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Boatswain2PA last won the day on October 12

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About Boatswain2PA


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    Physician Assistant

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  1. If you don't have troponin testing then it's a moot point. As to "how many do we get to misdiagnose"....I would say it's the same amount we in the ED get to misdiagnose. Should we just send every chest pain to the cardiologist? No difference with the ED. You just have to explain why you considered, but did your best in ruling out MI using the best testing/validated decision rules available. But back to the OP: Why would anyone listen to a this guy talk about healthcare when he goes to the UC when he's having an MI?? At least he didn't go to the orthopedist first!
  2. Well, it appears your ability to diagnose psychological conditions is equal to your ability to give financial/tax advice. Do you by chance work at the state psychiatric hospital in my state? That would explain why nobody I send there ever seems to get better. I take that as a correction. Note it has nothing to do with the "paying $10,000 in taxes for earning $0.01 over" that you originally stated, but at least it appears you are trying to backtrack instead of spreading more BS around for people to listen to.
  3. I accidentally used the wrong word (deduction), and yet you still used it to double down on your ignorance. As I said before, you can sometimes make too much to deduct real-estate losses (specifically passive-income losses), but these can be carried forward indefinitely until they either cancel out future gains or your income comes down, and then you can deduct them. Without checking, I believe the MAGI has to be less than $135K to be able to deduct passive-income losses. So if someone chooses to make $134K instead of $136K in one year simply so they can deduct passive-income losses this year instead of in retirement they are pretty short-sighted in their tax planning. However, in reality, this is impossible to plan for. People with such passive-income losses, such as myself, have such incredibly complicated taxes that it is impossible to forecast what your MAGI will be without having ALL of the documentation in hand...which doesn't happen until after the closure of the tax year. The other ways that someone can "make too much" and pay more in taxes is if they fall-out of "tax credit" windows. Like the Child Tax Credit, which gives $2K/child. But your supposed nursing friend (if married) would have to make over $400,000 and have five kids to lose out on the $10K in tax benefit that you described in your ridiculous comment above. The other big tax-credit program is the Earned Income Tax Credit which gives low-moderate income people significant tax benefits. But it has a gradual phase-in, and a gradual phase-out with one's MAGI, so at no point EVER does one suddenly get a huge tax bill because they made $.01 too much. You stepped in the Bull Excrement, then you tried wiping it off with your finger. You wanna keep going and try to see what it tastes like? Or you wanna just admit you stepped in BS and stop spreading it around.
  4. I'm guessing California did this to offset Trump's tax cuts that greatly benefited 1099 contractors. Solution? Move, or convert to a W-2 position with much higher pay and benefits.
  5. This is totally inaccurate. Your tax bill won't go up exorbitantly if you make just over the bracket threshhold. You lack the most basic, basic,income tax knowledge Whether you make $150,000/year, or $1,500,000/year, the amount of tax that you pay on that first $150K is the same. We'll use the numbers for unmarried, but the same concept applies for married or head of household (just with different brackets) For 2019, you will pay 10% income tax on the first $9700 you earn. That's $970 in taxes Then you will pay 12% on what you earn between $9700-$39,500. That's $3576, plus $970 for the previous bracket. So if you make $39,500, you will pay $4546 in federal income tax Then you pay 22% on what you earn between $39,500 -$84,200. That's $9834, plus $4546 for money you earned in the previous two brackets. So if you make $84,200 you will pay $14,380 in federal income tax. But let's say your nurse friend makes $86,000....that's only $1800 into the next bracket (which is 24%). Does she suddenly pay thousands more in taxes? No, she pays 24% of the $1800 (plus the $14,380 for income in the previous three brackets). So, at no time does someone make a few extra bucks with W-2 employment and suddenly have to pay an enormous income tax bill. Caveat - With our complicated tax laws there are times when you can make too much to claim a deduction and therefore have to pay more, but that's not what you inferred. For example - I make too much to be able to expense out real estate losses. However I can carry these losses into the future to make up for future losses. Better yet, there is no limit to how long I can carry them forward, so I can bring these losses with me into retirement when my income comes down, then I can expense them entirely and pay no taxes.
  6. Yes --- unless you are a genius, or have extensive hospital experience as a nurse. Otherwise this is a recipe for a trainwreck.
  7. I was just emailed an offer from Indeed for a county health department job, specifically for NPs but of course sent to me as well, for $48K. My wife is an RN and makes a little more than that. Bravo!! Well done!!
  8. This is corporate UC today. So, to answer your question....yes this is common. It also sounds like an absolutely terrible place to practice.
  9. Few insights, take them or leave them as you will. 1. Your screen name infers you are working in NYC - notorious for poor pay and unbelievable cost of living. Add in "six-figure student loan debt" and you will likely be financially insecure for years or decades. Move. Yes, you can. Yes, I know you love NYC, but it's (probably) killing your financial future living and working there. You can probably make 30% more, in an area that costs HALF as much, and therefore pay off $50-$70K/year in student loans. Hell, if you love NYC so much, move back in 3 years when you have the student loans paid off and a little money in the bank. Suddenly you've doubled your standard of living by not having student loans. 2. They don't "tax" your OT as discretionary bonuses, they "withhold" your OT as bonuses. You will get this back at tax time. If you routinely pull an OT shift or two a month then you can adjust your withholding so Uncle Sam withholds a little less to balance out the 41% they keep from your OT. 3. I understand burnout, and I also understand the psychology of working toward goals. Do you have written goals about when you can be free of student loan debt? When you can be totally debt free? Other financial goals? It helps with burnout if you know that today's shift is $xxx.xx toward your goal which you expect to be reached by ##/##/20yyy.
  10. Define "good and easy money" please? How much, and how many hours did it take for you to prepare, travel to, engage in, and then give the speeches?? I've looked at teaching a few times, but when doing the math I think I can make more per hour as an assistant manager at McDonalds! (I'm pretty sure I could land that job)
  11. The UC I worked in had an Istat. While they didn't do troponins (this was pre-HEART score validation), we did BMP/CMPs and got the results in a few minutes. CBCs (without diff) took about 10 minutes. Actually much faster than I get them in the ED. And you can purchase the troponin assay for the IStat. This shop used the IStat exactly BECAUSE it came back in a few minutes, and then we could turn the room over. Better/worse yet, most of the time the UA, chemistry, CXR and/or EKG was already done (all ordered by protocol) before the patient was even roomed, let alone by the time I saw them. This place was a money-making MACHINE!!!!! I was not trying to infer that any UC provider is weak or inept for sending CP to the ED, my apologies if I came across that way. Please chalk it up to incomplete communication inherent with written discussion. But IF your UC has (or can get) stat Troponins, EKG, and CXR, then a good H&P can rule out CP emergencies in many (most?) patients without sending them to the ED.
  12. If I'm looking for "extra cash" then I work another shift. I've found nothing that I can do that pays as well as medicine. One extra shift and I've made the $1K that Cinntsp earned doing surveys. But I do real estate for wealth-building. I took income from medicine and bought/renovated several properties who now make me a couple thousand a month, plus I am diversified in my wealth (actually, I'm probably too heavy into real estate as we also own these properties and our home outright). We are also now getting into agriculture for further diversification and wealth building. Maybe a paradigm shift for you...instead of looking for "extra cash", maybe do a side gig for wealth?
  13. Sure. But they usually looked sick. Someone comes in pale, diaphoretic, crushing chest pain and heaving with nausea I wouldn't work up in the UC. I also wouldn't wait for EKG/Trop before calling cardiology. Pre-HEART score validation I doubt any UC's had troponins. With the HEART score validation I can certainly see some UCs getting I-stat troponin assays. I don't disagree with this, but reason should apply. I don't call cards on patients I think have a high-pretest probability of MI until I get the EKG or Troponins, which technically delays the next step in "definitive treatment". Got the 50 year old with 1 risk factor who had three episodes of pain today, each lasting 30 seconds, one in left chest, one in right upper chest, and one in right lower chest who is hemodynamically stable and asking for a sammich? Please just do the troponin, EKG, and CXR in the UC and not send him to the ED. Got the 75 yo who is pale, diaphoretic, clutching his chest and saying the pain radiates to his shoulder? Call 911, give asa, and do the EKG. Unfortunately 9 out of 10 patients I get from UC/FP office is the previous. Negative troponin and normal EKG, without a strongly suspicious history, actually DOES rule out MI/ACS (with a 0.9-1.7% miss rate) in most relatively young (under 65) patients with only a few risk factors and they can be sent home from the UC. https://www.wikem.org/wiki/HEART_Score Several months ago EMRAP had a great interview with the doctor who developed the HEART score, and has several episodes on the validation of it. Yes. For about six months. It sucked terribly. EM. Single coverage provider in a 9000 annual visit ED two hours from tertiary care. Oh, and it's God, not gawd. And he loves you too!
  14. Troponin, ekg, and cxr rules out vast majority of chest pain patients. Dont see why an UC couldnt do that. Give em some aspirin while waiting for the troponin and you are doing what we do for most of ours in the ED.
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