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About Nakasoner

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  1. I used it for post-op Neurosurgery, mostly spine cases. It was one NSx's preference. 1g IV q8h for 3 days. Of course, I couldn't use Norco/Vic/Percs at the same time. We'd use either PCA or oral morphine elixir and then add up the morphine equivalent dosing over 24hrs and then convert to PO meds. The other NSx I worked with didn't use IV acetaminophen and would just do PCA and then transition to Percocet or Norco., which was simpler.
  2. I am in Neurosurgery at a County Hospital and I round in the ICU/DOU. Our post-op patient's are there for q1-2h neurochecks, usually for TBI, post-crani, or post severe spinal injuries, or high risk. Some are in comas/sedated and have many lines--intub/vent dep/trach/PEG, etc. Need to monitor lots of labs and work with the ICU/Medicine Team/Palliative care/Rehab and Social work teams for dispo after stable as patient have significant impairment. Anti-seizure mgmt, reading lots of scans--CTH/MRI brain, watching sodiums, ICP, BP, vent status, and attending family meetings. Lots of GCS and cranial nerve assessments, aphasia assessments. It can be grave. I have done this for the past 13 months.
  3. I believe this would be a viable work comp injury. Repetitive strain after a long surgery. Was it bothering you prior? Any past history of hand/wrist probs that impaired your ability to work, or caused you to seek care? The employer accepted you as is (Labor Code). While your employer might fight AOE/COE (causation), I believe you would prevail albeit a long and drawn out W/C process. You would most likely create an adversarial relationship with your employer and it would hamper your ability to work in your field of surgery and procedures. The question is is it worth filing a claim and opening up that box. It sounds like it would eventually get accepted as a work-related injury but their may be some apportionment to a pre-existing laxity if they can prove it was causing you some type of impairment prior to starting your current employment. Your other option is to continue to rest it, seek specialized help via hand specialists and diagnostic testing and try conservative care and bracing vs or surgical stabilization.
  4. I work in CA and used to work for a practice with 5 clinics, each one dispensed Controlled Substances, schedule III. I had 5 DEA numbers, one for each site, that the practice paid for. You need a DEA for each site that DISPENSES Controlled Substances. If you just write Rx's, then you only need one for the state.
  5. Tough to find osteopaths that manipulate anymore. The older I've met do manipulations as they were trained to manipulate and have some experience. The younger ones do surgery and Rx meds as that is where the money is to pay their student loans. I've never seen one do a manipulation. I see younger Osteopaths (less than 35 years old) in my rotations and they ask me tips on their manipulation as they didn't do much in Osteopathic College. I see the osteopaths in the OR though.
  6. Don't forget to check the hip. Many times I find pain with int rotation and ext rotation of the hip, causing the thigh/knee to give way when weight bearing. If the knee exam is benign to stress testing and the ROM is fairly normal without an effusion, check the hip. Get weight bearing xrays and check the joint space. If the knee and the hip are negative, check the lumbar spine and do a neuro exam for motor weakness esp in the L2-4 roots for radiculopathy.
  7. Proballr32. Sounds like a bad experience. How many chiro's have you worked with? I hope you are not painting an entire profession based on one chiro. It is true that there are many chiro's similar to the one you worked with. I can tell you I have seen many back surgeries gone wrong too, and some of them have been needless. I have been a PA in Spine Ortho, Pain Mgmt, and Gen Ortho and have privileges as 3 hospitals as a Ortho Surg PA.. I am about to start a new PA job as a neurosurg PA for the chief of neurosurg. I am also a chiropractor. My experience as a chiro has helped me tremendously in getting each of these jobs, but I did not fit your description of the chiro profession. It is true the stereotype does exist, but if you take time to ask around and dig deeper, you might be surprised to find a few good chiros here and there that do a fine job. There are certainly some idiot PA's out there too, and I would bet many patients refuse to see PA's because they are "not real doctors."
  8. Also, will need to learn to cast -- short arm, short leg are typical. Learn to do a splint. Achilles ruptures, Cast/cam walker boots. Learn how to inject the knee, the shoulder (GH vs Subacromial), hip bursae, DeQuervains. How to use Ultrasound guidance technique vs w/out US. Get good at reading xrays cuz you will be reading them daily many times over. Also MRI and CT's, Total body bone scans. Know your joint replacement techniques and materials--beware of metal on metal hips. Patellar fractures. Proximal humerus fx, Prox femur fx, distal radius fx. All of these are very common to see. Know what a reverse total shoulder arthroplasty is. Heterotopic ossification, anticoagulation, lovenox bridging, dental prophylaxis for total joints, know your spine differentials, DEXA scans. I could go on and on. My iPhone is filled with pics of fractures, end stage arthritis, wounds, etc that I use to communicate with the surgeon throughout the day/week.
  9. For TKA and THA, I am the 2nd assist. On a rare occasion, I am the 1st assist if our 1st assist is on vacation. He has 15+ yrs of experience and can suture with the best surgeons in Santa Barbara, like a mirror image. Me, not so much. I'm slower as I've only done this for the past year. However, on other days, I am the first assist on knee lig reconstructions (ACL, LCL), ORIF's, and Rot Cuff Repairs. Then I help position the patient, retract, suction, provide lighting, hold the scope, hold body parts, cut, tap, maintain the sterile field, provide the best field of vision for the surgeon as possible, help with any surgical technique he asks, inject local, help prepare grafts (I haven't done the whip stitch on my own yet) close the wound--suture (subdermal, subcutaneous, staple, simple interrupted, dermabond, etc)--a myriad of closing techniques. And then I dress the wound with our standard dressings (ex--for an LCL reconstruction, the post-op dressing would be: staples, betadyne ointment, adaptec mesh, 4x4s, 8x4 ABDs, 6" ACE wrap (x3) foot to thigh. With an ACL, I would add a cold therapy unit over webril but under the ACE. I'd use a post-op brace locked out at 0 degrees with the yellow tabs point up proximally. I have another list for my rotator cuff repair dressing, and for the total knees. I would ask the surg tech to have these things ready for me (and possibly the surgeon) before the surgeon has to ask for these things. The sharp techs already know what we want. I would usually inform the techs if we are going to do an open vs scope procedure since I usually do the pre-op. There are times when I'm closing and the surgeon has already de-gowned, de-gloved and goes to dictate the OP note while I finish and dress, so that we may move on to the next case. I have to order the tourniquet down at times as well. After dressing the patient, the tech and I clean up the patient for transfer to PACU. And I stand alot on my feet, so wear the best comfy shoes you can buy--for me, it's Nike Lunar Glides! For our Total Joints, I template the cases on the films and measure the femur and tibia. There is so much to learn and it takes time and lots of notes put into my iphone. Then I can run through the dressing prior to the surgery while I'm waiting. There is alot on youtube as well. I am a regular on the AAOS website too. However, I must say that I'm leaving my job in OrthoSurg for a new job closer to home for the Chief of NeuroSurg for Ventura County. If anyone is interested in a tough job but one in which one will definitely learn the ropes of OrthoSurg, there is a job with William Gallivan, Jr., MD, for Santa Barbara Orthopedic Associates at Cottage Hospital. It's a tough demanding job with long hours but without a doubt I have gained valuable experience. Fracture management, wound care and osteomyelitis/septic arthritis are also problems that I've dealt with alot the past year.
  10. pen, index card, steth, penlight, Rx pad, cliff bar, iPhone, business card holder, tape measure, goniometer.
  11. Heme: Please explain what you mean by "clinical sense situations." Would you get an MRI on a Lumbar Spine for a 45 year old patient with LBP x 2-3 weeks after doing yardwork, localized to the left lumbosacral region, rated 6/10, taking NSAIDS and even Norco, without numbness or tingling down the extremities and with symmetrical DTR's and good motor strength 5/5 in the LE's. No bowel or bladder dysfunction. XR shows Mild DDD at L4-5 and L5-S1 without Fx. What would you do? Would you get an MRI and then order PT? Or would you just order PT? Personally, I try to avoid surgery unless there are clear indications and imaging matches the clinical picture. I will more often than not order a diagnostic and therapeutic epidural before recommending microdiscectomy, particularly if there are multiple bulges involved. The same goes for the cervical spine.
  12. A good history and physical should be able to pick up progressively worsening neurological signs/symptoms that should alert the provider to severe disc herniations/extrusions/SOLs/cauda equina. I don't think it's good medicine to order an MRI everytime you want to order PT. Standards of care suggest the reverse in most cases.
  13. What's a PA like you doing in a joint like this?
  14. That's a good list by Ventana. Do PT, chiro, acu, home exercise program/diet/weight loss, bracing, bracing with electrical stim, topicals, Lyrica, viscosupplementation injections, judicious use of corticosteroid injections, surgery.
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