TheFatMan

Will try to respond to these a little later! You're all great.

Sorry playing a little catch-up here. Didn't read everyone's comments, sorry! Real quick, I think I asked about chest pain but not sure if that was answered. Also want to ask if it looks like she is perfusing clinically - does she have warm or cold extremities? Could we get a pro-calcitonin? In terms of other factors that make you think of PE in this case, I'd say she has signs of right heart strain. Would not get a d-dimer. She's already moderately high risk, so if we are thinking PE she would go to the scanner. Problem is (in addition to her being unstable and the problem of lying flat), her BUN is elevated (creatinine is okay though). Someone help me out here, does she get contrast or would you do a VQ? No signs of DVT so not sure if duplex would help here. Others on DDx (apologies if some of these have been mentioned) - acute/chronic mitral regurgitation (possibly secondary to rheumatic fever, endocarditis, ischemia, cardiomyopathy, trauma, [or PE?]). This explains the murmur and the pulmonary edema/CHF sx. - Sepsis...she has a lactate and a temp. qSOFA is 1 or 2 depending on if you think she is altered. - ARDS, I think pretty likely, meets Berlin criteria from what I can tell, just not sure what the exact cause is at this point. This could also be due to a pancreatitis, can we get a lipase? - She has an AKI as well. As for treatment. Right now we need to decrease her afterload. Would use nitroprusside or nitroglycerin. Slowly reduce MAP by 25% in 1st hour. Furosemide for acute pulmonary edema. Hypoxia has improved but has work of breathing? Consider early intubation here possibly with proning. Don't want to delay treatment if she has a big PE, so anticoagulate with LMWH after making sure it isn't contraindicated, VTE prophylaxis is also indicated for ARDS so I think its a good idea. Probably also a foley to 1) check for urinary cause (UA + culture) and 2) monitor diuresis. EDIT: Doesn't look like we can actually intubate. Start Bi-PAP and get on the phone because she'll likely need to go somewhere else.

Of course she is new to the system Off the top of my head though, I forgot to add a covid test and blood cultures. Other than that, I'll wait and see if anyone else wants to chime in.

Okay so broad differential at this point: AMI, PE, dissection, tamponade, COPD/CHF exacerbation, pneumonia possibly due to COVID, lung cancer, pneumothorax. What's on the monitor? I don't think it would hurt to have a crash cart nearby. Order a 12-lead, chest x-ray, CBC, CMP, trop, coags, lactate, ABG. While waiting for those do an exam, heart, lungs, abd, look for JVD, LE edema or signs of DVT, mental status. I have a feeling looking in her chart might be more helpful than asking more about history - so after exam I'd do a chart dissection. Could also ask about asthma, trauma, history of clots, smoker status (and other risk factors).

Thanks Mike. Bring into a room and get help. IV access, O2 (although possible she is a CO2 retainer, so be careful with this), monitor. Full set of vitals. Is anyone with her to help with history? To start: Onset? Chest pain? Febrile? Recent travel? COVID vaccination status/exposures. Whatever medical history is available (COPD/DVT/PE/Cancer/immunocompromise/CAD/CHF) Will wait on other history/physical/workup for someone else to chime in.

I echo what was said above. I had credits from 8 different colleges, was offered interviews at 10/12 schools I applied to and had 4/4 acceptances of the interviews I attended. Being well rounded helps. It is hard to say how this will affect you without knowing more about you, but, in general, if you are well-rounded, get good grades, and have dedication to the profession it shouldn't matter all that much. A good PA program would understand that it is okay to not take a 'traditional' route to your degree.

Ask them: if they think is experimental, how do they feel about being the control group?

Because it isn't required. I'm sure there are examples of applicants who were accepted who were very strong in other aspects of their applications that made up for their deficiencies. Regardless of that, why would an applicant want to be a PA without HCE or shadowing experience? It is up to the applicant to make themselves as competitive as possible.

Short Coat podcast All Access: Med School Admissions podcast PA Startup podcast

A former hospital system employer of mine, who also owned their own insurance company, was exposed for suing its own employees over medical bills.

Emailed several delegates 2 weeks ago and have heard nothing.

Nice post I saw re: anti-vaxxers from Your Local Epidemiologist (Katelyn Jetelina) A few days ago, I shared a Texas Monthly news article on Facebook. The article features a prominent anti-vaxxer, Heather Simpson, who ended up getting the COVID19 vaccine (AND who is starting to vaccinate her daughter). It’s a fascinating read. Wellllll…guess who I had coffee with yesterday?! That’s right. Heather Simpson. I, of course, had a million questions. Way too many for one coffee. I don’t know much about this world and we need to if we want to change the landscape. For this meeting though, I was most interested in two things from her unique perspective: Describe the problem Brainstorm solutions Heather and I chatted away. Describe the problem From hearing her story, I realized that there is a spectrum of anti-vaxxers. There are the extreme, but there are many others less extreme. This may be obvious to some, but I certainly wasn’t aware of the specific groups, in which Heather gave creative names. Scared. These are closest to vaccine hesitant. These people are scared, but CAN be helped with facts. We just need to get them the facts. For example, when Heather was an anti-vaxxer she was most worried about the aluminum in vaccines. Once she understood the science, though, Heather could hold the facts close to her heart. When her daughter got her first vaccine last month, Heather kept repeating those facts in her head at the doctors office. She couldn’t find a way to talk herself out of the vaccine because she had scientific based facts. Even through tears. Ex-vaxxers. This is the next group down the spectrum. This is a group of parents in which something happened with their kids (autism, ADHD). And no one has answers for them. And, worse, their physician sometimes brushes off the problem. Heather explained to me the only thing that would help this group is to offer an answer focused on data. For example, conducting more scientific studies on autism or ADHD. We need to provide an answer OTHER than vaccines. 100% natural people. She ranked this group next, which seems to be deeply rooted in religion. Basically, this group thinks “you can play God” or “God did not make a mistake with your body and your immune system.” For example, you won’t get cancer because you eat healthy. Or, your kid got a urinary tract infection because you let them have McDonalds. This group doesn’t touch anything pharmaceutical. Interestingly, influencers in this group makes a lucrative living by selling natural supplements through pyramid schemes. Light conspiracy theorists. This group is next. They are the willfully ignorant. They watched YouTube videos and can’t be pulled out. This group starts dabbling in off the wall comments, like they’re spraying “chem-trails” in the air. (I had to look up “chem-trails”. “Chemtrails, short for chemical trails, are what some call the white trails you see left behind as a plane passes overhead. Believers in the chemical aspect of chemtrails say those trails are actually clouds of chemicals used by the government or some other large scale entity for a variety of nefarious purposes from weather modification, to human population control via sterilization, to even mind control”.) Lizard people. And then, finally, we have the extreme anti-vaxxer group. They are deep in the conspiracy world. We are talking QAnon, thinking Hillary Clinton is a lizard and drinks the blood of babies. Their whole world view is altered. Heather called them “lizard people”. How will the COVID19 vaccine change the anti-vaxx world? It seems like the COVID19 vaccine is causing people to jump from one group to another for other vaccines. For example, she described a family who was vaccine hesitant, but still got all childhood vaccines. However, because of COVID19, they have moved from “hesitant” to “scared” group because COVID19 vaccine was “rushed” and so that must mean all vaccines have faulty processes. And now they won’t get any other vaccines. So what can we, public health officials, do? I’m not going to pretend that I have found the solution on how to stop a international movement. But, there were some themes that I gathered from our conversation… Primary prevention: Prevent it before it ever occurs through education and scientific communication. There is a lot of work we can do here. For example, we can specifically reach people when a family comes to a healthcare providers’ office. Secondary prevention: Reduce the impact that has already occurred. For me, at least, it’s helpful to know that not all anti-vaxxers are a lost cause. There is a spectrum and each group needs to be targeted in a different way. Tertiary prevention: Soften the impact of anti-vaxxer movement that has lasting effects. We are never going to win the battle of misinformation, so we need to figure out a way to calm the fire. This HAS to be a conversation with social media giants (which I’m having with FB) and a conversation at dinner tables, and everything in between. So, all this to say, I agree with the Texas Monthly article: “The movement entraps people but also that it’s possible—if much harder—for minds to change.” Love, YLE

For the record, I never said we should coddle them. I said they aren't necessarily stupid, which is true. In Tucker's situation, he is either incredibly stupid or being malicious - probably the latter. There is a HUGE difference between someone who just hasn't gotten info from the right sources and have been unfortunate to watch the wrong YouTube video or go to the wrong chiropractor and someone who is a full-blown anti-vaxxer who is completely down the rabbit hole. I do think that there are a lot of people on the fence because they haven't been given the right information and I would consider that an important time not to push them away, dismiss them, or make them feel stupid because that will only shove them further down the hole of lunacy and we'll have even more Karens running around citing the VAERS and greenmedinfo or mercola. I don't think it is as simple as being "willfully stupid." I have family members who subscribe to the full-out quack Christiane Northrup. I was told by this person my wife would never have kids after the vaccine, its satanic, mind-control, etc, etc, etc, but after a conversation the person decided to get the vaccine (still a little hesitant but they got it and and after a few weeks I think they feel comfortable about the decision). Hopefully they never listen to or read anything from that grifting POS again, but those type of people play on your emotions so naturally they will want to listen and they will believe what they say.

An update on the media stuff. Tucker Carlson is now using "data" from VAERS to claim that the current vaccine rollout is the deadliest in history. This irresponsible rhetoric is why so many are so adamantly opposed to vaccinations, if people were still wondering.

Some of it is quite literally unbelievable.

Not exactly. They are protected by the vaccinated for the most part. (and...most anti-vaxxers were fully immunized as children). Agree. It has little to do with intelligence. Intelligent people are susceptible to disinformation and can be manipulated just as easily as anyone. They aren't making a smart choice but I think a lot of that is driven by disinformation campaigns, which like I said, are manipulative and cult-like.

Granted I haven't really been paying too much attention to the news, I haven't really seen this. I know CNN regularly has Dr. Peter Hotez on whom I have much respect for. My major concern is social media where there is a fine line of choosing between "censoring" someone and preventing the spread of misinformation that could literally kill (see here: Disinformation Dozen). These people are pretty crafty and oftentimes employ the same tactics of cult leaders. It would be very difficult for anyone who is a part of news media to counteract these statements because of the distrust in the "MSM" that has already been sown by others. No matter how reasonable a message being put out by CNN, FOX, or whoever, the types of people who are fanatically opposed to these vaccines are highly unlikely to believe it as a reputable source anyway.

Not enough appointment time to undo the damage done by the internet. Finally saw the "18 reasons I'm not getting vaccinated" blog post that has been going around. What an absolute piece of smacked dog crap.

I think if we are talking about getting herd immunity it will be essential. ~20-25% of the US is younger than 16, so if we don't vaccinate them we will never be above 75% (not sure what the actual number for herd immunity is anymore, if anyone knows). Less transmission among adolescents means less mutation. Also, Michigan is seeing more and more young people being admitted to the hospital with their continued $#!7-show, so there is reason to believe it would benefit them more now than in the past. Every intervention has a possibility of harm - this one seems pretty low risk compared to tons of stuff we do. But let's wait and see the data they have. That being said, it does seem like a bit of a luxury considering so many places in the world are still not vaccinating the at-risk populations at high rates.

Haven't seen too much. I'm sure they work just fine and are safe... and I'll be happy to have them available to those kids. How are things in your neck of the woods?

To add, there are many procedures that even experienced PAs/NPs/physicians rarely get a chance to do and rarely get any opportunity to practice. This is where mental practice comes in. Find a procedures book or watch a video on a procedure. Repeat the steps over and over in your head until you can't get it wrong. Visualize the anatomy and get every step down. Think about complications. All of this should be available to you for little or no charge. Yes, there are certain things that require physical proficiency, but the more common things you can easily practice at home (i.e. suturing and knot tying - I practice knot tying with an old shoe string and fishing line...it works.) Here, Scott Weingart talks about expertise and gaining proficiency. I think he discusses procedures towards the end.

You never know if you don't try. I can't imagine anyone filtering you out based on GPA unless you apply to schools that only care about that (they exist). Some more questions: Who are you asking for LORs and will they write good recs? This matters. Shadowing hours? Worked with PAs? GRE? Might be worth retaking A&P (I or II?). The Jiu Jitsu thing may actually be helpful. Some programs really care about those little things that make you unique as an applicant and I'd say that would count. Not sure how time consuming those clubs are, but I'd consider dropping some of them if they interfere with your grades.

Does anyone have an email template I could use to send to my delegates regarding title change? Thank you in advance.

I think they are pushing to remove it altogether but that has to be done at a higher level. Interesting that we had to complete 24 hours of training to get people off opioids but no specialized training to prescribe opioids. I'm currently doing the training and I've found it to be pretty good and I'm glad I'm doing it regardless of requirement.