Monthly Archives: June 2016

Medical Musing of the Week: Atrial Fibrillation

Overview + Definitions

  • Most common arrhythmia
  • Increased risk with age
  • Irregularly, irregular rhythm and absent P waves on EKG
  • Valvular vs. non-valvular (valvular means that arrhythmia is being caused by some type of valve disease ie rheumatic fever or from a defect in a prosthetic valve)  Most cases are non-valvular A-Fib (you will hear that term frequently!)
  • A-Fib w/ RVR (stands for “rapid ventricular response”): This basically means that the person is not in rate controlled A-Fib and the ventricles are trying to keep up with all the beats being initiated by the atria.
  • The more days/weeks A-Fib persists the increasing likelihood that it will be permanent
  • Paroxysmal A-Fib: Self-terminating within 7 days onset.  Usually terminates <48 hours. Recurs with variable frequency.
  • Persistent A-Fib: Atrial fibrillation that fails to self-terminate within 7 days or requires medication for termination.
  • Permanent: Has persisted >12 months and cardioversion has usually been unsuccessful.  Focus shifts to rate control

Etiology + Risk Factors

  • Coronary Artery Disease
  • Congestive Heart Failure
  • Acute Coronary Syndrome
  • Hypertension
  • Pulmonary Disease (esp COPD flares)
  • Pneumonia/Infection
  • Etoh (“Holiday Heart”) –> Lots of patients will show up to the hospital around the holidays because of increase of alcohol use
  • Surgery or anything that will cause fluid shifts in the body either overload or dehydration
  • Has patient missed any doses of rate controlled medication?

Clinical Manifestations

  • Palpitations/Chest Pain
  • SOB (may have increased O2 requirement secondary to heart beating so fast patients are not perfusing appropriately and become SOB– once their HR slows the will perfuse better and O2 requirement likely subsides

Diagnosis

  • EKG
  • Troponin x3 + CKMB x1
  • CT PE study (for rule out–in hospitalized patients who have a new oxygen requirement
  • Telemetry Monitoring

Treatment

Steps to take/Questions to ask:

  • Calculate Cha2ds2 Vasc:
    • The “chads vasc” is a scale that determines an individual’s risk per year for stroke.  Based on their risk have a discussion with the patient about risks and benefits of oral anticoagulation
    • Scale includes:
      • Congestive Heart Failure
      • HTN
      • Age (2pts) >75, (1 pt) >65
      • Diabetes
      • Stroke/TIA history (2pts)
      • Vascular Disease
      • Sex (+1 if female)
  • Is the patient rate controlled?
  • New onset?
    • If rate controlled determine need for oral anticoagulation (watch providing with elderly who fall frequently)
    • If rate isn’t controlled do so with a BB
  • Is the patient rate controlled? (<110 BPM)
    • A-Fib RVR:
      • In a hospitalized patient options for treatment include IV Lopressor (may repeat for 3 doses, Cardizem 5mg +/- drip (may also repeat), Digoxin or Amiodarone bolus +/- drip
      • If low BP will want to hold off on Cardizem or Lopressor–cardizem will really drop the BP
      • Amiodarone is my go to when a patients BP is low 150mg bolus followed by a drip of 1mg/kg x6 hours, .5mg/kg for 6 hours, 400mg daily and then 200mg daily for maintenance
  • Are they hemodynamically stable?

Below is one of my favorite flow charts from UpToDate (love this source!)  This is a really good place to start to understand the treatment of A-Fib

image

 

Prognosis + Complications

  • The longer a person remains in atrial fibrillation the greater the risk it will be a permanent rhythm
  • RVR (rapid ventricular response)
    • Frequently seen in the hospital especially with CHF exacerbation, surgery (because of fluid shifts)
  • CVA/TIA
    • Because of the irregular rhythm of the atria and valves individuals with a-fib are at increased risk of developing clots on their mitral valve and throwing ot through their aortic valve and to the brain
    • Calculate chads vasc as above to determine risk

 

Breaking Down PA School Interviews III

Q: Why do you want to be a Physician Assistant

  • What are they looking for?

    • That you have the ability to demonstrate understand about who PA’s are and what they do. Basically that you can distinguish between other health care professions.  Your response should delineate why PA and not another health care field. 
  • What to avoid:

    • “I always knew I wanted to practice medicine”.
      • This is a generic response and tells them nothing about why you want to be a PA.  This type of response suggests you lack knowledge about the PA profession, because if you don’t demonstrate that you have that knowledge they will assume you do not.
    • Anything that suggests you weren’t able to get in to medical school so you “settled” on being a PA
      • Believe it or not people do this and actually say it
      • I hope it goes without saying that this is a bad idea and I hope no one is going into the profession for this reason (FYI it’s more difficult by the numbers to get in to PA school)
      • Responses such as “I took the MCAT and couldn’t get a good score” or ” I don’t want to do residency” are well—not good
    • Speaking poorly of other professions
      • Saying you “want to be more than a nurse”– any type of negative connotation towards any other profession is a very bad idea.
  • What to say

    • For my answer I talked about my experience in as a therapist and how I realized although I loved how the profession allowed me to help others it offered a lot of short comings that I wished I could address.  I went on to discuss a particular incident that a teenage girl was asking questions about the medication she was taking for depression.  I knew the answer.  I had studied neuroscience, however if I would have explained this answer I would have technically been”out of my scope of practice”.  I wanted to be the person who was able to provide these types of answers, thus adding to the reasons I wanted to pursue the PA profession.
    • Moving laterally across specialties and being trained on a general medical model
    • Practicing medicine in a collaborative setting
    • Providing patient care on a comprehensive level
    • Talk about the difference you saw a physician assistant make in the life of a patient while you were shadowing
    • As always–be positive and genuine!

Breaking Down PA School Interview Questions IV

This weeks question was submitted via e-mail and its a two-for-one! If you have a question you want broken down be sure to e-mail me at: all.things.pac@gmail.com

Q: What is your greatest strength?

What are they looking for?

  • This is pretty straight forward.  What do you do well?  What characteristic do you possess that makes you an excellent candidate and will make you a great PA?
  • Try to wrap the quality into a story to show that you have demonstrated that behavior in the past.  Behavioral interviewing is a large part of PA schools.  Admissions committees believe the old saying “history repeats itself”. Show them in addition to telling them with a story.

What not to say:

  • I’m a great student, I graduated with a 4.0 (they will have all these stats and likely on your resume).
  • Anything really vague or that they can get from your resume. Remember anything open-ended you are asked in your interview is your chance to tell them anything about yourself and why you are the top 1-4% of applications they received.
  • Don’t brag too much.  There is confidence and there is cocky. Be confident, not cocky. 

What to say:

  • I was not asked this on my interview.  Had I been asked I would have said perseverance.  I had a long, pre-determined and daunting road to the point of applying to PA school.  I saw something I wanted and went after it with my heart and soul. I had arrived at this point and would use the same perseverance to make my way through PA school and throughout my career.
  • Be genuine. People can sense when you give them a bunch of bologna.
  • This is a very individual answer. In my opinion appropriate answers include: compassion, team player, adaptability, thriving under stress and being able to work effectively with many different individuals (there are many more but these are just examples to get you started).

Q: What is your greatest weakness?

What are they looking for?

  • Also quite straight forward, but a little more messy than your strength.
  • You always want the weakness to be something you turn in to a strength, but not be overwhelming.
  • Demonstrate that you understand what you need to work on and how you can better yourself

What not to say:

  • Anything that can be misconstrued as a quality that would make you difficult to work with your impede your work as a PA or PA student
  • Stay away from politics, religion or anything that can be construed as racism–all very very bad things.  Anything that can be emotionally charged should always be avoided in interviews (I hope all of these things are obvious and not qualities anyone posesses but just as a friendly reminder).

What to say:

  • I was not asked this question for my PA school interview either that I remember.  However, I have been asked this at many interviews prior to PA school.  My answer has always been “Low tolerance for a poor work ethic” aka I can’t stand laziness.  I further state that I tend to take on responsibilities of others and it can take away from the quality for which I perform my own job.  I’ve since learned to better stay within my means by still being a team player.
  • What do you need to improve on? Are you too hard on yourself/you own worst enemy? Do you have a tendency to be an over-achiever and not know when to take breaks and relax? Do you take on too much responsibility in a group setting? Trouble stepping back and following because you’re a natural leader? All of these are good examples
  • Remember: BE GENUINE!  I cannot stress this enough, it’s so easy to see when someone is insincere.

 

 

Breaking Down PA School Interview Questions III

This weeks question was submitted by a pre-PA student who said she was asked this at an interview!  I was never asked this question; but, I can see programs with a primary care focus asking.

Q: What do you know about primary care?

What are they looking for?

  • This questions will likely come from programs who have a focus on primary care/underserved populations in their mission statement
  • Demonstrate understanding of day-to-day responsibilities of a primary care PA
  • Show interest in becoming a primary care PA
  • If you shadowed in this area, talk about it!

What NOT to say

  • Anything that would be negative about primary care
  • That you already know what specialty you want to practice in so you’re not concerned with primary care
    • First–you may practice in the area you are thinking about now but I can tell you I thought without a shadow of a doubt I would be an orthopaedic PA and I will probably never be caught dead in this area of practice (not saying anything bad just not my cup of tea)
    • I hope this is obvious to everyone as to why you shouldn’t say this 🙂

What TO say

  • Show interest in primary care–talk about a shadowing experience you had if you were able to shadow a PCP.
  • Importance forming relationships with patients and how being able to have continuity/longevity
  • Primary care is the cornerstone of medicine.  It is an individuals point of contact within the rest of the health care system
  • Responsibility for preventative medicine and managing chronic conditions
  • Generally fast paced with many patients in one day ranging from pediatric well visits to common colds as well as determining if sick patients with chronic conditions require a higher level of care
  • You can discuss the shortage and primary care physicians and how important it is to foster PA’s to go in to this area of medicine so that more people have access to care

 

 

Breaking Down PA School Interview Questions II

Q: Tell me about yourself?

  • This is a time a like to tell people “don’t over think it and don’t over do it”.  Given the freedom to simply just speak during an interview is really gut wrenching–especially about yourself.
  • What they want to hear/see
    • The point of this question is literally just to get to know you and see that you are personable and that you can hold a normal conversation.
    • Admissions committees don’t want to bring in students who can’t hold a normal conversation.  Translation: if you can’t hold a normal conversation with them how can you sit at a patients bedside and talk about serious stuff?
    • They are evaluating you as a future colleague.  Make small talk. Make eye contact.  Have confident body language.  Smile.  Keep it simple 🙂
  • What to stay away from:
    • Religion
    • Politics
    • Volunteering too much information about your family situation
    • Drinking, partying, etc (I hope this is obvious)– along the same lines MAKE YOUR FACEBOOK PRIVATE!  I also suggest changing your name to something other than your true full name.  For example I went by “Danielle Marie” when I was applying in addition to the most private settings I could find.
    • Don’t just re-state your resume.  They have that, and they know your experiences.  Tell them things that give them a better vision to who you are!
  • What TO say!
    • When I answered this question I talked about how I was a non-traditional applicant and having experiences from personal training to mental health.  I also talked about doing CrossFit and running half marathons.
    • Anything that is a bit different that you do will spark a two way conversation (which is better than aimlessly talking about yourself)
    • Talk about a recent trip you took or how you love to travel–something that makes you different!
    • Don’t be afraid to make a statement about how dedicated/passionate you are about becoming a PA.  This is your open ended question chance!  It’s ok to brag–but be tasteful and not over-bearing.

Breaking Down Interview Questions

In honor of “interview season” coming up, each week I will be breaking down one of my 41  most common questions to encounter at a PA school interview (find that original post here )

Q:  What do you expect a typical week in PA school to look like?

  • Why are you being asked this question?

    • Professors want to know that you understand the demands of PA school.  If you don’t understand the demands it’s a red flag that you might not be able to handle the arduous course of PA school.  It’s also a red flag that you haven’t done your simple homework to understand the process to become a PA and may further alert them that you don’t know anything about being an actual physician assistant.
  • What not to say

    • “I’m not sure can you tell me about it”
      • I think this speaks for itself.
    • “It might vary by program”
      • While this is true every program is different, again they want to know that you are expecting these 2 years to be the most challenging experience you’ve had so far.  Also, that you are up to the challenge.
    • “I don’t know”
      • Simply unprepared and unacceptable.  This would be a HUGE red flag to me sitting on an admissions committee
  • What will a good answer contain?

    • Demonstrating knowledge.
    • A typical week in PA school will contain multiple tests/quizzes and competencies. Likely spending 8 hours a day in a classroom learning new material at a very quick pace.  When you go home you study the days material get up the next day and do it all over again until clinical rotations.
    • Tell them it is your #1 priority.  State that you understand the demands of the program (as listed above) and are prepared to make your education to become a physician assistant the number one priority in your life.

 

Medical Musing of the Week: Pulmonary Embolism

Overview

  • Thrombus of the pulmonary artery or branches
  • MCC from lower extremity DVT
  • 12% without unclear etiology result in malignancy diagnosis

image

Etiology/Risk Factors

  • Virchow’s Triad: Venous stasis, endothelial injury and hypercoagable state
  • Hip replacement/fracture is a large risk factor (and other surgeries!)
  • Clotting disorders (Factor V Liden is MC), pregnancy

image

Clinical Manifestations

  • MC symptom is dyspnea
  • Pleuritic chest pain
  • Hemoptysis
  • Tachycardia (on a personal note I had a bradycardic patient with a PE last week!)
  • Cough
  • If PE is massive/saddle (spanning both main pulmonary arteries) pt can be very unstable or even unresponsive
  • Typically this is a patient that

Diagnostic Studies

  • D-Dimer is VERY non-specific.  Only perform if you have low suspicion of PE
  • CT PE is most common study used clinically (need good kidneys)
  • V-Q scan if bad kidneys
  • GOLD STANDARD (boards buzz word!) Pulmonary Angiography
    • Used when CT PE negative but still have high suspicion
    • Clinically I have never seen one of these ordered.  If you have that high of a suspicion and you cannot properly investigate you TREAT!
  • EKG: S1Q3T3, sinus tachycardia
  • CXR is most commonly normal
    • Hamptons Hump
      • Represents an infarcted area of the lung secondary to thrombus blocking vasculature
    • Westermark Sign
      • Lack of vascular markings distal to the emboli

image

Treatment

  • Unstable patient: Immediate surgery for embolectomy
  • Hemodynamically stable patient:
    • Heparin gtt w/ bridge to coumadin
      • 80 unit bolus
      • 18u/kg/hr
      • PTT goal 1.5-2x control value
      • INR of 2.0 or greater for 24 hours before d/c heparin
    • Lovenox with bridge to Coumadin
      • 1mg/kg SC BID
      • INR of 2.0 or greater for 24 hours before d/c lovenox
    • Xarelto
      • 15mg PO BID x 21 days; followed by 20mg PO daily
    • Eliquis
      • 10mg PO BID x 7 days; followed by 5mg PO BID
    • IVC filter in patients who cannot receive OAC (maybe they are a high fall risk or their HAS-BLED score is super high)
  • Duration of treatment with OAC depends on if provoked, unprovoked, underlying pathology, etc.
    • Provoked (surgery, pregnancy): 3 months
    • Unprovoked: 6 months (or longer)
    • Recurrent unprovoked: Likely life-long OAC

Complications, Prognosis & Stuff to know!

  • Check PT/INR/PTT daily
  • Watch for bleeding (obviously!)
  • Can do PPI for GI protection
  • Protamine Sulfate is the antidote for Heparin and Lovenox
  • Don’t use heparin with bad liver and don’t use Lovenox with bad kidneys
  • Be highly suspicious of malignancy in a patient who appears to have no other risk factors for PE
  • Remember to ask if pt has had prior DVT/PE (very important!)
  • Does the patient have a new oxygen requirement?
  • How does their breathing look?
  • Do you need a transfer to a higher level of care?
  • If early PE is not caught, subsequent PE’s are associated with a higher fatality rate so it is very important to catch that first one early and treat!

Don’t You Want to be a Doctor?

There is no yes or no clear cut answer to this question, but I get asked this a lot.  By prospective students, current students, other medical professionals and patients.

My honest to God answer is “I’m not sure”. So, I stumbled upon my desire to join the medical field a teeny bit later than most people at the age of 25 or 26.  Someone brought me a brochure about who PA’s and and what they do–and I was like this fits me (and I still think it does). I never considered becoming a physician at that point.  I didn’t want to embark on 10 years before my career was in full swing (shit I would have been 35).  Not that there is anything wrong with that (Seinfeld reference anyone??).  Also, for me I already had two degrees and a shit ton of debt.

I think being 18 and introduced into the medical field early and having different life circumstances (read about my journey here if you wanna hear about it) I would have explored the route of becoming a physician.  I’m competitive, mostly type A and strong-willed.  That being said, with all of the schooling and residency and lack of work life balance I’m not sure it would have been the right end point for me anyways.  That being said there are certain aspects of being a PA that do frustrate me.  No one knowing what we can do, everyone thinking you just take blood pressure, disagreeing with your supervising MD and people either expect you to know nothing or everything (both of which are frustrating).  I also think I would have found aspects of being a physician frustrating.  Being forever held in one specialty, duration of training, even more demanding work hours, etc.

Overall, I do think that I came out with the best option for me–regardless of minor day-to-day frustrations.  Plus who the hell wants to take physics and the MCAT?  I look forward to my next however many years of working, and that to me is a huge success!