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About sbellin

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    Physician Assistant
  1. In my small critical access hospital I am the attending. Hospital bylaws require rounding every 24 hours but they do not state by whom. Medicare rules require that mid-levels advise a supervising physician within 24 hours of an admission and discharge and discuss any major therapeutic intervention. It’s only a rare case when I’m on call that my patients see a physician.
  2. You haven't stated what their sugars are and do they drink. I find that the closet drinker or the undiagnosed diabetic are more likely the cause.
  3. The ADA has aptly moved away from stating that we should be treating everyone to a specific A1C number I think for a variety of reasons; they make recommendations for goals. In adding a second or third agent the prescriber must recognize what goal they hope to achieve with their intervention ( do we need an A1c of 7 in a 95 year old?), what are the risks of reduction ( increased risk hypoglycemia, weight gain/fluid retention), what are the costs to the patient ( financial, jobs loss with adding insulin), and is it really gonna make any difference in the long run in that particular patient. Ad
  4. I have been through this recently in regards to whether whenI’m on call for admissions that an MD/DO needs to be personally available tosee the patient if needed. Our CAH hascontacted our state department of health (Washington State) and they state thatthere is no requirement for an MD/DO to be personally available to seeinpatients. This though may vary fromstate to state. CMS states in CFR 485.631that mid-levels (PA’s and NP’s)may admit to a CAH but a physician needs to be notified (no time stated) of theadmission and discharged and if there are any major therapeuticinterventions. CMS doe
  5. I assume when you say “insulin dependent” you are actually talking about a Type 2 diabetic requiring insulin. In my practice there is no hard and fast rule that if you get started on insulin that the metformin goes away. As a general rule the metformin stays unless there is intolerance or renal disease. Adjunctive insulin use has a potential physiologic down side with side effects such as weight gain and the increased sodium retention. The literature lately seems to be downplaying the risk of lactic acidosis though it can’t be discounted. There is also a financial impact as well; metform
  6. Our By-law revision in the works extends full voting privileges to PA’s, NP’s, and CRNA’s. This will change the dynamics of the medical staff as currently there are only 5 doc’s in our hospital. We have including me the potential of adding 5 mid-levels with this change. Limitations exist lingeringmind in a critical access hospital (CAH) that NP’s won’t like. NP’s in CAH are not independent by Federal law and require supervision similar to a PA (a mid-level practitioner (physician assistant or nurse practitioner) may provide inpatient care under remote supervision of a physician). Also, in a
  7. Nobodies mentioned that metoprolol tart. and carvedilol while cheap are also bid verses qd atenolol.
  8. I agree that starting insulin from the ED or urgent care clinic is probably not the best choice; the teaching of proper injection technique and the ability to follow-up is usually not there. I’ve seen providers bothered by significant office hyperglycemia but realize that a Type 2 diabetic with a sugar of 450 and an A1c of 16 (average glucose over the last three month of 412) didn’t get there over night and it won’t be resolved by tomorrow no matter what therapy you choose; even if they’re admitted. Rapid return to euglycemia, if it could be done, in the outpatient setting is a recipe for di
  9. Working to the north in rural western Washington we have a State funded organization called the Olympic Area Agency on Aging or O3A that facilitates connection to community and State services. It’s not only a resource for the patients but has been a life saver for out of the area children struggling to find help for their aging parents. There might be something similar in Oregon. I like the idea of a thread for rural practitioners as it has its own quirks. The cardiologist, neurologist, or psychiatrist is not just down the hall they may be 2 -3 hours or more away. I have explored the i
  10. I’m interested in what you find out. Our hospital also is in the process of re-writing the By-laws. I am pushing for the maximal allowance that State and Federal law allow but this requires research into those laws. Here in Washington State the law only really limits you to not work beyond the scope of the sponsoring doc(s). Being a Critical Access Hospital, CMS places some and removes other restrictions; such as PA’s can be on the Medical Staff but CMS restricts PA’s from holding the Chief of Staff position. Another avenue to look at is how PA’s are privileged and credentialed since By-la
  11. [h=1]Medicare’sviewpoint on mid-levels in rural areas is changing; though driven by finances. Currently rural health clinics are required tohave a physician present every two weeks and Critical Access Hospitals (CAH)must have a physician available in person when a mid-level is on call (PA orNP). This proposal allows more independentpractice in clinics and CAH. When I takecall a physician still has to be available in the community even though 99% ofthe time they never see the patient. This change would allow physicians to notbe present in a CAH ever but only to be available for consultation
  12. I have used Audio-Digest for a couple of years and find it very workable. I only have a 15-20 minute commute so it may take a fews days to get through one. One of my hats is medical director of an ADA Diabetes Program so I use the Diabetes Insight programs to keep up to date without having to go to conferences just for diabetes.
  13. I went through this a few years ago. I graduated PA school with a certificate and no Bachelors. The University of Washington required a year of a foreign language for a Bachelors and I didn't have it and couldn't make that happen. I coasted along then found that A.T. Still was the only school that would offer a Bachelor equivalent based upon review of your education and experience and allow you into their Masters program. Worked for me and hope that helps.
  14. Still volunteering as a Medic the biggest difference I see inthe field between me and the paid crews is not the skill sets but the knowledgebase. Yes, I can intubate, cardiovert, andplace IO’s in the field and in the hospitalbut being able to look at the patient, their bag of medications, and along withthe patient’s complaint come up with a working diagnosis. Field medicine is more by the numbers and PAmedicine allows more free thinking with broader differential diagnostic possibilities.
  15. I had an interesting case recently I’ll share. An 8 year old male is brought to my clinicwith a vague LLQ pain for two weeks which is slightly worse with voiding. His appetite and bowel and bladder habits arenormal. He still continues in sportswhich include martial arts classes. Examshows him to be afebrile and with minimal LLQ pain on palpation; no suprapubic,RLQ pain, or guarding. Urine was negative. After discussion with both parents we decided to take a watch and waitapproach. Three days later (Friday) theycalled and said he was a little more uncomfortable and a two view abdomenseries
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