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About JoeM

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    Physician Assistant

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  1. Check the “internet book of critical care” on em crit. Incredible resource
  2. Honestly wasn’t sure if medicine was for me. Definitely had the grades and test scores but didn’t want to spend the time and money on Med school given my uncertainty; so I hedged and went to PA school. PA offers me A good living and a nice schedule. Only I regret I have is going into medicine unfortunately. Glad I didnt figure that out after spending 8 years and 250k on Med school.
  3. “Body habitus precludes ventilation” Fatelectasis is my personal favorite
  4. CC PA here. I see these cases everyday. Just a couple of pearls for you: this definitely wreaks of sepsis so definitely some fluids and ABX are warranted. However, Without better history and labs it’s hard to get a true sense of the differential. It sounds like she may have some comordities/chromic health issues (ESRD???) which would be helpful to know. Overdose? DKA? HHS? ACS unlikely without some EKG findings but agree that cardiac enzymes will be elevated regardless in a renal patient With renal failure patients you should be resuscitating with balanced crystalloid as opposed to saline (SALT-ED and SMART trials) Also this patient needs dialysis ASAP. Call your local nephrologist!! A tip for obtaining central access in acute renal failure-put the Cvc in the left IJ or the femoral. Patient will likely need temp HD catheter placement and the catheters have better flow when placed in the right IJ. also, I would have started this patient on pressor immediately when fluids werent doing much. “Filling the tank” only works when the tank isn’t leaking out everything you put in it into the interstitium. Give some fluid (30 cc/kg is COMPLETELY arbitrary and based no real data....also use ideal body weight) but if it’s isnt working start pressors! Pressors are not dangerous! Don’t keep pounding them with fluids. You can run pressor safely through a peripheral Line until you get central access so don’t delay. norepinephrine firstline followed by vasopressin and solucortef if she requires >15mcg/min norepinephrine. as far as volume assessment, she is likely dry based on your description. However, looking at the IVC with US is essentially a coin flip when evaluating volume status. There are a ton of confounding physiologic variables that muddy your assessment. Also, a CVP of 2 is not abnormal and again is absolutely useless in managing shock. A more valuable use of the ultrasound would be to look at the heart, kidneys, lungs and do a quick fast exam (rule out uremic pericarditis with effusion lol ?) Procalcitonin is useless in renal patients in my experience. Also, is it going to change your management of this patient? Agree with check a CK. Anyone found down needs a CK checked Cultures only grow something out ~1/3 of the time so don’t stop ABX based on that. Also, qSOFA is garbage. It’s not very sensitive and wasn’t validated. The sepsis guidelines in general are useless. Septic patients often have a mixed shock shock picture due to vasoplegia as well a cardiogenic component due septic cardiomyopathy...more common than you’d think! a final thought on her airway. I would’ve have intubated this patient. If her pH is truly 6.9 and she’s not breathing hard or has a normal pCO2 that’s means she’s crapped out. Also when patients are in extremis work of breathing can use a significant chunk of your cardiac output. Alleviate that burden!! If you do decide to intubate, have pressors and fluids going when giving induction agents or you can write “death by glidescope” on her death certificate! overall is an interesting case. Definitely enjoy managing these patients.
  5. Congrats! I just paid mine off two weeks ago. Graduated in 2016 with 55k. Sweet relief. Make sure you celebrate
  6. Strong work! I’m graduate with 60k 1.5 years ago. Now down to 12k. Paying 3k per month while maxing our my 403b, Roth IRA and HSA. Budget is uber tight but it’ll be worth it in a few short months. I would be done with them by now but I had a low salary my first year out of school as I did a critical care fellowship. Keep up the good work. Debt is slavery!
  7. just push bicarb until the QRS normalizes!
  8. I'm also a recent graduate (July 2017)....I currently work MICU in Columbus. Many of my classmates also work in Columbus and I don't think any of my classmates had trouble finding work in Ohio. I can tell you that there many ED job openings in Columbus if you're interested in that field.....and yes the practice laws and formulary in Ohio is beyond archaic and I'm having some issues with this at work
  9. was it the emory program? I got the same email!
  10. You can give her calcitonin or a bisphosphonate for the hypercalcemia. The calcitonin will work acutely and the bisphosphonate will take a few days to kick in. As far as fluids go, I'm don't know how much to give. I wouldn't think much would be necessary as she is euvolemic. If you can enlighten me on determining how much fluid to give I would appreciate it. A lot of my preceptors never really give me a straight answer! for the stool softener maybe dulcolax or milk of magnesia As for the thyroid mass -with an elevated PTH, a parathyroid adenoma is likely -I don't think a thyroid carcinoma with bone mets can be ruled out yet -since it's 3 cm and she's symptomatic I think an FNA is warranted Thanks for posting this btw I enjoy all these cases and how you help guide us through them. As a student, this is great learning tool!!!
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