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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 acidosis: I would like to see her attempting to compensate respiratory wise with a low PCO2, if the the PCO2 was normal or elevated/or if there was any concern she was not stabilizing>>>intubation and hyperventilation at least to compensate and improve the pH somewhat.
  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 physical exam findings c/w gross volume overload) -vasopressors -BS abx -rewarming of the pt
  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 causing GI upset/vomiting/bleeding/aspiration >>> airway. With the pt. in the ED>> resus/stabilization and appropriate dispo (in the midst of the fog of war with limited info and severe time constraints). ICU/medicine>> gets the luxury of time/more information/ability to see response to previous interventions to then monday morning QB the ED, which I don't believe is fair at all.
  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 while sorting everything out. CT a/p or at least RUQ US. I would assume there would be cirrhotic morphology noted, and if ascites, dx para to r/o SBP. -would definitely want to work this up to distinguish between decompensated cirrhosis vs ALF from acute infection/ingestion (he does have coagulopathy and encephalopathy). -would probably start him on lactulose -call GI/hepatology who seem to like ordering acute hepatitis panel (A,B,C), APAP level, salicylates, check for titers for HSV/VZV, ceruloplasmin.
  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? Extremities- edema? asterixis? pulses? Skin: other stigmata of chronic liver disease? bruising? Request>>> ABG, lactate, EtOH level, ammonia, Utox CBC, CMP, aPTT/INR Intvn: monitor MS/airway IV access- US if needed to place peripherals CT brain wait for labs to come back
  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 guess what I was trying to say is sometimes we generalize or make broad statements that can give the wrong impression or mislead (especially in an online setting, or to those who are new to medicine, have less experience, or come from a significantly different perspective). For you specifically in EM and previously in FM, based on those clinical settings, you were completely interchangeable with a physician counterpart. I can't dispute your personal and clinical experience (and while I can't really know your depth of clinical knowledge, procedural experience and expertise, and bedside manner ) but based on what you've shared it sounds like I would definitely want to be cared for by you (or have a family member cared for) vs some "run of the mill" EM physician who may be less dedicated, motivated, or talented. I guess what happens is someone may say something along the lines of: -in EM I perform essentially the same clinical duties as a physician. In my estimation, I believe I provide exactly the same care to X level/skilled EM physician. When I hear that, I imagine "his airway management skills will be on par with those of an experienced and excellent EM physician". But some (excellent caliber-whatever that means) anesthesiologist or ENT surgeon who's invested 20 years of life dedicated 100% to study and clinical advancement of skills doing complex head/neck surgery cases might just hear "hey I'm an EM PA who thinks he can manage airways (including the most complex/difficult airways) just as well as the best anesthesiologists/ENT trained guys in the business. * with that being said, if you had the experience and training opportunities on par with this said individual, I personally would be inclined to think that your skills could equal or maybe exceed that person's skills.
  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 some of your statements and would be genuinely interested in your response. I was not aware that PAs could perform (?independently) BAV, assuming this is so, I can imagine that the possibility would exist that some PAs possess technical skills "in performing the procedure" (?inflating a balloon across the aortic valve) that may be on par with some physician colleagues. With that being said, a few questions I would have are : -do these PAs evaluate patients for appropriateness of therapy for palliation, staging (bridge to more definitive transcatheter intervention (TAVR etc), or ?other indications -do they review history, imaging, US/echo studies, and cath reports) to determine whether they may be a candidate? -do they then independently formulate the plan for the procedure (decide which aortic balloon size to use, etc) and perform it without input from a supervising/collaborating physician? -do they also possess the skills and knowledge to manage (nonsurgically of course) any potentially catastrophic complications that may occur during or immediately afterwards? -also do you feel your statements would hold true if you were to correct for the # of times said procedure was performed by generic intvn cards guy so that the PAs #s were equal to the cards guy/girl? ** also I would be careful when making statements based on your personal experience with 1, 4, 16 or some other limited number of interactions with physicians, to make the statement "we are better than they are" unless you feel your n is sufficiently powered to be able to make the broad statement (from what little I remember from stats class). And when making these types of statements we should try to be aware of potential biases that may invalidate our claims. Try to remember/clarify who/what we are comparing. To keep it "fair", I would say try to make the comparison thinking that a PA with some arbitrary ranking of skill/medical knowledge in the 80 percentile among other PAs in her/his field is compared with the interventional cardiologist in the same percentile bracket amongst her/his own peers. With all that being said-I would think that your statements above are not entirely accurate and probably misleading (at least based on my interpretation of what you were trying to say). So please, please be careful when making comparative statements. Especially when they involve us PAs, as expressing views that are not accurate or misleading probably lead to animosity (somewhat justified) from some physicians towards us as an entire group/profession (because they are also allowing the same conscious or unconscious biases to affect their opinions). Sorry for the long post but it's something that's always bugged me when I read these types of arguments/statements online regarding all areas of life/medicine/sports/whatever. -
  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 Cards/anesthesia and ED/CCM -privileging for the procedure/demonstrating competency/liability/billing -logistics/maintenance/storage of equipment to be quickly accessible in the ED/ICU
  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 death to be directly attributed to blood loss, and besides urosepsis (which I would not think of as a complication of the event), I can't think of a reason for someone to die from a complication related to the event. If there was disease progression of whatever else was ailing him/her , leading to encephalopathy>foley self removal and ultimately their demise, that would make more sense. But interested in hearing if others have had different experiences with this..
  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 with actual experience with NYC may be more helpful
  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 grad (if they do-it may be to gauge your critical thinking ability more than your fund of knowledge) -realize that during the site visit phase they are interested in seeing how you are as a person and whether you "fit in" to their existing group or practice setting, and also your potential for staying with the job (they prefer to avoid turnover as it's more work for them to continuously hire new people) -come up with a list of questions to ask, e.g. what is their philosophy on the role of PA's in X setting, how are the relationships/work place dynamics between physicians, PAs, nurses, etc, and any other questions that demonstrate your genuine interest in the position -last but not least, if they give you an itinerary for the day with names of specific physicians/PAs you will be interviewing with, I try to google them and research their educational background, professional interests, etc to try to get a grasp on what kind of person they are (but usually don't let on that I have done so during the actual interview) -typically at the end of the day-depending on how it goes- they will let you know when to expect to hear back from them (ie by the end of the week). If they don't specifically say-then I would ask. -usually they should give you a cpl days to respond to the offer
  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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