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About jk5142

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  1. Yeah definitely an interesting case! I'd want to see the pH and temp corrected to see if hypotension/shock improves. At least the lactate was not elevated which is somewhat reassuring. I think the only other thing that came to mind was considering intubation for this lady. Sounds like she didn't need it (protecting her airway) etc, and the hx and scene you describe seems to imply her clinical condition was somewhat stable for the past 1-2hrs. (or at least somewhat responsive to interventions/not actively deteriorating). But with a pH that low, and if was a metabolic acido
  2. Off the top of my head with the hypotension and acidemia w/ pH 6.9>>very concerning -couple amps of HCO3 stat (if no concern with ventilation, and assuming this is a metabolic acidosis/?AGMA (uremia, renal failure vs some toxic ingestion -Central line placement>> and probably dialysis catheter for urgent/emergent dialysis With a pH that low you can definitely have: -vasoplegia/distributive shock -also can have some element of cardiac dysfunction (ScvO2 off the central line/bedside echo) Otherwise same as the above -IVFs (barring phys
  3. definitely didn't sound like one could r/o sepsis (especially if he looked sick and there was worry he was on the verge of decompensating). Interested to see if he does end up with dx of HRS. But I would guess/hope he responds to fluids and renal function improves. -In my limited experience, I think the ED starts lactulose if pt is a known cirrhotic/home med and presents with fairly obvious HE. But as encephalopathic as the pt sounded, not sure if the ED would be eager to shove an NG down (with ?any varices present if he's suspected to be a cirrhotic) to start lactulose with the risk of
  4. It does sound like his encephalopathy could be multifactorial (UTI, HE despite normal ammonia, uremia assuming BUN is up along with that Cr) The AKI (?CKD) could be HRS but I believe HRS is usually a dx of exclusion. Workup AKI with renal US, FENa/FEUrea. Check urine sediment for ?ATN. See response to IVF boluses from ED. Hope he makes urine. To me this sounds more like an undiagnosed cirrhotic now presenting with decompensation. Not quite convinced he is septic (no fevers, no leukocytosis, BP stable, breathing ok) although would definitely still keep the abx on board whil
  5. A-seems to be protecting for the moment B-satting ok, no mention of labored respirations or other specific patterns of breathing C-appears hemodynamically stable Hx: comorbid conditions, known liver disease, EtOH hx, drug user, meds/APAP use, onset of jaundice, any belly pain or GI sx, any other neuro sx, increased edema, recent weightloss Exam: Neuro/HENT- look for head trauma, scleral icterus, neuro deficits, mvmt of extremites, mallampati score Neck-JVD? CV-usual Lungs-usual Abdomen: pain? RUQ tenderness? ascites? Extremi
  6. I'm definitely on board with most of what you said. I agree that we have the potential to perform/provide the same level of care as an "?excellent" physician. I agree that everything being equal (especially motivation, training opportunities, and experience) we can perform at a similar level, because as individuals we have the potential. Enrolling in a PA program vs MD program does not intrinsically determine the caliber of individual you are, and ultimately what is medical school and residency? It's a course of study/training program that is designed to produce medical providers. I gue
  7. "This is correct. PAs do a lot of things that doctors can't do and frankly we are better than they are at many tasks. One example is our pediatric CV team has 4 PAs and they are all better at balloon aortic valvuloplasty for aortic stenosis than the interventional cardiologists are in the cath lab. All those cases are done by the PAs, not the MDs." The views that you express here seem quite ludicrous. While some of these statements may be true, it is important to contextualize them in order to prevent them from being misleading. I would like to evaluate som
  8. Thanks for the post! Did the pt/facility need to get special consent/release of liability in order to get the imaging? Did radiology in-house agree to interpret the films? We have gotten the occasional pt who is too large to fit, and/or too heavy for the table to support and unable to get CT/MRI/radiation therapy. This possibility of sending the pt to the zoo was brought up, but our staff here said it wasn't possible due to the liability associated with trying to image a human in a machine (ostensibly) designed for animals.
  9. Not too familiar with the literature there, but the literature/data would need to be compelling enough to overcome a number of barriers to implementation (even for EM/CC physicians with the subsequent trickle down to PAs) I haven't heard/seen anyone perform TEE during cardiac arrest in medical ICU settings. Even utilizing GDE/TTE in code situations doesn't seem to be a given.. perhaps it may be different in other ICU settings where anesthesia/cards involvement is greater? I imagine there would be a number of obstacles to implementation..even aside from the turf battle between Card
  10. 1. consider/cover for possible opportunistic infections (to include viral, fungal organisms) 2. drug levels/monitoring -consider drug toxicity -if continuing current IS regimen, probably consult whoever is managing tx 3. close monitoring of renal function
  11. Seems to happen every once in a while in the icu...I've never examined the foley after a traumatic foley (self) removal to be able to say whether the balloon system remained intact. FWIW.. Usually with the few traumatic foley (self) removals I've encountered with patients, there is hematuria without significant evidence of blood loss. We call urology and they will typically re-place the foley and order regular irrigation of the catheter for some period of time. There may be some minor hematuria following but have never had significant drops in Hgb. I wouldn't expect the cause of deat
  12. Salary is usually discussed at the time of the offer. I would avoid bringing it up specifically during the site visit unless they broach the topic. That's my opinion
  13. In my experience, depending on the number of positions they're filling-they usually whittle down the applicant pool through the interview process, and if you've made it to the site visit it's usually around a handful or so (definitely if they are paying for travel/lodging expenses related to the visit). I'm not sure what it's like in a setting like NYC, I imagine most applicants will be local as they probably don't want/need to pay for out of state applicants. If they are all local-there may be more applicants at the site visit phase? This is just based on pure conjecture-perhaps someone
  14. FWIW in my experience (I'm a fairly recent graduate with <2 years experience in CCM) my approach has been to: -be punctual, professionally dressed, genuine, polite to everyone, show interest throughout the entire day, silence phone -display humility and self awareness (basically the awareness that if you think you know what you're doing as a new grad-then you are probably going to be dangerous), but balance that with faith in yourself and your ability to learn and become a competent provider -I wouldn't expect them to grill you with clinical scenarios, especially as a new gra
  15. Agree. It's important to appreciate and understand the origin of the PA profession. But it is also important to understand the changing landscape of healthcare delivery in the US and adapt as a profession.
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