jmj11

The first time I went into surgery, as a student, I had a panic attack, the first of my life. I was working with a thoracic surgeon. I had been sitting and talking to the patient and then the next thing I know, I was holding his beating heart in my hand. No one noticed but I had a full-fledged panic attack. Eventually the anxiety abated. With such panic attacks, as you may know, may be provoked by an anxious event. But then the anxiety becomes centered around the fear that you will have (or have another) panic attack. Vasovagal induced LOC is uncommon. Hyperventilation can lead to LOC, but it is very hard to hyperventilate while wearing a surgical mask.I think a good cognitive therapist can help train you to self-talk you way down. Remember, exposure helps and leaving the OR, to never come back, will make it worse (or rob your life of the experience). I've heard that OR anxiety and panic attacks are quite common.

We just upgraded our EMR (MediTech) and my life is profoundly better. I don't want to sound like an advertisement, but I have more time to spend with patients, I come to work 30-60 minutes later (used to have to prep charts) and I go home a the end of the day with all charts complete and signed.

The only lesson I learned from chiropractors (which many of my patients love) is that the patients love them, because they touch them. I have made it a habit of touching my patients whenever the situation invites. "My head is hurting here today," I touch it, rub it and ask, "is that sensitive." I touch their necks, not as treatment (like a masseuse) but to give a sense of empathy. However, I always end each visit with, "Anything else going on in your life?" If they respond, as they often do, "I had breast cancer this year", or they "just found a lump," or "my mother died" or "my son is on drugs," I often give them a hug at the end of the visit and conversation about those things. I try to always hug in a way that would not be mis-interrupted. I give women, and sometimes men, side by side hugs, my arm around their shoulder and a squeeze, rather than any kind of frontal embrace. Same with kids and always with their parent right in front of us.

I wish I could give you up to date information as I was in the Air Force in the early 90s. It was a great job with abundant time off and a great way to raise a family. However, our based closed and I asked for several overseas assignments, but was giving a terrible assignment in the desert of NV, where I could not bring my family so I got out.

Aimovig was approved at midnight. Go here, Aimovig.com. This is exciting!

It's a drive, but I can work it out and I'm in Anacortes.

This one isn't so funny as interesting from a psych standpoint. Psychotic patient, who had an obsession with her past "sexual sins" came in with a severe vaginitis after douching with undiluted lysol cleanser. (the bar of soap above reminded me of this one).

Thanks. That was great.

You seem to be hinting at a acute inflammatory process. I skimmed the above (I'm with patients right now) and didn't see BUN/Cret but I'm sure were done . . . and normal? Early I was alluding to a inferior vena cava syndrome (not leg clots), which I've seen once with these symptoms, but is very rare. I thought of Erythema nodosum, but have never seen pitting edema with it, just the stereotypical sub-q leg lesions. Just thinking out loud. Doesn't sound like a pump issue.

US, Inferior Vena Cava for starts.

I can't think of any hard-to-solve cases right now. But does anyone else have one? If so, take us all on a guessing-figuring-out process. Let me throw out one, which is interesting, but not that difficult. I recently saw a 35 year old lady who had a neck-pain syndrome. No injury. But she had severe neck pain for about 10 days each month (around her menses) and no headache. She pursued this from a neck pain perspective and had multiple scans (moderate DJD but nothing more). She had multiple neck injections (facet joint) with no benefit. Then she saw a neurosurgeon who eventually did a cervical fusion. Still no help for her disabling neck pain for 1/3 of her life (the other 2/3, no pain). She was several medications (gabapentin, amitriptyline) with no help. So, she finally started to think that this may not be a neck problem. She, of course, was right. The neck pain was totally aborted with sumatriptan and when we worked up to 40 MG of nadolol, the number of days dropped down from 10 to 3 per month, easily treated with sumatriptan. The neck is often a referred area for migraine, but I can't remember seeing a case where the pain was exclusively neck. So, give us a more challenging case!

Yeah, I got an idea. Go to PA school! You will love being a PA if you loved medicine. I would go crazy being a pharmacist.

Having attended virtually every national and international scientific conference on headache for the past 30 years, I can say that there is a world-wide standard for best treatments. It can vary slightly between individual provider. I'm not sure what "natural physiotherapy" is, but there is limited evidence (not really placebo controlled) studies to support acupuncture as well as PT. One evidence based study ( only one ever) comparing chiropractic and a medication (amitriptyline) and it showed chiropractic as equal and some debate the merits of the study design. There is a lot of pseudo-"best treatments," because some providers rely on mythology for treating headaches rather than giving it the same scientific respect as COPD or cardiac diseases.

I follow the Washington State Quality Medical Assurance newsletter, which list (among many other things) those MDs and PAs who have lost their license. For MDs it is almost always sexual. For PAs it is mostly, something along the lines of "providing medical care without documentation." Some of those are writing Rx for narcs for family and friends, but some of them are providing other medical services "off the record." I have done exactly what you have said, but I create a chart note and fully examine the kid, before I sign off. If I remember right, I cleared it by the practice I was in at the time (about 20 years ago, so I don't remember).

This is somewhat billing 101. Surely most clinics are not doing this. When I owned my own clinic, I followed the rules to the letter (usually billing at the 85%, rarely meeting the 100% requirement).