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JoeM

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About JoeM

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  1. Increasing temperatures with high humidity (increasing air density) will assuredly affect COPDers for example.
  2. Unfortunately patients are real people and things like climate change, race, sexual orientation, immigration do affect the medical issues we may encounter when providing their care. Do I think medical education should be entirely centered around these things? No. But I do think ignoring them in the society we have today is short-sited and narrow minded. If you don’t think climate change is going to affect people’s health I think you will be in for a rude awakening.
  3. Question, is the fear of NP takeover more-so for the primary care/urgent care/ED settings? I work in critical care and under no circumstance do I think any provider other than a physician should have the ultimate say in some of these incredibly complex patients. In the inpatient and surgical settings I don’t see how their independence would have that great of an effect on us. I work with a lot of great NPs and we both have required chart co-signatures as there is always a physician in house. Another thought I have had regarding corporate medicine only hiring NPs due to their independence is if an independent NP were to severely mismanage a patient what type of liability the practice/corporation would be open to if a physician with the gold standard medical training was not available for collaboration. i am all for OTP. Just wanted to see what everyone’s thoughts were regarding these scenarios. I’ve been reading these forums closely and find a of these threads unnerving to say the least so figured I’d chime in.
  4. Check the “internet book of critical care” on em crit. Incredible resource
  5. 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.
  6. “Body habitus precludes ventilation” Fatelectasis is my personal favorite
  7. 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.
  8. Congrats! I just paid mine off two weeks ago. Graduated in 2016 with 55k. Sweet relief. Make sure you celebrate
  9. 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!
  10. just push bicarb until the QRS normalizes!
  11. 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
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