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coloradopa

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coloradopa last won the day on February 13 2009

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  1. We don't have Procalcitonin so my experience with this is limited. However, 40% of sepsis is culture negative. The negative lactate is a bit of a puzzle but I have seen this in hypothermic patients. Once you resuscitate them and get them warmed up the lactate will probably go up. In our shop the patient would get 7 days of broad spectrum antibiotics unless they have something we could target. By the time the cultures come back negative the patient is either dead or getting better and nobody wants to stop abx.
  2. This is septic shock until proven otherwise. It smells of GNR sepsis. This is a relatively common presentation for someone with untreated sepsis for a while. Especially when found down. would be willing to bet that the urine comes back dirty. A couple of things. When you have a pH like that and found down I would check a CK. You could have a superimposed rhabdo. It really wouldn't change management much except to go to dialysis early. On the subject of lack of tachycardia. Two answers either temp or the patient is on a beta blocker (fairly common depending on age). For that matter a certain subset of patients don't mount a tachycardic response no matter what. It probably has to do with the hyperdynamic nature of the heart in most sepsis. The way that I put this together is patient gets a UTI. Develops septic encephalopathy and shock. Goes down. Lays there an unknown amount of time and the goes into renal failure as well. The reason that the pressure didn't come up is you haven't filled up the tank yet. The CVP of 2 (while not generally used as a measurement any more) indicates the patient is profoundly intravascularly dry. It sometimes takes 5-6 liters until the patient is tanked up although this is controversial:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5209309/ I generally give 30 ccs per kilo then put them on pressors. I also agree with dropping a probe to look at the IVC. That's a good way to guide further resuscitation. Also the Hgb is likely falsely high since the patient is probably hemoconcentrated. The patients BP is also probably artificially high due to temp. When you warm her up it will drop even more. I also disagree that you need SIRS plus a source to treat. In the new guidelines you have a QSOFA score of 2 which is enough to treat. Outside of known heart failure volume, pressors and early antibiotics are what improves survival. Overall it sounds like you did the right things. I would have gone to pressors earlier to get the pressure up while resuscitating but thats probably a style thing.
  3. coloradopa

    CCM fellowship after EM residency

    I don't know if we have any PAs that split between ED and CCM but some of the CCM PAs moonlight in the ED. For us we work 3 days a week so there is time work elsewhere. We also staffed up critical care beds in the ED. Critical care in the ED is more difficult just due to the nurse staffing in our institution. On the other hand we do have PAs splitting jobs between departments. One of my coworkers is 1/2 time CCM and 1/2 time with our ID department doing sim training in Serious communicable disease (Ebola). She works six shifts a month then spends the rest of the month flying around the country doing training so the opportunity exists.
  4. I have a pretty simple way to address this problem. This is a nursing problem and nursing has to deal with it. I have variable relationship with the nurses but I have a very good relationship with the charge nurses who have a very dim view of nurses not doing their job. So if I have a problem with an order or timely work I simply point out the issue to the charge nurse who addresses it. Problem solved.
  5. coloradopa

    Shared visit?

    Doesn't matter as far as shared billing is concerned. The person billing for a procedure must perform the critical portion of the procedure. The injection should be billed under your NPI.
  6. coloradopa

    Everything being billed under physician

    Here is a pretty good article. Look at question #3. http://www.medicaleconomics.com/modern-medicine-feature-articles/incident-billing-clearing-confusion Here is another: http://www.mdmag.com/physicians-money-digest/practice-management/non-adherence-to-incident-to-billing-can-prove-costly Here is CMS guidance: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf
  7. coloradopa

    Everything being billed under physician

    Two different issues: 1. For Medicare/Medicaid the first encounter must be by the physician and must document the plan of care. The APP can then see the patient for the same problem under incident to as long as the physician is in the suite of offices. This is called incident to. If this does not happen then it should be billed under the APPs NPI at 85%. It doesn't matter if the chart is co signed. Any patient that the APP sees for the first encounter or sees without the physician present is billed under the APP NPI. 2. For other insurance they are usually billed under the physician NPI at 100% unless the practice contract says different. With Medicare you are talking about fraud. I will also guarantee the ABIM does not say this is the way to bill. It seems you are working in a multispecialty center. I would talk to you practice manager or whomever is doing the billing let them know they may also be liable for fraud.
  8. It depends on how the physician contract is structured. Essentially both the PA and the surgeon need to be paid by the same entity. If the hospital is paying the physicians a salary and then billing for them they can bill for your services since both are employed by the same entity. Alternatively if they are given a stipend but then billing for their services then the hospital cannot bill for your services. In addition your assistance in managing their patients may be considered a Stark violation. In this case the surgeons can pay the portion of your salary dedicated to their patients and then bill for your services. Don't forget for Trauma you can also bill critical care if indicated. Contrary to whats posted above you should not be included in the hospitals cost report. Prior to 1998 PAs were included in the cost report but after 1998 with the ability to bill for our services Medicare rules state the hospital must bill for your services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1168CP.pdf
  9. Hello Mr. Carpenter, PA-C, 

    I am a senior in college planning to apply to PA school this upcoming cycle and am interested in RRCC's program because of its heavy emphasis in primary care and the community.  I noticed while perusing the PA forums that years ago you lectured there and are familiar with the community. I was hoping you could provide me with more information about the program:

    1. How are the staff and faculty? Do they help create an environment that promotes the growth of students?

    2. Does the RRCC PA program have volunteer opportunities to give back to the community?

    3.  What makes the RRCC PA program different from other PA programs?

     

    P.S. I wanted to PM you, but when I tried it said you could not receive messages. If you could PM me then that would be appreciated.  

  10. coloradopa

    Statistics on PA residency advantages??

    What ARC-PA told you is true. There is a new accreditation process coming online through CAAHEP probably some time next year.
  11. coloradopa

    Making the switch from PA to MD

    Critical from EM or IM is 2 years. So if you do 4 year med school 3 year residency and 2 years CC then its 9 years. If you are in a 4 year EM residency its 10. LECOM would take 1 year off that.
  12. coloradopa

    Making the switch from PA to MD

    Actually there are now multiple options for EM/Critical care. We have two attendings that are double boarded.
  13. coloradopa

    ARC-PA accredited residency?

    ARC-PA isn't going to look at this until at least November. However there is a new PA residency accrediting organization forming under CAHEP.
  14. coloradopa

    Military Spouse (Pre-PA)

    You can have licenses in more than one state. A lot of practice in border areas have offices in 2-3 states. Generally to have an active license you a practice relationship with a physician. If you move and think you might come back you can usually put your license in suspension (lower cost to renew). Otherwise you can suspend/let the license lapse once you get your new license. Also if you work on a military installation or for VA you don't have to be licensed in the state you are in. You simply have to be licensed somewhere in the US.
  15. coloradopa

    Critical Care PA pay

    We cover our ICU 24/7. We have night shift and day shift. Basically we do 3 13.33 hour shifts per week (0600-1930 or reverse). You have to work 6 shifts per 2 week pay period. We get PTO instead of vacation/sick time. 8 hours per pay period (400 hours per year). We also get $2000 and 40 hours for CME. We have differentials for nights and weekends. If you are not weekend option you get $125 per weekend day or if you cover a night you get the same (if you are not on night differential). For extra shifts (beyond 6 per pay period) we have have a system that is specifically not called overtime. Since we are salaried and exempt we don't get overtime. Instead we get extra duty pay (for hours beyond normal duty). It essentially works out to $75/hour for days and $100/hour for nights. You have to do it in four hour blocks. Our group looked at weekends and essentially from a quality of life issue doesn't want to do more than 1/4. We have a weekend night and weekend day position that carries a differential. Basically 10 FTEs give you 2 providers 24/7 with extra for vacations.
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