulse ox, clear CXR,  and who tested + for strep, - for flu but who didn't have a sore throat, and hasn't responded to Augmentin? And what is your ddx?

 

(4) As an ortho PA, how would you manage/treat a 3 week old worsening sinusitis in an 80 yo/F uncontrolled diabetic on dialysis with an uncertain reaction to penicillins that takes immunosuppressants for breast CA? 

 

That's a weeks work for me.  Or, truthfully, a day's work. But I'm just a stupid NP with barely 24 months of post-grad clinical experience who doesn't know one vein from another.

 

You apparently have an expert grasp of vascular and orthopedic anatomy, all of which you undoubtedly mastered in PA school long before graduation, probably even in your first semester (while you were also learning how to hold and take a temperature with an oral thermometer).  

 

I'm certain your grasp of vascular and orthopedic anatomy has nothing to do with your post-grad experience, as your knowledge of such reached expert levels -- not by experience -- but strictly from your superior PA didactic and clinical curriculum vs NP's.  And you certainly know much more than any stupid, poorly educated NP.  

 

So answer my questions above.  Show me what else you know.

 

-Signed:

 

Stupid NP lacking in knowledge of vascular anatomy

[Boatswain2PA]

UP - your point of specialization is adequately made, and agreed upon.

 

But then there is BASIC anatomy and physiology. Peritoneal vs peroneal falls into this category.

[UpRegulated]

UP - your point of specialization is adequately made, and agreed upon.

 

But then there is BASIC anatomy and physiology. Peritoneal vs peroneal falls into this category.

 

The OP is either lying or confused.  Period.

 

Homan's sign is pretty much (no wait, IS) worthless regarding specificity and sensitivity and has NOTHING to do with the veins of the peritoneum, perineum or any other "neum" above the knee. IF the OP is telling the truth, then his "catch" is luck, not clinical acumen.  

 

But then, I am a stoopid NP that thanks that Homan's sign pertanes to them there vane thangs in the calf thang, rather than the crotch or belly thang.

 

No wait, that's just the trooth.  Homan's has NOTHING TO DO with thromboses in ANY vein other than those of the lower extremity.  As a stoopid NP, to me that means that it has NOTHING TO DO with the peritoneal/peroneal veins, yet the OP rests his argument on it.

 

And I'll await the OP's responses to my questions.

 

Oh, and OP. Google all this.  Take a selfie after your Google search and attach it to this thread. I'm sure it'll be priceless.

 

Edit: please, anyone, explain this to me.  The more I read the OP's post, the less sense it makes.  How in the heck can a blockage in a peritoneal vein OR a peroneal vein cause DIMINISHED PULSES IN A DISTAL EXTREMITY?????  I'm just a stoopid NP that believes that pulse amplitude is an artery thang, especially when several feet distal to a supposed venous blockage, which is several feet distal to distal the pedal pulses???? Surely anyone with a basic grasp of anatomy realizes that a capillary bed separates the arterial from the venous system peripherally, mitigating pressure differences, and sustaining the higher arterial pressure vs. venous pressures regardless of a blockage or not.

[turnedintoamartian]

The diminished pulses with DVTs is related to the edema that occurs.

 

Peroneal vein is a deep vein below the knee.

 

Agree Homan's isn't reliable.

 

You lost the mora high ground with the thermometer comment.

[TWR]

UpRegulated,  Got under your skin with the NP comments huh?  You are obviously well educated and smart.  Probably quite good at what you do.  Don't be so thin skinned.  Also why do you use (hide) behind a pseudo photo?  Your (own words)?  Show yourself.  Be a man or woman.

[Guest ral]

.

[Guest ral]

 

Homan's sign is pretty much (no wait, IS) worthless regarding specificity and sensitivity and has NOTHING to do with the veins of the peritoneum, perineum or any other "neum" above the knee.....

 

...rather than the crotch or belly thang....

 

....Homan's has NOTHING TO DO with thromboses in ANY vein other than those of the lower extremity....that means that it has NOTHING TO DO with the peritoneal/peroneal veins.....

 

.....How in the heck can a blockage in a peritoneal vein OR a peroneal vein cause DIMINISHED PULSES IN A DISTAL EXTREMITY?????  I'm just a stoopid NP that believes that pulse amplitude is an artery thang, especially when several feet distal to a supposed venous blockage, which is several feet distal to distal the pedal pulses????.

.

 

At the risk of receiving a private message from a moderator,

UpRegulated:

You cannot be effing serious with the above statements.

[LT_Oneal_PAC]

While I think you, up regulated, shouldn't respond to these kinds of things because it's only going to give you gray hairs, you are correct.

 

Sorry guys, but diminished pulse would have significant enough edema it would be apparent by looking at it and a homan sign is worthless. It's predictive value is about the same as flipping a coin.

 

TWR, I don't think it's necessary for them to relenquish anonymity. Most of us don't. Hell, I'm a milPA and I don't tell anyone personal info on here.

 

As to the OP, I leave with the wise words of my IM preceptor when we caught a stupid mistake by an FM physician. "One day you and me are going to F up. And when we do, you'll be hoping the person who catches it isn't the judgemental type, blabbing to everyone."

[Avalon]

I must have missed the point here. 

 

What I thought the OP was calling attention to was less the NP's anatomic error, and more the NP's adamant refusal to listen to, contemplate, and reflect on a colleague's opinion and contribution to a shared case.  To me, this was by far the more egregious error. 

[GetMeOuttaThisMess]

While I think you, up regulated, shouldn't respond to these kinds of things because it's only going to give you gray hairs, you are correct.

 

Sorry guys, but diminished pulse would have significant enough edema it would be apparent by looking at it and a homan sign is worthless. It's predictive value is about the same as flipping a coin.

 

TWR, I don't think it's necessary for them to relenquish anonymity. Most of us don't. Hell, I'm a milPA and I don't tell anyone personal info on here.

 

As to the OP, I leave with the wise words of my IM preceptor when we caught a stupid mistake by an FM physician. "One day you and me are going to F up. And when we do, you'll be hoping the person who catches it isn't the judgemental type, blabbing to everyone."

 

 

Or loss of hair, as in my case.  I reserve the right to lose mine from talking to patients, not other providers.  At this stage I have to be selective and keep it short so I can't grab/pull it out.

[UpRegulated]

The diminished pulses with DVTs is related to the edema that occurs.

 

Peroneal vein is a deep vein below the knee.

 

Agree Homan's isn't reliable.

 

You lost the mora high ground with the thermometer comment.

 

(1) The OP said NOTHING about edema.  Venous blockages have no inherent effect on pulse amplitude.

 

(2) Well aware of what and where the peroneal veins are.  When I originally read the OP's post, I read it is as "perineal" instead of "peroneal" perhaps because he mentioned hip replacement and I was thinking regionally, so the whole post made no sense to me.  I then (see my post edit done before anyone responded) mentioned that a peroneal, or any other venous blockage, does not inherently change pulse amplitude.  Regardless, the points raised in my posts stand, regardless of switching an "i" for an "o."  

 

Drug reference sources often warn of look alike/sound alike drug names precisely because names have been confused, even in less subtle differences, so perhaps the OP should have given the NP the benefit of the doubt.  Brintellix was getting confused with Brilinta, so its name was recently changed to Trintellix, for example. 

 

(3) The "thermometer comment" is in reference to how some PA's act like 3 years of science prerequisites and nursing courses as an RN are somehow irrelevant to being a provider, and that the NP's true education doesn't start until grad school (which many PA's would say is weak at that).  In undergraduate nursing training, RN's are exposed to fairly in-depth physical assessment (I was trained with Bates), pathophysiology, and pharmacology in just their 1st semester of RN school. Vital signs are the first week only and we move on.  Physical assessment, patho and pharm are covered fairly deeply in our first semester as undergrad RN students, all of which is subsequently integrated into remaining courses going even deeper every semester. Many PA's are first exposed to the basic measuring of vital signs in their first week of graduate school. 

[UpRegulated]

UpRegulated,  Got under your skin with the NP comments huh?  You are obviously well educated and smart.  Probably quite good at what you do.  Don't be so thin skinned.  Also why do you use (hide) behind a pseudo photo?  Your (own words)?  Show yourself.  Be a man or woman.

 

This coming from a poster that has NO profile pic?  How would posting a real picture of me change anything?

 

As for being "thin skinned," read my posts.  I am quite complementary of and supportive of PA's, and I ignore most of the anti-NP posts that appear here from time to time.  

[turnedintoamartian]

Your extended fixation on amplitude was of your own doing. I'm sorry the OP didn't specify if edema was present but I thought it was helpful to understanding why diminished pulses is a common finding in DVTs.

 

You seemed genuinely confused/outraged about the location of the vein and how it was related to homan's sign.

 

I understand where you pulled your thermometer line from but it discounts the varied prior experience found in a PA class and the basic ability to use a common household item. This doesn't aid much in attempting to pursue some collegial relationship across professions.

[UpRegulated]

Your extended fixation on amplitude was of your own doing. I'm sorry the OP didn't specify if edema was present but I thought it was helpful to understanding why diminished pulses is a common finding in DVTs.

 

You seemed genuinely confused/outraged about the location of the vein and how it was related to homan's sign.

 

I understand where you pulled your thermometer line from but it discounts the varied prior experience found in a PA class and the basic ability to use a common household item. This doesn't aid much in attempting to pursue some collegial relationship across professions.

 

Extended fixation?  Seems to me that my "fixation" is quite relevant to this back and forth discussion.  Glad you are sorry the OP didn't mention edema.  Me too.  It seems like an important factor in light of the discussion.

 

As previously mentioned, Homan's sign is pretty much useless, regardless of what vein(s) a potential thrombosis is in.

 

Discounting the varied experiences of PA's?  Hardly.  A CNA with 3 months of experience prior to PA school matriculation needs to learn how to adequately take vital signs (they didn't get in CNA school, and likely just doubled down on bad habits in practice).  The RT in PA school, on the other hand, is comfortable using a stethoscope. The varied experience of NP's and PA's is sort of my point.  Compare an RN with 5 years of ER experience going into family practice as an NP vs. a physical therapist with 6 months of experience prior to PA school going into family practice.  We all have varied experiences, which is precisely why none of us should be stereotyping, which, as you mention, hampers collegiality.

[ventana]

Mod hat on

 

 

Unregulated - you came across as condescending, and you were wrong on a few points - you miss read the initial post and this was your error. Asking an Ortho pa the FP type questions you did - is seemingly worthless as the answer is "ask the hospitalist" or "see your primary" Instead lets ask the FP what they should know about Otho - which is what the OP was talking about.

 

Others - keep the conversation professional

 

I would suggest everyone takes a breath and the PA versus NP really has no place on this forum..... it is just everyone's little stories.

 

IF YOU MUST POST a story about another PROVIDER just say PROVIDER and leave it at that.... I have corrected more then a few PA, NP and Docs, and as the same time I am sure NP, PA and Doc's have corrected me. It is just a fact of life and practice of medicine.

 

 

I do however agree with the one poster that stated the worst thing is that a provider devalued another providers input..... that is not cool..... and certainly not anything any of us want to be doing......

[jwells78]

Somebodys feelings got hurt....

 

 

Where is all this "6 months experience before PA school" talk coming from?

 

I'm offended.

 

So offended.

 

Horribly offended.

 

And now dammit my Peritoneal vein is acting up.

Sh** sticks.

 

 

Hell, more whiskey.

[turnedintoamartian]

Hello again Kenneth. You asked for someone to explain to you how a blockage in a vein can cause diminished pulses. The answer is edema, which wasn't specified as being present beyond "swelling". You were focused on the wrong thing, which easily happens with the limitations of internet based discussions.

 

We agreed on homan's uselessness posts back, I specified the location of the vein because you specifically said homan's can only be used for lower extremity blockages and that's where the thrombosis was. It's a runaround I know but it really did appear you weren't sure where the vein was and how it factored in, that was also a point made by the OP regarding the NP he was with.

 

You saying PA students have to learn the proper way to use a thermometer via class is just as disingenuous as when many PAs water down the education of nurses prior to becoming NPs. But hey I did see ND just gave you guys full independence. Regardless of the infighting between PA and NP you guys are crushing it.

[mgriffiths]

I have responded directly to UpRegulated.

 

To others, I am well aware that Homan's sign is not very specific or sensitive for DVT, and many of the other things mentioned here. This was less about the actual clinical case and much more about how the NP responded to the situation.  And, to be honest, I was extremely proud of myself for catching that DVT as it could have resulted in a very poor outcome for the patient.  Was there luck involved, OF COURSE!

 

The NP I was referring to works specifically in an orthopedic office, and worked in an UC before that.

 

I have no disdain for NPs.  I apologize if that is how it came across.  While I believe their education is a bit lacking, let's be honest - so is PA education.  MD/DO education is lacking.  Nothing beats experience in the PRACTICE of medicine.  I was commenting much more on the utter inability to think through the high risk of DVT associated with a hip replacement and that you should have a low threshold for ordering the doppler - not that you do it every time, but it has to be high on your list.  I was also commenting on the NP's inability to learn from a colleague.  I have learned much in my short time as a provider from NPs - including when I was a student on rotations, but at the same time I have yet to meet an NP that did not treat me inferiorly because I was a PA. I hope that one day I will meet that NP, but that has not happened yet.  Does this mean that all NPs have a superiority complex, NO, but the ones I work with daily treat PAs poorly and to my knowledge do not receive this behavior in kind.

[Kaepora]

Whoa, this thread has blown up since last I checked.  

 

You have to take every anecdote you read on this site with a grain of salt.  Most of them on this site will be pro-PA and anti-NP, whereas if you check a similar nursing site it will be the reverse.  And if you check SDN it will be anti-PA and anti-NP.  So it's nice to know we are on the same side on that site.  Haha.

 

I have a book full of anecdotes that show every type of provider is wrong A LOT.  I just had a conversation with one of the MDs I work with describing how precedex works as an alpha 2 agonist.  He thought it was a general alpha antagonist and that alpha 1 and 2 receptors functioned essentially the same way.  His education must have been severely lacking.

 

I'd like to take a second to turn this around and point out, that while the PA education might be heavier on some basic sciences, NP's are doing pretty well for themselves.  Maybe less anecdotes on a private forum and more self-promotion (not at the expense of other providers) on a more public platform.