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VictoriaO

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  1. Hey folks, Just wanted to share this fun game, this was made by hospitalist at Stanford as part of the "Surviving Sepsis" campaign. I like how the pt's keep drifting towards the bottom of the screen as their vitals get crumpier until you do the right intervention. Great practice for newbie EM and inpatient folks, definitely have had ward days like this! http://med.stanford.edu/septris/
  2. Yup, my mentors in the TICU/SICU were the last of that class. Believe me I tried to apply. Tide is turning in favor of PAs up at my hill in the past few years so hopefully more good things to come for us.
  3. Great group! I'm a member. Have truly felt nothing but supported by my physician colleagues as a PA in hospital medicine, seems be a really welcoming field. (haven't been on the forum much but hopefully will have some news soon about a possible Hospitalist PA/NP fellowship at my institution that's been talked about).
  4. Hey there, So I've been working on getting more involved with projects around the hospital and through the Society for Hospital Medicine in general as a PA. One thing that's come up as a "hot topic of interest" is how to integrate a PA/NP into a Hospitalist team. As I was the first PA on my team and sort-of made a "niche" for myself with my interests in the sickest and most complex patients in a very pro-learning environment, I'd be interested to hear from other Hospitalist PAs about their role and integration into the MD groups. What worked for you/didn't work for your group? What would you change about it? How would you recommend PAs be used in regards to admissions, rounding, discharges, etc? What sorts of schedules work for your teams? Thanks guys, I'm really hoping to get a good guideline/presentation outline created to help both us and our MD hospitalist colleagues, I really appreciate any input. Feel free to PM me as well.
  5. 1 year out as the first hospitalist PA at a major academic institution and loving it! In the past month have found ANCA-vasculitis with renal failure, a few multiple myelomas, neurological Wilson's disease to name a few, just found a possible calciphylaxis in my ESRD gal with hypercalcemia (waiting for biopsy today). Do my own procedures when they come up, am 7on/7off and we function as the "pop-off" valve for when the teaching services cap throughout the day. I have my own patients I follow and I'm first-call for them, though I staff them and give updates to my MD's later in the day and we usually talk about the interesting cases as a team. Usually have about 5-10 on my panel and am up for consults or admissions throughout the day. What will your schedule and hours be like? 7on 7off? Days or nights? Academic or community hospital? Formal rounds? If you're doing admissions, how many per shift? Do you do consults for the surgery services or admit ortho patients? If academic, are you the pop-off valve for the resident service for when they cap? Or do you see the patients the house staff don't want (like I've heard at some institutions) like the CFers, chronic pain with gastroparesis, homeless dispo nightmares etc What did you do before PA school and what appeals to you about being a hospitalist? Are you a new grad or have you been out a few years?
  6. Hey folks, Decided medical critical care is where I want to be, our MICU is talking about adding PAs in a few years, I would love to wow them post-residency and breeze through my procedure credentialing (hopefully). Problem is there's not much choice for more medically-focused CC residency/fellowship (lots of surgical programs), UMass is on hold for the next year (and possibly longer). Does anyone know anyone who's been through Hopkins CC residency? I'm hoping to hear back from the program director soon and/or set up a time to talk with one of the recent grads. It looks really amazing, access to the sim labs every month, opportunities for electives in Renal, Palliative, etc. Would be great to talk to someone who's been out in practice a few years post-residency if by chance they're floating around on the PA forum, Thanks! -V
  7. Sad news, this residency is on hold for at least one year. Was planning to apply next year, their curriculum looks stellar. Let's hope they get up and running again soon.
  8. Agree with what everyone said above, things are getting better though. New legislation now that the Oregon Medical Board cannot dictate scope of practice, scope of practice is between us and our SP. As far as Portland goes, one of my classmates got a CT surg job as new grad. Ortho is always hiring, if you like doing pre/post op clinic (most of what I've heard from classmates in ortho, not sure if much OR time). You might get a better gig at a non-teaching center for ortho. EM is very tough as a new grad, believe me I tried to find a position nearby. If you wanted to live in Portland you could commute to somewhere more rural. Most places want 1-2 years of experience at least. As far as Trauma-only 2 hospitals with Trauma PAs (that I know of) in Portland, one (my hospital, the one on the hill :;)):) has trauma PAs that hold down the ICU and they are very experienced CC PAs who have been through residency. Did my elective there which was super-procedure heavy and high-acuity. Not a place for a new grad, IMHO. Other hospital has trauma PAs that go to the ER for trauma and manage all the patients stable enough for the floor. Not much OR or procedures from what I heard, no ICU time, also do do trauma clinic follow-up. Gig might be better than when I got an offer from them which I didn't think much of, know a new PA grad who's starting with them and she was happy with her offer... Feel free to PM me if more ? about Portland. -V
  9. This is posted in multiple workrooms around my hospital. I pretty much fit the internist pic to a "T", coffee cup included.
  10. <----Posting without coffee! Excuse my poor sequence of events details. Again, yes you're right, his neurological state quickly went downhill, as to what happened first and the exact sequent of events in the ED (fluids, drugs, products, initial gas), I couldn't tell you with acuracy as I picked up him in the unit. His inital gas in in the unit was of an acute respiratory acidosis (I may be overly high on his CO2 but it was >50), and he had bilateral significant pleural effusions. Had more of a metabolic acidosis picture later. We actually had an ID specialist come in and round with us about this guy. I wish I remember more of what she said about S. pneumo coinfection with H1N1 but it was very interesting. We were worried about Osler's triad: http://www.aaf-online.org/php/member_area/onlinecases/index.php?act=view&id=165
  11. He had a pretty quick respiratory decompensation, I don't recall the Bicarb being that depressed (was on the low end of normal), but by the time he got up to the unit that's about what his gas looked like. I should have clarified sequence of events, it's hard to say what came first neuro or respiratory decompensation (that was in the ED). I think he was initially compensating but he quickly burnt up his reserve once he got the pleural effusions. I'm not sure what it is about the post-H1N1 S. Pneumo strain that makes it so nasty, he went from walking around that morning to intubated that evening. Scary stuff!
  12. Good pick-up. Must be a bad habit I picked up during case presentations at our institution. "Statting at "x"L" for some reason seems to roll better than "satting" *shrug*
  13. <meta charset="utf-8">Here's a typical long-winded response from me as a huge fan of teaching cases: What were her O2 stats? Her vitals concern me a bit more than r/o PE, I'd recheck them and if they were still looking tachy and hypotensive, I would be curious to know what her lactate is and start running some fluids. But I agree in our current medico-legal climate (unless she had slam-dunk CXR findings and elevated CBC) to at least send a D-dimer (since she's tachycardic and low pre-test probability) and a lactate. There was a recent excellent podcast about using PERC and Wells criteria to r/o PE and the pre-test probability values: http://blog.ercast.org/2012/01/decision-tools-perc-nexus-and-curb-65/ Great discussion on some of the germane issues to this conversation. Here's some odd cases (to give something to think about) that I saw just as a student: Case #1: young and reasonably healthy guy presenting nearly identically after 1-week of flu-like illness to UC with a probable PNA. He was sent over to the ED and it was quite good that he was, he decompensated significantly in the ED and by the time he came upstairs he had a signicant hypercapnea on his ABG and got intubated. Was up walking to the clinic that morning and on a vent by evening. Nasy bug, ended up being post-H1N1 S. pneumoniae. We took care of him in the ICU, had a ton of complications, got pericardial tamponade, bilateral pleural effusions (fun times tapping them!), terrible renal failure, CNS complications. Plus he was a Jehovah's witness so no blood transfusions. Made an amazing recovery though. Case #2: Same ICU. Pt presents very similarly to the ED, young healthy male, some shortness of breath, mildly tachypnic, thinks he has bronchitis or PNA. Has mild bibasilar crackles on exam. Labs look like this: Na: 135 K: 6.5 Cl: 104 CO2: 22 BUN: 225 Cr 24.5 Glucose: 125. Needless to say ED provider nearly has a stroke looking at those labs, kid gets more tachypnic, comes upstairs, gets tubed and dialyzed. Had unknown CKD his whole life, now went into renal failure with uremic pleural effusions. Case #3: 7-bed rural ED. I'm down there admitting a septic lady to our 3-bed ICU, dumping fluids into her when a respiratory code comes through the door. Pt was a young adult male, seen earlier that day in the ED. Presented with a several-day hx of URI/bronchitis symptoms, clear CXR, pt was a smoker. Had some bilateral leg swelling, but had been riding his bike, has been out of shape. No meds except new anti-psychotics (had bipolar disorder, no other medical hx) Pt had some mild tachycardia, but he was coughing in fits. No fever. Was sent out with doxycycline for bronchitis and an albuterol inhaler. On the way to the pharmacy he seizes, turns blue, his girlfriend brings him through the door. He's on his was to the CT scan when he codes. They work on him for almost 45 minutes. D-dimer sent pre-code comes back at 6,000. ABG was 6.9/80/50/18 or so (I hear this read aloud during the code). Was a bit of a s#$T-show since my septic lady started to circle the drain during the code, I was running to the pharmacy for Levophed since the pharmacist was participating in the code (heck the whole rural hospital staff was hovering over the kid). Was tough to find anyone to supervise me to put in the Central and A-line she needed! Rough night all around.. I think there was an interesting thread a while back about some of the newer anti-psychotics increasing the risk for DVT/PE.
  14. I interviewed at Stoneybrook in NY, I recall they had (may not still be the case) cadavers for exclusive use for their PA program.
  15. Hello, sorry for the delay in posting the rest of this case, our house staff was graduating the past week, thus I was busy (working up a new onset non-ischemic dilated CHF with fevers! cool ID stuff) Anyways, so good job PA student, we were worried about tumor lysis syndrome prior to administration of IV steroids. We did a full lymph exam and a chest/abdomen/pelvis CT scan and a blood slide to look for malignancy, as this can be precursor in up to 20% of cases of onset of Sweet's syndrome. This was negative for any obvious malignancy (though pt had some thyroid nodules and a whopping big gallstone). She looked much better after just 24 hours of steroids, blisters went down, her face was much clearer. She ended up telling us she had a history of ulcerative colitis, it just hadn't been acting up the past year so she "didn't think it was relevant". There are about 40-some cases of Sweet's syndrome in patients with UC, more in pt's with Crohn's it seems. She was pretty reluctant to see her GI specialist after this, she was having trouble understanding how the two events could be related, though she became more and more reasonable after multiple steroid doses. Also per other outside records that showed up had a history of alcoholic pancreatitis. Again, squirrelly historian, so that always makes things tough. But ended up being a really interesting case! Thanks for participating, I'll share another case soon if I get a good one. I'm constantly on safari hunting zebras (which are common at my hospital) so I'm sure it's only a matter of time.
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