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LT_Oneal_PAC

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LT_Oneal_PAC last won the day on September 11

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  1. Not sure. It might be something for my daughter to see and hopefully inspire her. I personally don’t care much for the ceremonies.
  2. That’s a tough one. You derive a lot of personal satisfaction from your job and that makes it harder to “be in charge” when you’re not in charge at all. if it were me, I would let someone else have the headache. It’s not worth the moral injury IMO. In your shoes, the way you explain it, I may stay. You’ve had it on your resume long enough that it’s rock solid and easy to explain why you stepped down. Also, doesn’t sound like you’re being any less of a leader. You don’t have power, they know you don’t have power, so how are you or anyone else expected to get anything done? But there is a lot to be said about making your own schedule and feeling your job is secure. With a new baby, that is huge weight off. Maybe talk it over with your wife? I think that would help. Aren’t the furloughs over though? I feel like the volume is up everywhere and jobs are picking up. this is a really personal decision. Do you prioritize your mental health so you can be a great dad and not have this weighing on your mind, or do you risk less time with them and job security just for a little stress relief. What new stressors are going to come up if you step down and will those be less than the stressors you have now? good luck buddy. I’m hoping to create a chief APP position at my hospital and I’m worried this is how it’s going to turn out.
  3. Taking this 6 weeks off of classes to write my case report and submit for the final project, then will be finishing up in May if you have questions. Obviously though I haven’t finished
  4. All sounds fine. Classes at CC are fine. We do not care about stupid crap like research.
  5. High speed GSW/blast trauma will definitely occur more frequently as a SF medic. Level one medical resuscitation is a different animal. I just put this out there because I see a lot of over confident former medic/corpsman that don’t understand they cannot operate independently day one in a rural ED without a residency or minimum 5 years OTJ training. Not saying you are implying this or are over-confident. Just a point of clarification that mastering trauma is not the the hardest thing you’ll manage independently.
  6. My way probably isn't the right way, but I was going to quit over stuff like this. I was too depressed, clinically, over the terrible things I was seeing. However, justice ultimately comes to these people... I too have been struggling with an NP ( not that I think credentials matter because the last dolt they had was even worse and was an MD) at hospital that was awful. Reprimanded as an RN for opioid diversion. Fired from last job for unknown reasons, just rumors of unable to take direction. I sent 2 people he put into renal failure for emergent dialysis. I suspect he sees himself as a angel of mercy because not a single parkinson's patient has survived admission since he started a little over a year ago. A patient with a ileocolic anastomis leak developed an abscess with puss and fecal matter draining from abdominal incision after retroperitoneal mass was removed, on TPN and hasn't been able to eat in over a month. Patient refused transfer back to the surgeon and discussed hospice. He told them it was inappropriate that I discussed hospice with them, and some other not nice things about me. Failed to intubate a COVID patient on the floor x4 before ED provider arrived. Then next time he has to intubate and I hear about and come to the floor, tells me to butt out. These are just a few things he has done. I arrived at work this weekend expecting to tell my boss, who also wants this guy gone but both of our complaints have fallen on deaf ears, that I quit if he isn't gone by my next shift in 2 weeks. I couldn't be apart of an organization that would subject their community to this guy. A miracle was granted as before I had that conversation I see an email that he is on leave indefinitely. He has a disciplinary hearing this month for sleeping with a patient of his that was a minor at his last job. Sad that is what it took, but I had the best weekend shift I have had in a while with the knowledge he wasn't going to come in and destroy all the work I put into patients. Give them enough time and they hang themselves....Now if I can just keep them from hiring a 3rd dope in a row as hospitalist I'll be golden.
  7. I would have started meropenem (push dose) and linezolid on someone looking this sick as soon as the I had urine and blood cultures drawn. There is a EM infectious disease guru out of Cali that has really pushed that this should be the new vanc/zosyn. I'm not quite there yet, but I'm quicker on the meropenem these days in people who have recurrent UTIs and septic. The questions below are what I would be asking myself at some point: ECG? Troponin ? POC cardiac US show any depressed LV function? are we flogging a dying heart as well as fighting distributive shocK? Glucose? Beta hydroxybutyrate? Did infection lead to DKA or HHS? IVC indicating fluid tolerant? Do I need to give more fluids? Metabolic panel? Making urine? Does this lady need dialysis? ABG? Is she tuckering out with her rapid breathing? Does she need Bipap or intubation? Is the sepsis causing the tachyarrhythmia or is the high dose NE causing it? Should I be using phenylephrine now? ScVO2? Could consider steroids if failing 2 pressors as they may have their adrenals in the crapper, but I haven't thought much about that since I was in the SNICU. Call the ICU PA and ask them to take this patient off my hands. Ask them family if they would like the Chaplain.
  8. You cannot compare lock down versus no lock down in different years, in states with vastly different population densities, vastly different climates, beginning versus mid-pandemic, and most importantly vaccine versus no vaccine.
  9. I would sign a deal with the devil himself if I could go a shift without spending hours straightening out multiple COVID patients, arguing with them about ivermectin, and a line out the door of people “just wanting a test” at the ED. Do I think this proposal is the method needed to fix the problem? No. There would be many unintended consequences that would affect not just those refusing the vaccine. I could elaborate, but it would be pretty long and boring. I’m fine with coercion in the name of public safety. Just like I’m okay with forcing people to get TB treatment, arresting people knowingly transmitting HIV, wearing seat belts, wearing helmets, not using cell phones when driving, not allowing them to shit in the street, making restaurant employees wash their hands, AND our history of mandating vaccines.
  10. Would be happy to help out. Just send me a DM @PAtoMD
  11. @MediMike my bad, I didn’t reread it. I thought you asked something about the CXR and not the ekg. Interestingly we were taught it was very specific as well, but I have lost faith in that since I’ve seen it several times with no PE found. I remember in heart transplant seeing a lot of hypotension from dobut, but then again those were the sickest of the sick so I was probably seeing correlation and not causation. Thanks!
  12. Is this an actual case? If so, do you think the mitral regurgitation caused the appearance of r>L lung pulmonary edema? I’ve seen a lot of reports of primarily or even unilateral pulmonary edema if certain leaflets were affected in MR. Were you saying westermark sign on the CXR as an indicator of PE? Little less fluffy in the bottom left, but then again I thought maybe it was due to the above. Would dobutamine ever be something you would use here? Obviously the nitro is best in flash pulmonary edema, but in hypertensive emergency with acute heart failure, could it Improve forward flow and dobut can also lower blood pressure? We can often oversimplify in the ED (norepi is often the go to for every shock type except anaphylactic shock where we use epi) but I like to be more nuanced. I haven’t used dobut since I was a heart transplant nurse.
  13. Hypertensive emergency! Ding ding! We can determine this pretty quickly. Patient comes in, can’t breath. IV, O2, monitors. Simultaneously grab cardiac probe and look at heart and lungs. No RV strain, no LV dysfunction or wall motion abnormality, B lines present. If she has PE, unlikely to need thrombolysis. B lines, JVD, history suggest likely either CHF exacerbation and unlikely PE as the cause, as PE does not cause fluid in the lungs. It backs up the RV. The normal EF suggests she has HFpEF. All this combined with the vitals and acute onset (as opposed to a more insidious onset in volume overload) that the hypertension is our primary issue leading to FLASH pulmonary edema. I wouldn’t hesitate to start some NTG. Now if I was really concerned for PE, I wouldn’t start NTG. Some would get a CTA here “just to be safe” and I firmly stand by not being a Monday morning quarterback, but would encourage students to follow the evidence. The burden of evidence is to do the test, rather than thinking you need evidence to not do a test. It’s all Bayesian statistics. What is the pre-test probability of a positive test. For me, I’m this patient, it’s less than 2%. Maybe an easier thing to say from a standpoint of experience. NTG is our bestest friend here. Normally it’s garbage in HTN emergency, but this is one of its few indications. With its primarily venodilation, we rapidly expand the tank, sucking out the fluids from the lungs. Combined with bipap (or cpap)pushing it out, you would have this lady tip top before the admitting service calls you back. now she is a little tachycardic. I would not fault someone for also giving some metoprolol, as NTG can lead to reflex tachycardia. while typically this person would go to an ICU, I would 100% admit this lady to me (I’m also the Hospitalist) and put her on the floor. Larger centers won’t take any infusions like this and certainly not bipap. Though I suspect she’ll need neither in about 6 hours with some good inpatient management and all will be good. @MediMikebrought up a good question: what do we do if she doesn’t tolerate the bipap?
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