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sbellin

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About sbellin

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  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. Adherence to a medication and treatment plan that the patient themselves ascribe is worth much more than any add on agents. I also think an A1c is only a rough guide as to how the patient has done and must be interpreted with caution in subjects that have wide swings in their day to day sugars or that have home monitoring that contradicts the A1c. As for the question of what's the best second line agent it depends.
  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 does notdifferentiate between NP and PA supervision. Although there may be a statespecific law CMS does not place an hourly limit on when an MD/DO should be madeaware of an admission or discharge. Iusually will talk to the docs once a day about who I have in-house. With all that said, the biggest glitch may be hospital by-laws. They are many times archaic andrestrictive. If there is within yourfacility an hourly restriction then it is probably there.
  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; metformin is cheap and insulin is not. If you can keep their expensive insulin use to a minimum by keeping the cheap metformin on board there is a greater chance in adhering to the prescribed regimen.
  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 CAH med staff office positions can only be filled by a physician, so even though we will be able to vote we cannot hold office. Lingeringmind I would be interested in your progress. If you wish you could PM me and we could compare notes. This can be a pivotal point in your hospital. These by-laws will probably stand for years and with recent recommendations to relax supervision requirements on PA’s and NP’s in rural facilities it can make your hospital on the cutting edge of PA utilization. http://www.ohsu.edu/xd/outreach/oregon-rural-health/hospitals/cah.cfm
  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 disaster (hypoglycemia, hypokalemia). Assuming they have no acute pathology such as an infective process that’s driving the sugars higher now or symptomology which may suggest the need for admission, metformin would be an acceptable management option (if you’re convinced they’re a Type 2 and not Type 1): But even then you would be giving a starting dose which will have minimal short term effect but at least it looks like you did something. As for the insulin dosing if they’re an adult onset Type 1 10 units of Lantus may produce a profound reduction in their blood sugar whereas in a Type 2 that has severe insulin resistance it will have essentially no effect. The best thing you could do as an intervention is making a phone call to a PCP and connecting that patient directly to a provider who will manage this chronic condition in very short term follow-up. Giving them insulin or even metformin and sending them off without a connection for follow-up means that they in most cases won’t do anything. Also, remember that a majority of diabetic patients die from cardiovascular disease not hyperglycemia. So even correcting their hyperglycemia in isolation can generate in the patient and providers a false sense of security.
  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 idea in the past of putting together a CME course specifically for rural clinicians with both didactic and skills station. The Oregon Health Sciences University consult line has been valuable to bend a specialist’s ear to find out if you’re on the right track also.
  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-laws may refer to scope of practice. I’ve included the rough draft of the proposed privileging for PA’s here. This same format would apply could NP’s but with pertinent changes in the education and certification. The procedures may be limited but we are not a big facility either. Also, I went to a PA Hospitalist course at Scott&White Hospital in Temple, Texas last month and they seem to have a progressive PA Hospitalist program. Dr. Santosh Reddy spearheaded the PA service there and seemed very open to accept questions on PA utilization from other facilities. You could look him up there and give him a call. Good luck. PHYSICIAN ASSISTANT INITIAL APPPOINTMENT REQUIREMENTS: Basic Education/Certification: Graduation from a physician assistant program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) and certified by the National Commission on Certification of Physician Assistants (NCCPA). Required Previous Experience: Provision of inpatient care to a minimum of 60 patients in the past 24 months. Some clinical activity must be documented within each of the 24 months. For individuals that have completed training within 24 months current clinical competency must be verified by the applicant’s program director or if there is no documented previous experience attestation of clinical competency by their supervising physician. Supervision: Application for privileges must be accompanied by a letter of recommendation from a physician or physicians that will be supervise and be responsible for the physician assistant while performing patient care at Ocean Beach Hospital. Changes in supervising physician(s) will require a resubmission of Core Privileges form and re-approval of the credentialing committee. REAPPOINTMENT REQUIREMENTS: Meeting the requirements of documented clinical activity as outlined within the Medical Staff Bylaws and/or Medical Staff Policies and Procedures within the scope of core privileges requested, without significant quality variations identified. GENERAL INSTRUCTIONS: Applicants who limit their practice to general internal/family medicine need only complete the privilege request form. Applicants whose practice incorporates the addition of sub-specialties must complete a sub-specialty request form. A representative but not conclusive list of internal medicine/ family medicine procedures is stated below. It is expected that other procedures and problems of similar complexity will fall within the identified core and special privilege requests and are not within the scope of listing. Privileges are awarded to the physician assistant in conjunction with Chapter 246-918 of the Washington Administrative Code (WAC) that limits physician assistants to not practice beyond the scope or specialty of their supervising physician(s). General Physician Assistant Core Privileges: Core privileges include admission, work-up, consultation, and providing non-surgical treatment for general medical problems. Core privileges also include surgical assisting, management and closure of uncomplicated lacerations, wound and ulcer debridement, management of uncomplicated fractures not requiring major manipulation, reduction of uncomplicated dislocations of upper and lower extremities, excision and biopsy of uncomplicated cutaneous and sub-cutaneous lesions, and providing local and digital nerve blocks. Core privileges include the following procedures: Thoracentesis Lumbar puncture Arthrocentesis Paracentesis Arterial line placement Central line placement Electrocardiography Cardioversion Holter monitor interpretation Ventilator management Peripherally Inserted Central Catheters (PICC) Incision and drainage of abscesses Procedures that fall within the scope of Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS). PLEASE DRAW A LINE THROUGH ANY PRIVILEGES OR PROCEDURES THAT YOU DO NOT WISH TO REQUEST. Procedure Special Requests: Procedural sedation Chest tube placement and management Exercise stress testing Submit in a separate letter a request for procedural privilege not listed above. I certify that I possess the necessary skills and expertise to justify granting a clinical privilege in each of those areas which I have indicated. I understand that in making these requests, I am bound by applicable bylaws, rules, and regulations or policies of the hospital and medical staff. I also certify that I have no mental or physical conditions that would limit my clinical abilities. Signature ________________________________________________ Date _________________
  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 by some formof electronic communication and never show their face in a rural health clinic.Though my state law (Washington) follows CMS rules I would expect modification ofthe law if CMS changes their rules. Thischange should foster new respect and will open new opportunities for mid-levels.[/h][h=1]. [/h][h=1] [/h][h=1]Critical-access hospitals get breakon staffing[/h] By Ashok Selvam Posted:February 5, 2013 - 4:00 pm ET Tags: Barack Obama, Hospitals, Kathleen Sebelius, Not-For-Profit, Pharmaceuticals, Physicians, Rural Health, Staffing, Telemedicine The CMShas proposed reducing hospital staffing requirements at critical-accesshospitals, rural health clinics and federally qualified health centers, whichcould save those facilities as much as $676 million a year. The proposed rule, issued Monday (PDF), would eliminate therequirement that a physician be present at those facilities at least once everytwo weeks. The CMS called the ruled burdensome and outdated. “Many rural populations suffer from limited access to care due to a shortage ofhealthcare professionals, especially physicians,” the proposed rule read.“Recent improvements in, and expansion of, telemedicine services allow for physiciansto provide certain types of care to remote facilities at much less cost." [TABLE=class: MsoNormalTable] [TR] [TD=bgcolor: transparent] [TABLE=class: MsoNormalTable] [TR] [TD=width: 300, bgcolor: transparent] Advertisement | View Media Kit <image001.jpg> [/TD] [/TR] [/TABLE] [/TD] [TD=width: 20, bgcolor: transparent] [/TD] [/TR] [/TABLE] Related Articles More in: [Pharmaceuticals \/][Go] Critical-access hospitals get break onstaffingFox named CMO at MyoKardiaForging a new path More Pharmaceuticals Articles Theproposal, which revises a final rule issued in May, (PDF) is part of President BarackObama's 2011 executive order to reduce burdensome regulations. Other changes inthe rule include allowing dietitians to order patient diets without needing theapproval or supervision of a doctor or other clinician and allowing nuclearmedicine techs in hospitals to prepare radiopharmaceuticals without constantsupervision of physicians or pharmacists. “By eliminating outdated or overly burdensome requirements, hospitals andhealthcare professionals can focus on treating patients,” said HHS SecretaryKathleen Sebelius in a release. Both the American Hospital Association, whichrepresents not-for-profit hospitals, and the Federation of American Hospitals (PDF),which represents for-profit hospitals, lauded the proposed rule saying it freesup hospital resources. Another regulation eliminated by the proposed rule involved requirements thathospital governing boards retain a physician on their governing boards. The CMSinstead mandates boards to consult with physicians over matters including scopeof hospital services. “CMS recognized that the requirement was not feasible for all hospitals,” AHAPresident and CEO Rich Umbdenstock said in the release. “CMS revamped therequirements to focus on the need for good communication between governingboards and medical staff members about patient care.” The AHA singled out a requirement that multihospital systems with a singlegoverning body consult with each of the system's hospitals. “Hospitals aredelivering more coordinated, patient-centered care and CMS should not letantiquated organizational structures stand in the way,” Umbdenstock also said. http://www.modernhealthcare.com/article/20130205/NEWS/302059968/critical-access-hospitals-get-break-on-staffing?AllowView=VW8xUmo5Q21TcWJOb1gzb0tNN3RLZ0h0MWg5SVgra3NZRzROR3l0WWRMWGJWdjBFRWxiNUtpQzMyWmVwNTNrWUpicXBiUlF0emxjUTRXNmJRZk15Z0M2SHRaeXdYY3lsWHI4YkJydE8yNlAzTXFQNTd0MVpKc21ZdEZoNUE2QXlnbXdG Read more: Critical-access hospitals get break on staffing | ModernHealthcare http://www.modernhealthcare.com/article/20130205/NEWS/302059968#ixzz2KEB9KXfD ?trk=tynt
  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 showed normal gas pattern and they were to call me over the weekend ifhe got worse. The following Wednesdaythey called and reported increased pain and overnight fever of 100.5. He was seen again in the clinic and found tonow to have fullness and tenderness in the suprapubic region with slight RLQtenderness. There was now little LLQtenderness. Repeat U/A againnegative. CBC showed WBC 13.7 and slightleft shift. U/S showed suprapubic solidand cystic mass. CT revealed again solidand cystic mass to the left of the bladder that was compressing and displacing thebladder to the right. Being in a ruralarea without regular surgical services I discussed the patient with theregional children’s hospital and arranged transfer to them. The child was diagnosed with a urachal cystand had a drain placed and after antibiotics will return for removal. I must admit that this diagnosis wasn’t on my radar havingnever heard of a urachal cyst before. Myresearch places them as a fairly rare disorder frequently presenting as a dischargefrom the umbilicus and can present at any age. Anyone with other experiences with urachal cysts?
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