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ral last won the day on December 10 2017

ral had the most liked content!

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About ral

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    Physician Assistant

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  1. Didn't mean imposter in that sense. I know what I'm doing. Of course, everyone questions themselves about decision making and such, from time to time. I mean it in the way that patients like me (for the most part), and have a genuine sense that I am completely engaged in taking care of them. I am not. As soon as I am out of a room, my brilliant smile fades, and I check the clock to see how many more hours and minutes are left before I can go home. I would never burden a patient with my dislike for the job. They deserve the best care I can give them.
  2. I'm an imposter in front of patients.
  3. Twofold actually: 1. vasoconstrictor properties of the decongestants may be beneficial for the headache ( I am from the old days of using DHE-45 by direct venous injection; we wouldn't even bother putting in a saline lock), although I realize there would be minimal vascular uptake. 2. Pre-treating could reduce mucosal edema that sometimes accompanies headache syndromes, enabling the lidocaine by atomization to really get up in there.
  4. I remember the nasal "lidocaine on cottom tipped swabs" trick from twenty years ago. Never really gained much ground at the time. Had one older doc who liked viscous lidocaine, with the claim it would "stick" better. (We also went through a period of adding 20mg of lidocaine to nebs on our COPD exacerbations in the ER) EMED: Any plausible benefit to pre-treating with a nasal decongestant (Afrin, NeoSinephrine) 5-10 minutes before utilizing the atomized lidocaine? I know there are some compounding pharmacies who provide the combo to ENT practices.
  5. What is this "bonus" that everyone keeps talking about? I think I got a voucher for a ham or a turkey one Christmas, and that was a long time ago.
  6. Back in 2003, a group of us (PA and NP) were hired on by a rural hospital, to replace a physician ER group. I think they were paying me about $35 or $40/hr. Very busy place, with a lot of high acuity stuff brought in by first responders and county EMS. My first six months there, over $300k was billed in my name. I eventually moved on, and pay has gone up since that time but, so have the billing numbers. We make people a lot of money. As long as they share what I feel to be a fair amount, I'm okay with that.
  7. From the "You can't make this stuff up" pages of my ER days: Had a father run into our small rural hospital many years ago, screaming for help, while carrying his toddler. He basically throws the kid at me and says, "The last time his fever got this high, he had spinal laryngitis!"
  8. To keep things as simple as possible, I will give a most basic example. Let's say you see nothing but established patients in a family practice setting, and every one of those patients is a simple 99213 code, with no procedures (think typical URI symptoms, exam, buh-bye). 2017 CMS fee schedule for wRVU for a 99213 has a value of 0.97 To meet minimum expectations on your contract of 3800, you would need to see 3918 (3800/0.97) patients per year. If you want to break it down, that's an average of 327 patients per month, and if you work twenty days per month, that comes out to about 16 patients per day. That is what earns you your base salary. Anything above that number, either by volume of patients, higher EM codes, or additional CPT codes with the visit (you put a splint on a wrist, did an I&D, etc.) earns you more RVUs. Remember though, the additional bonus structure only starts once you have hit your minimum 3800, and only pays for RVU above that number. If you are seeing 18 patients a day, that means an extra 40 patients per month, or 480 patients per year. So, an extra 480 patients per year puts you at 4280 patients (3800+480). The extra 480 at an RVU value of 0.97 (we're still using the basic 99213 for every patient) gives you 466 total additional RVUs for the year. Since you haven't hit the upper threshold of 4500 that you stated, those 466 RVUs are paid at the $22 per RVU rate, which comes out to a $10,252 bonus for the year. Substitute patient numbers and RVU values to play around and figure potential earnings. Clear as mud, huh?
  9. ral

    Opinion/advice needed

    I would not but, that's a personal thing, and not a knock to the profession. If you can see yourself being truly happy, then definitely go for it. I am sure it will bring you much reward.
  10. Well, I must have been typing loudly. I see they’ve added an echo and nuclear stress to the plan, for positive murmur on exam. The PhysExam notes specifically state “No murmur”. GMOTM: some radiation upward but relatively quiet carotids.
  11. Stress echo was part of the plan. PCP said to give a ring to the cardiologists’ office, and kill two birds with one stone. They have all the needed equipment at their clinic. Works for me, and I am new to the area and practice, so still collecting contacts. I am just confused as to how a 3/6 disappears in 30 minutes.
  12. So I looked at the original title I posted for this thread. It was uncalled for. My apologies. Twice in the past two months, I have made referrals to cards for murmurs. First was a young twenties female in for allergies/URI. Murmur heard midsternal border. Increases on inspiration. I’m thinking maybe tricuspid regurge. Make referral and discuss with her primary. He has her in, and notes same murmur. She goes to cards. I read the note: regular rate and rhythm, no murmur. Today I am clearing an elderly lady for surgery, and hear a 3/6 SEM RUSB. Talk to her primary, then get her over to cardiology, so that she can be checked out to carry through with surgery. Just read note: “bla...bla bla bla... no murmur”. WTH?? I know a frikken murmur when I hear one.
  13. My favorite of the “lesser of two evils” decision lately, has been older gentlemen with prosatitis. Review of med hx and labs frequently reveals they are on an ACEI, and last three potassium levels have been right around 5. Bactrim warns me of lethal potassium levels, and Cipro or Levaquin says they will be crippled when their achilles all snap. Funny how none of this crap was a consideration until the lawyers got involved.
  14. One case of anything can hurt you, if it's in the literature. That said, where do you stop prescribing? Commonly held associations such as c-diff colitis with a large number of antibiotics, gastric ulcers with NSAIDs, ototoxics, nephrotoxics, hepatotoxics, rashes, nausea, headaches, myalgias...anything resulting in loose correlation with any medication can burn you.

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