sk732 Posted May 29, 2017 Share Posted May 29, 2017 Mid thirties dude brought in, found in gonchies on street C/O severe chest pain after doing lines of coke and crystal together...he was still talking to "Phillips" (his telemetry unit) quite animatedly and the glove dispenser 9 hours after being brought in. Phillips was a nice guy, but the glove dispenser wasn't so much apparently... SK 1 Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted June 8, 2017 Share Posted June 8, 2017 Sometimes rural medicine SUCKS. We've all heard that heartwrenching wail of a family member in the ED. Sucks even more when you're friends with the family (all too common in rural America). Can't wait for this shift to end. 3 Quote Link to comment Share on other sites More sharing options...
sk732 Posted June 8, 2017 Share Posted June 8, 2017 Hear you Dude... SK Quote Link to comment Share on other sites More sharing options...
ace17 Posted June 15, 2017 Share Posted June 15, 2017 EMEDPA Are working on those unique and possibly more complicated scenarios more common in the rural environment in general or perhaps just your hospital specifically? I am a pre PA in my undergrad now and want to work on more than minor cases (colds and flu) but some are saying that you can't do much in the ED as a PA while others disagree. Your cases sounds very intriguing and I would love to work on similar work if I had the opportunity. Thanks! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 16, 2017 Author Moderator Share Posted June 16, 2017 EMEDPA Are working on those unique and possibly more complicated scenarios more common in the rural environment in general or perhaps just your hospital specifically? I am a pre PA in my undergrad now and want to work on more than minor cases (colds and flu) but some are saying that you can't do much in the ED as a PA while others disagree. Your cases sounds very intriguing and I would love to work on similar work if I had the opportunity. Thanks! Much more common in a rural environment. These cases happen everywhere, but at most places they are seen by docs. go where the docs don't want to work and you will have the scope of practice and autonomy you desire. That post is now 5 yrs old and I am full time at that place . solo coverage, high acuity, low volume. I see everyone and do every procedure. love it. this is not a job for a new grad unless they have an em residency under their belt. that is the way to go in 2017 for anyone wanting to do real emergency medicine. there is a list of all the em residencies at the top of the em forum here. there are around 10,000 EM PAs. probably less than 2% do this kind of work(rural/solo coverage, no in-house doc). fortunately several of those folks are on this forum (me, Kargiver, Boatswain, a few others). most of us have extensive prior experience in emergency medicine. the most common prior experience for solo em pas is paramedic. 4 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted June 24, 2017 Share Posted June 24, 2017 Late comment: how about a hematoma block prior to trying to reduce the radius fx? I've had great experience with 10-20 cc's of local, my personal favorite is a mix of 80% marcaine & 20% lido with epi. I've seen it do more to control pain than fentanyl. Quote Link to comment Share on other sites More sharing options...
SERENITY NOW Posted June 24, 2017 Share Posted June 24, 2017 I've had pretty good success with hematoma blocks in residency as well, but now that I'm on my own I found myself a little bit scared to do them. The bad fractures with a lot of swelling... so many of these patients are complaining of paresthesias/numbness and you can never get a good motor exam in them. I worry now that dumping a ton of lido in there would screw up my post reduction neuro exam and I might miss a nerve injury or something... any thoughts from the experienced guys? Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted June 24, 2017 Share Posted June 24, 2017 I've not had it affect the neuro exam distal to the fx, unlike a nerve block. BTW, at SEMPA, I heard about a nerve block for a hip fx/reduction. Anyone ever done that? Thanks Quote Link to comment Share on other sites More sharing options...
sk732 Posted June 25, 2017 Share Posted June 25, 2017 I've not had it affect the neuro exam distal to the fx, unlike a nerve block. BTW, at SEMPA, I heard about a nerve block for a hip fx/reduction. Anyone ever done that? Thanks I've heard of them being done more frequently in one of our urban centres but never seen one...one of the guys there also does scalene bundle blocks for reducing shoulder dislocations. SK Quote Link to comment Share on other sites More sharing options...
medic25 Posted June 25, 2017 Share Posted June 25, 2017 I've heard of them being done more frequently in one of our urban centres but never seen one...one of the guys there also does scalene bundle blocks for reducing shoulder dislocations. SK We have a hip fracture protocol at our shop; part of the order set is a call to anesthesia to come to the ED and perform a femoral nerve block. Some of the EM attendings are also trained, but no PAs yet to my knowledge. Sent from my iPhone using Tapatalk Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 22, 2017 Author Moderator Share Posted July 22, 2017 Back from Mosul since 7/4. worked every day but 4 (and 2 of those days recerted ATLS all day). trying to play catch up. 84 hrs this week at 3 facilities in 2 states. It's not as bad as it sounds though. Am I sleep deprived? sure, but my 24 hr shift today has landed me 4 patients in the first 8.5 hrs, all legitimate and some decent downtime for working out while looking out the window of my call room at a snow capped mtn in the distance. life definitely is good. all my jobs are rural now. Hoping to hop to my favorite of the 3 in a full time capacity in the next year. I would also keep my weekend/month on the coast job. that would have me working a total of 10 days/mo. I now do 12. this allows for lots of time for medical missions, short vacations, more cme leave, etc. My part time teaching job starts soon as well and as it is 100% online I expect to do most of the work during down time at my regular jobs. 2 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 25, 2017 Author Moderator Share Posted July 25, 2017 In order to save money, one of the rural depts I work for has decided not to replace their one benefited PA who is leaving with another(say me), but to only staff the dept with independent contractors. As I am already per diem there, this does nothing to my pay, but likely does away with the possibility of me ever working there in a full time status as the hourly pay, while good, is not enough to buy my own benefits. I was really hoping to be full time at this particular place as it is my favorite position. it sounds like they will offer me as many hours as I want for hourly + malpractice only.....:( Quote Link to comment Share on other sites More sharing options...
ajnelson Posted July 26, 2017 Share Posted July 26, 2017 In order to save money, one of the rural depts I work for has decided not to replace their one benefited PA who is leaving with another(say me), but to only staff the dept with independent contractors. As I am already per diem there, this does nothing to my pay, but likely does away with the possibility of me ever working there in a full time status as the hourly pay, while good, is not enough to buy my own benefits. I was really hoping to be full time at this particular place as it is my favorite position. it sounds like they will offer me as many hours as I want for hourly + malpractice only.....:(Ugh. It always seems to happen that way [emoji53] Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 6, 2017 Author Moderator Share Posted August 6, 2017 On 7/25/2017 at 3:52 PM, EMEDPA said: In order to save money, one of the rural depts I work for has decided not to replace their one benefited PA who is leaving with another(say me), but to only staff the dept with independent contractors. As I am already per diem there, this does nothing to my pay, but likely does away with the possibility of me ever working there in a full time status as the hourly pay, while good, is not enough to buy my own benefits. I was really hoping to be full time at this particular place as it is my favorite position. it sounds like they will offer me as many hours as I want for hourly + malpractice only.....:( actually, looks like I was wrong. I will have to set up my own business, pay state business tax(in addition to 1099 employee tax and soc security) and buy myself a work comp policy. I am meeting with the new group next week. They initially stated "pay will remain the same". Going to see if there is some wiggle room there due to these factors. We are currently paid well, but slightly under market rate when compared to other similar depts. Quote Link to comment Share on other sites More sharing options...
sk732 Posted August 8, 2017 Share Posted August 8, 2017 Had a really bizarre thing with a Foley the other day...getting urine into collector tube, but not draining into bags. I actually was close to just calling this dude OCD at one point. I irrigated, changed bags and tubes, tried introducing air into downrange system to inflate the bag, etc. I waved the US on it - seemed to be in right place, bladder wasn't especially big. We changed the cath even. Finally the nurses and I admitted defeat, called urology to ask if he'd seen anything similar - the thought we came to in the end was that the bladder wasn't full enough to keep the tip patent, like collapsing on it, causing something similar to a vapour lock in a fuel line in a combustion engine. It's the only thing I could think of since the physics weren't making sense to me. Started PO hydration - if they come back (as instructed), then that wasn't the problem. SK Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 8, 2017 Author Moderator Share Posted August 8, 2017 On 8/5/2017 at 5:59 PM, EMEDPA said: actually, looks like I was wrong. I will have to set up my own business, pay state business tax(in addition to 1099 employee tax and soc security) and buy myself a work comp policy. I am meeting with the new group next week. They initially stated "pay will remain the same". Going to see if there is some wiggle room there due to these factors. We are currently paid well, but slightly under market rate when compared to other similar depts. Just met with new group. They are giving me a significant raise for per diem and we are discussing full time of 1 24 and 1 12 per week. May join boats as a 1099 full time guy. 3 Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted August 9, 2017 Share Posted August 9, 2017 On 8/5/2017 at 7:59 PM, EMEDPA said: actually, looks like I was wrong. I will have to set up my own business, pay state business tax(in addition to 1099 employee tax and soc security) and buy myself a work comp policy. I am meeting with the new group next week. They initially stated "pay will remain the same". Going to see if there is some wiggle room there due to these factors. We are currently paid well, but slightly under market rate when compared to other similar depts. You don't have to "set up your own business" to be paid 1099. You could set up an LLC, but there really isn't any benefit to it (ie: no liability protection). The employee tax will be the same as you would have had withheld from employer. However, as a 1099 independent contractor, you will be responsible for paying both halves of the 15% social security tax (ie: as a W-2 employee, you pay 7.5% and your employER pays 7.5% social security tax). So, effectively, tax-wise....to be a 1099 IC vs W-2 employee, the 1099 IC pays 7.5% more tax. (Caveat, some states don't tax 1099 IC pay, but do tax W-2 pay. I don't know about OR or WA....guessing they tax everything that moves/breathes). But it's the benefits that really add to the kitty. If you have to get your own malpractice ($5-$10K depending on state), retirement (3-10%), and health benefits ($20K+ sometimes) then you really have to charge more for 1099 IC work. Oh, and there's no unemployment/work comp/disability provided either, so you gotta figure that into your estimates of what you need as well. If you can get health insurance from your spouse or other means then it can really make IC lucrative. My biggest fear being an IC is disability. I've looked into private disability insurance and, for me, the costs are astronomical due to previous injuries. Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted August 9, 2017 Share Posted August 9, 2017 6 hours ago, EMEDPA said: Just met with new group. They are giving me a significant raise for per diem and we are discussing full time of 1 24 and 1 12 per week. May join boats as a 1099 full time guy. As a 1099 there is no "full time", "part time", "over-time", PTO, holiday's, etc...unless you put it in your contract. STRONGLY encourage you to list out in your contract the holidays that you will BILL time-and-a-half. Nuthin like getting $132.50/hr on a holiday! Conversely, a 24 + 12/week schedule could give you enough time off to pick up extra 24 hour shift, or maybe a 48 hour shift somewhere else, and the money (well....2/3 of it) is icing on the cake (the other 1/3 is taxes). Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 9, 2017 Author Moderator Share Posted August 9, 2017 they are covering the malpractice. by full time I mean they would guarantee me 144 hrs/mo. I would still work 24 hrs/mo at my coastal job and maybe pick up a bit more when the mood strikes me at both places. my retirement is basically covered by a prior pension I have from my last job so won't have to contribute any more in that direction. health care for my relatively healthy family runs around 1000/mo. I would need to buy disability policies. I already have life insurance. would have to pay my own licenses/dea/cme, etc, but could write it all off. as far as 48 hr shifts, they don't exist within commuting distance of my home. 24s is as good as it gets, at least in em. there are some inpt psych gigs with 48-72 hr shifts to which I say hell no. 1 Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted August 10, 2017 Share Posted August 10, 2017 E- I'm sure you already know all this, but I'll put it out there for others to read as well. A prior defined pension plan from previous employer? I advise you (not that you asked!) to be cautious there. Many defined pensions are finding themselves under-funded and there are now court cases leading to judicial precedence allowing them to be "re-defined" as much lower pension. If you have a company provided 401K, recommend you roll it to a to an IRA. Most company provided 401K's are over-expensive and under-perform (especially larger companies). With an IRA YOU can choose inexpensive but high-performing mutual funds/stocks. I think it's tough to have "too much" in retirement, especially with the tax implications of doing nothing. If you have a high-deductible health care plan then recommend you fully fund an investment HSA. It's pre-tax money that grows tax free, and you don't have to withdraw health expenditures in the years that you use them. That means you can put $6750 a year into a HSA pre-tax (saving you $2K in taxes) and have it grow tax free. Meanwhile you save your healthcare expenditure receipts for decades until you want to withdraw some tax-free money from your HSA. If you no longer have an employee-provided retirement plan then I recommend you fully fund a ROTH. While this is post-tax money, any withdrawals after retirement are tax free as well (ie: tax free growth). And lastly, if you start a SEP-IRA then anything you put in there is pre-tax as well, saving you about $.30 on the dollar in taxes. 2 Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted August 10, 2017 Share Posted August 10, 2017 Use EFTPS online to pay quarterly taxes (I actually paid mine monthly) as necessary. 2 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 11, 2017 Author Moderator Share Posted September 11, 2017 had a little pucker moment recently...doesn't happen much anymore...middle aged obese lady stung inside the mouth by a bee, presented with significant resp distress and torso urticaria. smoker. big neck. malampati 3. poor landmarks for crich and swollen uvula. lips and tongue were nl. maintaining sats ok with positioning and nasal cannula o2. rash resolved and some improvement with epi, Benadryl, fluids, Pepcid, racemic epi neb. steroids given, but no real help anticipated for hours. considered cpap, but pt very anxious and unlikely to have tolerated mask. didn't want to sedate to facilitate bipap or cpap. glidescope with size 6 tube at bedside. crich kit at bedside. relatively stable so called in anesthesia for potential elective intubation. anesthesia feels pt stable enough to obs in dept and await steroid effect. signed out pt to my partner 1 hr later at shift change. by the time I got home 2 hrs later had a text that anesthesia electively intubated with fiberoptic scope when pt worsened. I feel like I could probably have managed the airway with glidescope/small tube or crich, but pt was relatively stable so involved anesthesia. 3 Quote Link to comment Share on other sites More sharing options...
sk732 Posted September 11, 2017 Share Posted September 11, 2017 I go by the rule of "If they're there, can't hurt to use them". SK 2 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 11, 2017 Author Moderator Share Posted September 11, 2017 11 hours ago, sk732 said: I go by the rule of "If they're there, can't hurt to use them". SK yup. and when it's time to be a cowboy, be a cowboy, but when there is time to summon the troops, involve a specialist. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 1, 2017 Author Moderator Share Posted October 1, 2017 great recent 24 hr shift at rural facility with student: 12 patients, 11 of them actual emergencies including a nonstemi with 20 min of chest pain and an initial trop of 0.9. flown to nearest cathlab facility on ntg and heparin drips, 4 vessel critical stenosis, got a CABG. a code a 96 yr old with pneumonia and sepsis I think my student is now hooked on a career in EM....:) 2 Quote Link to comment Share on other sites More sharing options...
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