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LT_Oneal_PAC

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LT_Oneal_PAC last won the day on July 7

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About LT_Oneal_PAC

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    PA-C. EM PGY-1

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    Physician Associate

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  1. I was formerly in CRNA school. Great gig. Time off, no call. You’d have return on your investment in about 1 year depending on tuition. My personality just did not fit in the OR. I loved what I did, just could not stand surgeons and not much of the other staff either. They all are very opinionated people who think there way is best, even in confrontation of evidence. Had plenty tell me the evidence and then do the opposite saying “this is the way I’ve always done it” as if that’s a valid reason. Couldn’t do the anesthesia care team model. but if you think you have thicker skin then me, I would go for it.
  2. LT_Oneal_PAC

    Natural medicine in a PA's career

    It actually didn’t escalate quickly. The original post is 3 years old. Let this thread Rest In Peace. Begone necromancers! naturopathy = quackery homeopathy = criminal malpractice prevmed and nutrition is apart of any good clinicians education and treatment. Thats all there is to say.
  3. LT_Oneal_PAC

    Benzos

    I agree that really no geriatric (no one really) needs a daily benzo. I hate benzos altogether and wrote for maybe 60 total pills in 3 years for all my patients combined, but we are treating this man like a seeker. He didn’t do this to himself. Someone did it to him. He trusted that last provider who got him dependent, thinking they were doing what was best for him. Now you step in and without talking to him, from my understanding, decide this is going to stop. You’re doing something, giving him a referral, but to him this just feels like you saying no and then punting to someone else his problem. A significant part of our job is establishing rapport. So while benzos are bad, I wouldn’t hesitate to bring this guy in, call him personally to explain why you want to see him and it’s because you care about him, small refill to make it to next appointment. Explain why this may have been okay in the past, as you don’t want to be seen as adversarial with th last provider he already trusts, why it’s not okay for him any more, and how you’re going to get him through it. Having done this before, it can be painful for all involved, but they are much more likely to work with me and make that psych appointment I get them.
  4. LT_Oneal_PAC

    What's this in jaapa

    PA aren't licensed independent practitioners Depends on who you ask and what are you defining as independent. The license may be tied to someone else but they make independent decisions. They may work at a facility like mine, where they are stated as such. In the military it specifically says they have a collaborative physician and hold independent privileges with them listed under LIP section along with psychologist, podiatrists, NP, etc.
  5. i would have d-dimer him probably even without the tachycardia. Poor history, smoking, poor pcp follow up. Chest pain going to the back, this guy would have made me worry about dissection, though I may have been less worried with a good cardiac US, but I still would have had low threshold to do CTA. Something on to remember in these alcoholics too is holiday heart and alcoholic heart failure. We don’t understand why it happens, but I’ve seen it.
  6. Hmm... Could be PE or dissection. I suppose I'll go with dissection. Lots of things here that go with both. I dunno. Maybe he does have both. Just woke up from a well deserved nap and thinking more clearly. PE with lung Mets is high on my diff.
  7. LT_Oneal_PAC

    Physician Assistant with tattoo sleeve on arm?

    Lots of EM providers with tattoos where I am, and even more nurses. Don't think I've seen a PA with full sleeves, but I doubt anyone would think twice about it.
  8. CBC (terrible screening test, but it is a routine lab in our world, could also reveal low Hgb in the case of a leaking dissection) BMP (standard to eval electrolytes and kidney function which will help with interpretation of troponin) Troponin EKG: Looking for STEMI and STEMI equivalents(always) PR depression (pericarditis, but there are other stages with other findings) Eval Well's. He can't be PERC'ed Ethanol level. He may not actually be drunk. CXR looking for widened mediatsinum, mediastinal air in boerhaave, calcification sign, PNA, westermark sign for PE, pleural effusion, water bottle sign/oreo cookie sign Physical exam to include BP bilateral arms, unilateral leg swelling, abdomen for pulsatile mass, JVD, feel chest for rib step off/crepitus, check for chest symmetry and subcutaneous air (PTX or boerhaave). Check a weight and look and see if he's been there before for previous weight gain or loss. He's thin and thus US would be easy. Cardiac US to eval for right heart strain caused by massive PE, pericardial effusion in subxiphoid, eval for obvious LV hypokinesis, and should be able to see aorta posteriorly in thin male through parasternal view. Alternatively look in epigastric and track it back up looking for dilation or intimal flap. Lung US to identify PTX quickly and with more sensitivity than CXR One could argue LFT to eval ALP and bilirubin in case of cholangitis causing his confusion and not alcohol, as well as lipase for pancreatitis, but I have low pretest probability of this giving my answer and likely would not order. Not wrong though. For my lab order "stored blue tube" incase I want to add a PT/PTT if he needs to go to cath lab emergently or need to start heparin. Consider d-dimer for PE. To condense the above: CBC, BMP, troponin, CXR, EKG Ethanol, US, good physical, well's and heartscore calculation. May move to d-dimer and CT or CTA chest depending. DDX: Higher- Trauma with possible rib fracture or pulmonary contusion, boerhaave, dissection, aneurysm, MI, PTX, esophageal spasm, PNA (possible aspiration), pneumonitis, sepsis, bilateral shingles (hey, you want a full ddx or not?), costochondritis, PE, pericardial effusion, hiatal hernia, GERD Edited to add: Oh, maybe look at his shoulders. Could be stopped drinking for bit and had ETOH withdrawal seizure. You laugh but I saw a case where this was missed, bilateral anterior shoulder dislocations.
  9. LT_Oneal_PAC

    A calling? A job?

    We have that option, but I’ve already decided on wilderness med and MICU. I would love an international elective, but I’ve already practiced overseas in austere in environments as well as disaster areas, so it wouldn’t be as educational, which is the reason I’m doing the residency. Plus I’d have to pay for the travel, which I could better do after the residency.
  10. LT_Oneal_PAC

    A calling? A job?

    I’ve loved doing them in the past and had a great time helping in PR after Maria. Unfortunately no time to do it in residency.
  11. LT_Oneal_PAC

    What's this in jaapa

    To be fair, my current hospital and the military refers to PAs and NPs as “licensed independent practitioners”
  12. LT_Oneal_PAC

    A calling? A job?

    Medicine is my calling. The paperwork is not. I will take care of whatever. Drug seekers, criminally insane, Darwin Award winners, the hypochondriac, the whiny teen, the nursing home dump, whatever. I’ll do it with a smile on my face and a skip in my step. Then when the paperwork starts, I’d put a cigarette out on my arm if it would make it vanish.
  13. My god I can’t wait to go rural. I’ve gotten mouthed off by family medicine and GI because I asked them to do their jobs. I went up to a nurse and said her name pleasantly, her response was “what.” I just don’t get rude people. The 2 ! times I lost my cool, which for me is the development of a perturbed tone, I profusely apologized 2 minutes later.
  14. LT_Oneal_PAC

    Off duty employment

    Nope. I'm sure its command dependent. Personally I had enough work to do at the hospital. The NP in the same office moonlighted in an urgent care. Never looked that appealing for the money to me, but I value time off a LOT.
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