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Everything posted by MediMike

  1. Don't trust the science of an RNA vaccine whose theory and development have been around for a LONG time...but will take a drug developed in mice with genetically engineered "humanized" immune systems. Got it.
  2. Will you turning down a shot mean that someone else gets it? Seeing as how we are throwing away vaccines at a disgusting rate in this country I'm not sure that logic really applies. With Moderna's success as well as your current natural + vaccine status I doubt that I'd take the 3rd shot either! Yep. I'm a Pfizer kid as well, working with these folks in the ICU. I'll be getting it for myself and my family.
  3. Started a student run homeless foot clinic while in school, continue to help out. Volunteer with the local humane society, fostering etc. Teach at the paramedic program Precept PA students Lecture at the PA program
  4. https://smartasset.com/data-studies/most-promising-jobs-for-employment-and-pay-2021 Well, NPs beat us for growth but we got them for pay. ... probably why they beat us for growth.
  5. Ugh. Don't do that. There is a record of your activities, plus this also shows a lack of integrity and lying about it on a credentialing form down the road can get you blackballed from an entire organization.
  6. The majority of patients in my ICU with a COVID diagnosis are admitted due to complications of COVID rather than it being an incidental finding. Are you able to cite the study you're referencing? I'd enjoy reading it. My personal feeling is that people should die at home with loved ones, or in a hospice house type situation. You don't want me to be one of the last people you see. There is a definite degree of moral injury experienced by my staff when we are flogging what is effectively a corpse simply to appease family who refuse to even do a Zoom conference call because "We don't want to see them like that". Not to mention the obscene cost. My professional opinion is that this is the system we have built and encouraged in our society and we simply have to toe the line at this time. I do my part with goals of care conversations but man is it a struggle sometimes.
  7. Totally agree. In 5-10 years time all of these folks who do survive with some degree of fibrosis or diffuse alveolar damage of significant degree are going to end up right back in.
  8. Ah yes. The classic Doctorate of Physician Assisting.
  9. Why didn't you just reference the pre-print non peer-reviewed article directly? https://www.researchsquare.com/article/rs-898254/v1 The math doesn't add up from my brief look. You're also forgetting to add in the fact that the data they are representing is A) From the VA alone, so a horrible representation of 'murica and B) Stopped in June, before the damn Delta variant really kicked in, which has been the major factor driving the "government and media" facts. Everyone was fine and happy before this 15th wave or whatever the hell number we're on. What specialty do you work in @CAAdmission? Because it's clearly not one that admits to the ICU, or boards patients in the ED, or somewhere that needs to transfer a patient for something similar, unless you are somewhere way out in the middle of nowhere.
  10. Wait...why is her mask down? Honestly this makes it look like they are congratulating the grit of the PA brave enough to take their mask down ...unless that was your point and I'm an idiot.
  11. It's a conglomerate of multiple patients I've seen. The acute pulmonary edema d/t MR was a classic patient I'd see in the CCU. You are spot-on with the R>L being seen with posterior leaflet issues, the jet ends up directed into the PV in just the right fashion. Crazy. I wasn't trying to imply anything at all on the CXR, it's just pure edema to my read. The stupid sign I was referring to was S1Q3T3 which one if the posters picked up on super quick. We teach it as being pathognomonic when in fact the specificity is crap and can show up with any kind of RV strain (COPD, pHTN, ARDS etc) For treatment I prefer nitroprusside as it has a greater arteriodilatory effect, can run into problem with lack of familiarity among staff when trying to give it, NTG works too! Main goal is afterload reduction to improve forward flow. When I think about MR I break it down into primary and secondary causes, primary is related to the leaflet or valve itself while secondary is due to structural changes of the LV or LA. In my experience primary is well managed with afterload reduction via meds or worst case a balloon pump. Secondary MR, particularly those involving a dilated LV will often have a low EF to begin with and will require both afterload reduction and inotropes. The beta 2 action of dobutamine isn't all that pronounced in my experience unless you've reached the maximal B1 augmentation of the myocardium and keep pushing. I miss the CCU sometimes
  12. Great work. You're going to do wonderful on your rotations Some type of anxiolysis may be necessary. Be careful with ketamine and patients who have a HTN emergency as it can result in more HTN and tachycardia. Benzos are an option in some patients, or if you're lucky enough to have dexmedetomidine that is my preference. Nicely done all. If there are any questions about this case please shout them out!
  13. I'm in a bit of a hurry but @LT_Oneal_PACis spot on with everything, although dropping the word Bayesian on a Friday is kinda messed up.
  14. Couple other items I forgot: Nitrates are fantastic. Venodilation>>arteriodilation but this lady will benefit from both. Be careful with furosemide. When patients aren't actually volume overloaded it can tank their pressures and hypokalemia and worsen an AKI...But it also has some rapid venodilatory effects via prostaglandin pathways which is pretty cool. Opiates (morphine in particular) are also an option but again, be wary as it can knock out some respiratory drive, plus if someone starts puking on NIPPV you're gonna have a bad time.
  15. Nice. Thank you for initiating treatment Couple items: Do you need to scan this patient? What makes you think she has a PE? Is her CXR compatible with it? Hemodynamics? Echo? A V/Q scan in a patient with any kind of other lung pathology (edema, consolidation, atelectasis, infiltrate) will be useless as you will inherently have a mismatch in ventilation. Great thought though! I remember them being pushed hard in PA school, outside of the classroom they are only ever used in stable patients in my experience, workups for PH etc. ARDS criteria can't be met if you believe this has a cardiogenic component to it. We don't do DVT prophylaxis BECAUSE of ARDS, we just do it on everybody that comes in the hospital who is immobile. Treatment; Absolutely fantastic. This lady appears to have flash pulmonary edema, possibly due to worsening mitral regurgitation. Afterload reduction is key, and in this setting I'd take her down until the dyspnea resolves. You also want to reduce her preload, and positive pressure ventilation does both of those. She would definitely benefit from CPAP! The PEEP generated will reduce preload, redistribute water, and increase functional residual capacity, "popping open" those soggy alveoli. BiPAP is an option too, can help reduce the work of breathing. If you need to intubate you can definitely intubate. Someone can bag the patient if need be. What do you do if she starts fighting the mask and refusing to wear it?
  16. Dude (or Dudette), you asked for opinions on the position and you got them. The point folks are trying to get across here is that this wouldn't be considered a fellowship. You've got many people on this board who have done fellowships, are part of a fellowship training program or are even directors of said programs. They (we) have a tendency to take these terms pretty seriously as there are multiple programs out there who use exploit new grads as cheap labor. Once they leave that program and tell the next hiring position "I'm fellowship trained" and then blow it their first week it casts a negative light on all fellowship programs. Is this a fantastic sounding job for someone who wants to break into EM while they have the ability to live at home, in the location they want? Hell yeah. Would I call it a fellowship or a residency? No. If I'd chosen EM right off the bat it's an offer I likely would've taken as well. The 120 days notice is a little brutal though, unless that goes both directions. Best of luck in the position and maybe I'll take a patient off your hands someday.
  17. Did anyone read the actual suit filed? Quite possibly the worst written piece of literature I've ever seen. Talked about the patient "ripping the breathing tube from his esophagus" or some such. How that alone didn't get it thrown out I don't get. Maybe lawyering ain't that hard after all... I'd also love to know what this guy's thoughts were on how ivermectin is going to affect aspiration pneumonitis/pneumonia on top of probable fibrotic dz at this point in the patient's course. Glad it got overturned! Transfer that guy to a hospital where Washgul has privileges...
  18. The FDA approval recs are outlined right here. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/immuno.html Where were you looking?
  19. Hey @LFPA94! Thanks for chiming in. It is so hard to get a good idea of CC salaries as there seems to be a huge disparity across the country as you've mentioned. I'm south of Seattle in WA state. Pretty good COL in our area. I started off as a new grad working in the CCU of a university hospital in Seattle, advanced heart failure/transplant, no CT just CCU. Up there we did 11 (12) hour shifts/month, it shook out to around $115k/yr ($73/hr) for exclusively days and no procedural expectations outside of arterial lines and CVCs. Sounds like you've got some room for negotiation! Feel free to ask anything you need either via pM or on the thread.
  20. Yeah thats a great point. I was in the same boat as @rev ronin, working very soon after graduating, took my PANCE as soon as possible etc. If they have the time then I'd say for sure get it done. Way cheaper, way less time.
  21. Do you have any idea what they used as a "positive" CXR finding in those studies? I'm honestly a little too lazy to read through all 6 in the MA. Wonder if they had to ONLY have pulmonary edema or if they allowed "increased interstitial markings" etc. Was also interesting that the majority of them used a PA modality rather than AP if I read through correctly. (Okay, maybe I scanned/glanced)
  22. @LT_Oneal_PAC and @rev ronin I totally agree POCUS is a fantastic tool in the right hands. But throw a probe at someone who doesn't have the opportunity to scan many folks and all you get is a really slippery patient. (Or a really clean one when I can't find any ultrasound gel and it's all about that hand sani) @LT_Oneal_PAC I was wondering how long you EM folks were gonna hang by the sidelines while the ICU guy dicked around with an ED scenario. Jump on in and help guide/teach my man. I am almost 100% positive you are able to generate a much broader list of differentials than I would any day! (that gif about killed me btw)
  23. Good thoughts when you are looking at each individual test in isolation! One of the hardest parts of medicine is taking allllll these data points and figuring out the likelihood of a certain dz process over another. You will definitely meet some folks who will just shotgun every lab/imaging modality possible, and depending on how sick the patient is that's oftentimes the only approach you can take, A) Buys you time to wrack your brain and B) Sometimes more than one thing is going on Alright, back to the case: B-Lines on thoracic U/S can indicate edema, nice work. So you've got a little old lady with a CXR consistent with pulmonary edema, U/S findings consistent with pulmonary edema, and a murmur that you've correctly identified as MR. 1) Do you still want to have this lady (who is still working hard to breathe and requiring hi flow oxygen) lay flat for a CT scan? 2) Is there anything besides the S1Q3T3 and hx of CA that makes you think this lady has a PE that is causing her immediate issues? I try to develop a mental model of several differentials, what labs/imaging/diagnostics/exams I can perform to rule those differentials in/out. So let's revisit: Older lady working hard to breathe. SpO2 88% on 15lpm NRB. Speaking 3-4 word sentences. Elevated neck veins. Loud murmur. Significant HTN. What are your working differentials and how do you start helping this lady who is probably going to start crashing soon if you don't do something?
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