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Everything posted by EMEDPA

  1. Recently ran a hypothermic arrest at a rural hospital. As expected, it did not go well for the patient. In brief: Found with agonal respirations and coarse vfib after long downtime lying outside in the snow after syncope of unknown cause for 3-12 hrs based on family estimates. Older patient with multiple bad comorbidities(DM, Afib/anticoagulation, htn, etc). Cpr started in field by medics and IV line started. epi x 1 given and 1 shock for coarse vfib. BVM only as they could not open pts mouth at all. core temp on arrival approx 24c/75f. Sux x 2 rounds and ketamine x 1 relaxes jaw enough for placement of king lt airway. considered fiberoptic nasal, but decided to focus on other priorities. Foley placed and bladder continuously irrigated with warm saline. warm IV fluids and warmed, humidified o2. bear hugger placed. continuous cpr. end tidal co2 in 12-15 range(8 at the cessation of efforts at 45 min). standard acls to include multiple rounds of epi, lido, amio for persistent coarse vfib. defib x 2. d50, narcan, bicarb given. decision made to hold on additional drugs or defib attempts until temp raised. considered, but decided against peritoneal lavage and thoracic/chest tube warmed lavage as likely futile. In consultation with hospitalist and family present at bedside opted to stop efforts after unable to raise temp more than 2 degrees in 45 min in dept after 30 min in field. I know at a big center there are lots of options like ecmo, hyperbaric o2, etc. Anyone here run hypothermic codes and do you have any wisdom to share? This case presented immediately(2 min) after the paced 2nd degree type 2 HB pt discussed in the em quiz post recently had left the dept.
  2. just treat the bonus like a bonus. don't depend on x thousand/yr. I know many who have and they got into financial trouble over it by buying cars, boats, etc they could not afford.
  3. MCAT is not required for LECOM. *Recognizing that alternative measures can be used to demonstrate the ability to handle challenging curriculum and that GPA is more predictive of successful completion of medical school, we consider the LECOM Academic Index Score (AIS) as an alternative for outstanding applicants who have not taken the MCAT. The AIS uses the overall total for undergraduate and graduate GPA in formula calculation with ACT and/or SAT Critical Reading and Math scores in consideration of offering interviews. A minimum AIS of 110 is required. Calculate your AIS score here. Once you have submitted your AACOMAS application, please email the APAP Administrative Coordinator so that additional information can be gathered. Accelerated Physician Assistant Pathway (APAP) Accelerated Physician Assistant Pathway APAP Curriculum Overview APAP FAQs

    Am I Setting a Good Example...

    mmmm, smoked thin mints....all melty like smores....
  5. Looks like a reasonable first job. ask for them to cover dea and a few bucks more/hr and you are golden. if they say no, take it anyway...

    APP Fellowship in Inpatient Pediatrics

    there is one in KY https://pediatrics.med.uky.edu/pa-neonatology-residency and this one in philadelphia: https://www.chop.edu/pages/neonatal-physician-assistant-residency-program
  7. you can try. you don't have much room to negotiate as a new grad unless you have a unique skill set that they need that other new grads don't have (surgical tech, ortho cast tech, etc). hopefully there is good mentoring/teaching and you will have backup at night when on call to the floor.
  8. at 50 hrs/week that is around 109k before bonus. If it is a very low COL area and you like the group it might be worth a try. Hopefully they cover licenses, dea, etc.
  9. at the other end of the spectrum, I just set up an elderly pt with multiple risk factors for a nuc med study despite being sx free in the ED with nl trops and a stone cold nl ekg. it's all about risk stratification. pretty much as soon as this pt walked in the door they had a timi score of 3 and a heart score of 4-5(and would every day of the week).
  10. agree that in someone with risk factors your probably want more than a basic EST, but what about a 51 yr old guy with zero risk factors who is in great shape? imagine someone(say a marathon runner) with no No FH of ACS, good cholesterol, non-dm, non-smoker, bp 110/50, resting pulse 52, no recreational drugs, both parents still alive in their 80s and several prior good experiences with anesthesia for common stuff like ear tubes as a kid, appy as a 20 yr old, etc
  11. I agree that a nuc is probably overkill, but a basic stress test is a simple, inexpensive and easy office procedure. I have done more than 80 in ED obs units for stories sillier than this. for a while we were treadmilling everyone in the ED with a c/o chest pain. 16 yrs old. hurts when you do push up only and you just started at a new gym last week? treadmill after 2 neg trops and a cxr. not my call. I don't work there anymore...
  12. on 24 hr shifts, having a student means i get less sleep, because the uti at 3 am that takes me 5 min takes them 20
  13. EMEDPA

    PA vs. PT

    lateral mobility is getting harder every year and will likely vanish within a decade when residencies, specialty boards, and doctoral degrees become the norm for the profession. Honestly, I think that is a good thing. you can't go from pediatrics to trauma surgery(or vis versa) and be anywhere close to competent in your first several years in practice.
  14. EMEDPA

    PA vs. PT

    Good points above. I would add that someone interested in orthopedics could consider an ortho PA residency, which might include many of the same skills learned. As a PA you can write RXs, as a PT you can own a practice without a sponsoring physician. There are advantages to both paths. There are a lot of PAs out there who are former athletic trainers or exercise physiologists who end up going into ortho or physical medicine and rehab.
  15. EMEDPA

    Am I Setting a Good Example...

    you could donate your cookies to a local food bank...
  16. EMEDPA

    Hypothermic cardiac arrest

    Thanks. All the research I read basically said if temp on presentation is less than 80 degrees F it will be a futile effort.
  17. Yup, I know of several programs in the planning stages , which are planning to pay preceptors in the community to insure clinical spots for their students. Community docs frequently decline to teach students, but I imagine many would if told they would receive $1000/student/month. 12k/yr would be hard to turn down as a small practice owner.
  18. yup, I get cold calls and emails all the tix, and like Rev, I try to convince new grads NOT to come to my area as there are 3, soon to be 4, local programs here churning out lots of folks destined to work at crappy jobs like zoomcare because they can't find anything else.
  19. EMEDPA

    Hypothermic cardiac arrest

    I know the "not dead until warm and dead", but there was no getting this pt warm. I also know the "they are dead with end tidal co2 less than 10 at 20 min into the code", but don't think that applies in hypothermia due to slowed metabolism. I knew it was futile, but wanted someone else to agree with me, so called in the hospitalist to sign off on cessation of efforts.
  20. I have seen a handful of these with two fairly serious. Nice summary article on management here: https://first10em.com/tonsillectomy-bleed/ Bottom line: don't send these folks home! Even if you have to keep them in the ED for hours until ENT can see them or transfer them a great distance , next day f/u in clinic is NOT ok.
  21. NYCOM has a similar bridge for FMGs to DO. I believe it is 3 years.
  22. identify the following ekg finding and the xray finding pictured below. hint: the ekg finding can be made just with the leads pictured. both pts seen today within 1 hr of each other. xr1.bmp xr2.bmp xr3.bmp coolekg.bmp
  23. EMEDPA

    em photo quiz( occasional series)

    first trop negative an unk time after syncope(pt found on floor after unk down time). 2nd trop not done as pt transferred emergently for pacer.

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