Category Archives: Physician Assistant & Medicine

Healthcare Culture: Everything Hurts and I’m Dying

There are a lot of issues being discussed in healthcare today.  One point I don’t hear a lot about, but see everyday comes directly from our patients mouths.  They come in to clinic with the mindset of “everything hurts and I’m dying”.  What this means is that if they have a headache they think and know that they have a brain bleed and they need and MRI.  If their child has a cough they definitely need an antibiotic.  They woke up sick this morning or have an ache in their shoulder x1 day: everything hurts and I’m dying.  

The undertone of this statement that they don’t directly say: And you BETTER do something– better yet– what I think you need to do. 

Now, let me be clear it isn’t that I’m not empathic to patients who are feeling ill or in pain.  However, there is this culture out there that extreme measures, investigations and treatments need to be taken if you have a headache.  Are there the small percent of people who do need these measures? ABSOLUTELY.  That is why we do history and physical exams to weed these people out and send them for these tests.  

Why does this matter? What is this causing in medicine? Cost. Waiting room lines. The emergency department being used for non-emergencies (sorry people this was not created for you to get a pregnancy test free or score some morphine for back pain– it was meant for people with asthma exacerbation, CHF, PNA amongst so many others). 

How does this effect providers? We also have to act like someone who thinks they are dying are dying.  If we don’t they’re not satisfied. Re-assuring patients has become the most difficulty part of my job.  We all know when we have this person in front of us.  I always make sure to do a full physical exam.  I talk them through it saying “your ears are clear–no infections, airway is patent– tonsils are not enlarged, no lymph node enlargement, lungs sound great, your neurological exam is completely normal, vital signs completely within normal limits—– etc etc”.  But for some people they just aren’t satisfied.   

What else are we to do?  Patients who push for further intervention, I tell them I cannot treat an infection that is not there or worry about signs or symptoms that you do not have.  I tell them this is good news.  

My question is where are we going wrong? It seems like more and more people are lacking basic concepts about colds, headaches and belly aches.  I do my best to educate my patients.  Viral bronchitis is a BIG one.  I tell them 98% of bronchitis is caused by a virus. The cough can last 3-4 weeks even after you begin feeling better.  I state “Scary symptoms that you DO need to be concerned about are persistent fever or coughing up blood streaked sputum.” I ask them EVERY TIME “do you have any questions”.  I usually ask this twice. Yet somehow there are still people who come back a week later cause they have a dry lingering cough?  

Would love to hear thoughts from students on rotation and practicing providers with how you best handle these situations.  As well as suggestions.  May this serve as a reminder to always educate your patients as much as possible!

Don’t Call Me Honey: An Open Letter to Patients Older Than Me 

When I enter a room with a patient I have a routine.  I knock, I introduce myself “Hi my name is Danielle, I’m a Physician Assistant I’m one of the providers here today”. I give a firm, confident handshake looking the patient in the eyes. I’m self assured and confident–not cocky, confident. I’m 32 years old.  I have a bachelors degree and two masters degrees.  I look like I’m about 18 and at least once per day I get asked “Are you old enough to do this” or get called “Honey” or “Sweetie” or “Dear”. 

Let me be clear, when older adults call me these things in different contexts of my life such as someone holding a door at Starbucks or in the check out line at the grocery store it doesn’t irritate me.  Hell, thanks a lot I’m 32 and you probably think I’m in my early twenties.  

However, when you walk in to a providers office I view these potential “terms of endearment” quite differently.

  1. Just because you are older than me doesn’t mean that you have better judgement with your google search

    Let me be clear, I don’t disregard statements my patients make.  Many times per day I have patients that come in and say “my kid just isn’t acting right” or “Every time I have a UTI this is what it feels like”.  However, you walked in to this office and you are paying for my medical opinion and clinical judgement. If I am unsure of something, I am the first person to directly tell my patient and seek a second opinion.  Until that time, please remember that you sought out a medical professionals opinion.  Again, let me be clear it isn’t that I don’t listen to my patients.  I understand when a patient says “Yea, my fever is only 99.5 but I am never about 97 or 98” or “Last time this happened I ended up with pneumonia because it wasn’t treated right away”.  Those are important things to know, and I am more than happy to hear those statements–hell it helps my clinical judgement. Saying “honey I looked this up on the internet and this is what it is,” is rude and disrespectful.  Don’t talk at me, speak with me. I give you this same respect and decency, please give me the same.

  2. Its degrading

    I’m not “honey” or “sweetie” to you.  I’m your medical provider. I’m here to offer the solution I believe based on my clinical judgement and education best suits the ailment or symptoms you are presently experiencing.  Also, dare I ask the question: If I were a man would you still use these terms? If I were older or looked older or always wore a white coat–would you make these statements? Perhaps, but I do strongly believe that it is geared towards the female gender and that if I were a man it wouldn’t occur nearly as frequently.  

  3. Your terms of endearment undercut my education.  

    You may not intend to do this, and maybe I am misinterpreting.  Think about it, we frequently call small children “honey” and “sweetie” or “dear”.  They sure don’t have the education or intellect necessary to perform a clinical assessment and prescribe treatment.  Using the terms you use to speak to children makes me feel like you do not respect me as a professional medical provider.  Period.

  4. Please do not ask me if I am “Going on to Become a Physician”

    Ok, confession this doesn’t quite fit the mold of this blog.  However, I am a Physician Assistant.  It is a profession and a damn good one.  In fact it is projected to be the #1 Masters degree and profession through 2025 at this time.  We are not in 1970 where “people just don’t know what it is”.  This is 2016.  PA programs are more competitive by the numbers to earn acceptance than medical school.  I am not a medical assistant, nurse or resident.  I’m a PA.  If you want to know more about my profession, please ask me I am happy to speak with you about it.  But please, please do not ask me when I’m becoming a physician.  

5 EKG Resources for PA Students

EKG’s are a part of my daily life at work and also one aspect of clinical medicine I struggled with the most.  Below I’ve handpicked 5 EKG resources I wish I would have watched both before I started my first EKG lecture and throughout learning EKG’s. Disclaimer: By “BEFORE” I mean a few days prior to your first lecture when you have reviewed your classroom materials and want to have a deeper understanding before class.  Again, I also recommend using these tools throughout school to continue to learn!

1.How to Read an EKG: Khan-Academy Style Tutorial

If you let this continue to play to the next video it is actually a series of 10 videos that through your journey of learning EKG’s will be extremely helpful!  I recommend only watching until you don’t feel overwhelmed.  This may vary for individuals based on their background.  For instance I may have watched the first three videos; but, for someone with a paramedic background this would probably be too simple or they may watch all of them for a refresher!

 

 2. ECG Zone: Tutorials & Cases

These are case studies that help you learn how to interpret EKG’s. This may be too much for someone before in class lectures.  Definitely a great resource to have as you go along and learn!

 

3. The Rapid Interpretation of EKG’s

This is a comprehensive book of all the rhythms you need to know in PA school and clinical practice.  At times it is a bit slow and basic; but, I’m sure a review never hurt anyone.  I think I paid around $14.99 and I think you can get it cheaper on kindle/ibooks. Contains everything from physiology explanations, the different pacemakers of the heart, pictures of EKG strips, explanations of arrhythmias, etc. This is the resource that I used in PA school.  Click here to buy.  DISCLAIMER: The link is to the 5th edition.  There is now a 6th edition out; however, it costs about $50 dollars more.  If you want to purchase the 6th edition click here.

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4. EKG Interpretation: 24 Hours or Less to Easily Pass the ECG Portion of NCLEX

 

Made for nursing boards but also great for the PA student.  Again, if you were a paramedic to fulfill your health care experience hours this will probably be too simple for you (you could probably teach the EKG portion in PA school). Contains links to videos, explains basics of conduction and how it relates to the physiology of the heart.  Explains all of the arrhythmias and gives good picture examples.  The BEST part about this book is that if you have kindle unlimited with amazon ($9.99/month) it is FREE!.  If you don’t have a subscription you can buy for about $2.99.  Definitely a great buy for the dollar value.  Click here to buy!

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5. ECG Interpretation & Rhythm Recognition

Another great Amazon Kindle Unlimited find! This is a bit more in depth that the above option with more pictures and nitty gritty information on arrhythmias and how the are represented on EKG. I would read one of the more simple/basic resources such as #3 or #4 first before delving in to this book. Click here to buy!

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How I Chose my Specialty

One of the biggest areas of concern for me while I was in PA school was what specialty I was going to enter after graduation. I remember sometime within the first week of PA school one of my professors asked for a survey by show of hands what specialty we wanted to practice medicine. I rasied my hand when she said Orthopedics. I had shadowed in ortho before school and was literally HELL BENT on definitely surgery and most likely ortho becuase of my athletic background.

Disclaimer: I don’t work in surgery or orthopedics. I honestly don’t think I ever will.

Here are the top 7 factors to consider when choosing your first specialty and job!

1. Medicine VS. Surgery

I think this is the first major decision. Do you like the OR or do you primarily like a medical based specialty? I did not have a great surgical roation and I think that definitely skewed my perception of PAs in surgery. Through rotations I learned that I liked the puzzle solving porition of medicine. I also did not want to deal with surgeon egos. The director of my program looked at me one day and told me I was not meant for surgery. I took this offensively at first, I now see the full picture (touche Dr. Opacic). Needless to say I am so happy I am in general medicine.

2. General vs. Specialty practice

Maybe you did a rotation in cardiology and loved it. Or you thought you would love your Nephrology elective and it made you miserable. Maybe you know that the OR is the place you want to be. Or emergency medicine is great for you because you love the idea of seeing a patient once, fixing the problem and saying peace out.

3. Work/Life Balance

Think about what hours you would like to work. Not that they always happen; but, in general what appeals to you? Days, nights, four 10 hour shifts, 7 on 7 off 12 hour shifts, 8-5 M-F, call/no call. Those are the basics. I think if I could have it my ideal way I would work two 16’s and 1 8 hour shift. That would be great (I’m not een sure that exists anywhere but I would jump on that opportunity!)

4. Who is hiring and Received Offers

Sometimes as a new grad you can’t seem to find EXACTLY what you want, and you need to take a job to get experience on your resume and that is ok. Don’t take just anything. However, taking a position slightly sub-optimal for a year or so is not a terrible idea. Obviously I would not express that thought process in an interview.

5. Collaborating Physicians and Co-workers.

If a company or group wants to offer you a job, ask to shadow for a few days and see what the work flow is like to make sure you like what you see on the inside. Everything can seem great superfically; but, when you shadow there are somethings that are less than appealing for whatever reason.

6. Salary

It is always going to be a factor. Areas of salary to consider/negotiate include: Overall salary, CME money, CME days off, vacation time, sick days, possibly maternity leave, sign on bonus, RVU/bonus incentives, non-compete clause (not exactly salary but something to be aware), raise policy/incentive. If you are between two job offers with all of the above you are pleased with and one job is offering you 5-8k more–it’s a no brainer. If you really want the other job–tell them. Maybe they will counter offer for more money.

7. Location

Do you want to stay in your home town or move to the beach, mountains, etc. What will your commute to work be? My first job ended up having a terrible commute. 45 minutes for 7 miles to and from work. Which to some may not seem bad but that was an hour and a half out of my day, everyday that I was basically contributing to work.

Disclaimer: The beautiful things about the PA profession… You can always pick something new 🙂

ABC’s of Interpreting Chest X-Rays!

I’m sure I wasn’t alone the first time someone showed me a chest x-ray and asked me to interpret.  I believe “FML” was the first thing to hit my brain.

So, let me help you not have the FML moment when it comes to looking at chest x-rays.  The picture below is quite detailed and can be overwhelming.  What I am going to review is much more simple; but, it doesn’t hurt to take a peak at the image below just so you have some orientation.

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ABC’s of Chest X-Rays

A: Airway/Assessment of Quality

I’ve seen both written for the letter “A”.

Airway: make sure the airway is patent and is not deviating to one side or the other which might indicate a tension pneumothorax.

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Obvious tracheal deviation.

Adequate Study: 

  • Position.  Make sure the study was not taken with the patient turned more to one side than the other.
  • Lung expansion.  10-11 ribs should be visible in each of the lung fields to be considered adequate.
  • Penetration (too dark/too light)  Can you see the spaces between vertebrae?  That means its a good study!
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Example of how to properly count ribs.  There are 8 visible.  Finding a study with 10 visible was proving difficult.

B: Bones

Don’t forget there are bones to look at in a CXR!  Although in most cases its secondary and in the background make sure there are no clavicle or rib fractures or shoulder dislocations.  You never know what you might find.  So take a quick glance at the bones.  Start from the top and work your way down to stay organized and on track.  There can be a lot going on in a CXR.

C: Cardiac

What does the patient’s cardiac silhouette look like? The size of the heart should be <50% of the PA film dimension.

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Outline of cardiac silhouette.

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D: Diaphragm

Look for position (right will always be slightly higher than the left due to liver), make sure there isn’t free air or maybe flattening due to emphysema. Make sure the costophrenic angles are both visible.

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Example of how the diaphragm should appear on each side of the lung fields with the right slightly higher.  Also visualized is the gastric air bubble (which is normal).

E: Effusions

Simple.  Presence or lack of pleural effusions.

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Obvious right pleural effusion with what looks like tracheal deviation to right likely due to the large effusion on right.

 

F: Fields & Fissures

I’m not going to pretend like I can appreciate a lung fissure on an x-ray.  I am definitely NO radiologist.  Fields stands for lung fields.  Basically what do you see in the lungs.  Take a look around for infiltrates, kerley B lines, pulmonary congestion, granulomas, pneumothorax, masses, etc.  Symmetry is your best friend in radiology–make sure both lung fields look roughly the same in vascular markings, etc.

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Potential findings when looking at the lung fields.

G: Great Vessels

The Aortic knob is probably the only thing I can really appreciate well on a chest x-ray.  Make sure the aorta in it’s entirety isn’t obviously out of proportion.

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H: Hila & Mediastinum

Look for widening of the mediastinum which is a pearl for Aortic Dissection or Hilar Lymphadenopathy as seen in Sarcoidosis. image

I: Instruments/Impression

Instruments stands for anything implanted in the patient such as pacemakers, etc.Summarize all of your findings as concisely as possible and to the best of your ability!

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ICD visualized on Chest X-Ray.

Women In Medicine?

I read an article recently regarding the sayings surrounding women, their lives and careers and what would happen/how ridiculous it would sound if we applied them to men. For instance “Men in Medicine” or “Men, how to have a career and family”.  May favorite were the beauty remarks regarding wrinkles and weight.  It sounds absolutely ridiculous when you apply it to men–so why do the majority not see it as ridiculous when the latter are applied to women? It is kind of appalling when you think of it, at least it was to me.

To me these statements suggest a lot of things. First, that women are not a majority in advanced positions in medicine–which is false and also that as women we need to push for some type of movement to raise awareness that women can be health care providers, too.  Don’t get me started on the career and family balance.  In our country it is always always assumed that the woman is not the bread winner and if a man and a woman both have great careers the woman should be the one to make the sacrifice.  False.  Some personal stats for myself.  For my first job I worked with a group of 5 male and 5 female physicians–2 of the women whom brought home the sole salary.  All 3 of the mid level providers were also women.  So, why do people continue to be shocked that I’m a PA? Or that the female physician who is seeing them is actually the doctor.

How about some numbers?

Medical schools are supposedly comprised of a majority (>50%) women, so I have been told.  However, the best supporting statistics I found for that were from the AAMC from 2013-2014 stating 47% of medical students were female and 46% of medical residents were women.

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As for PA’s, the tale tells it that the profession was dominated by men.  Now, per a qualitative study conducted by the NCBI greater than 60% of practicing PA’s are female.  The statistics they utilized for this study was the AAPA Census Survey and over 16,000 PA’s were a part of the study.  I also read numbers that suggested up to 72% of today’s practicing PA’s are female, although I cannot quote a direct source.  The NCCPA Statistical Profile of 2014 revealed of the total 101,963 practicing PA’s, 67,901 were female, 66.6% total.  It does reveal the trend that when the profession first emerged it was in fact male dominant (if we are assuming older PA’s have been practicing longer which is not always the case).

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I realize some people may think that I am just perpetuating the cycle by talking about the subject; but, there is a part of me that thinks there hasn’t been much attention to this concept.  I guess my whole point–or even question is by making statements such as “women in medicine” are were fighting the stereotype or enabling it? Honestly, I’m not really sure. I do think that when you apply phrases directed towards women and replace it to represent men it sounds pretty off to say the least.  Until later, I guess it’s just something to think about and I would love to hear feedback!

Name Change? Physician Assistant to “PA”?

Below I’ve included an article from the most recent PA Professional regarding the interest in changing the name of the ‘Physician Assistant’ profession and renaming us to just “PA/PA’s”.  I’m incredibly interested to receive feedback from others on this article.

For myself, I have to say overall, I’m not excited about this and I do not think it will have the positive effect the powers to be anticipate. However, it has also made me think about how I can contribute to helping the public and my patients understand who PA’s are and our scope of practice (because that is what really matters, right)? Perhaps it doesn’t really matter what we are called, it matters how we treat out patients and how well we perform our jobs.  I do want patients to have a better understandinfg of who we are and what we do, overall I feel as though the AAPA should be working on promoting awareness for “who are Physician Assistant’s/PA’s?” As opposed to just changing our name.

So, I decided to focus on what I directly–meaning with patients–have the capacity to affect.  Tonight, at work prior to interviewing my first admission I asked myself how I could incorporate a short (30 seconds or less) dialogue in my introduction that would bolster patients understanding of who we are and our role in the health care system.

I will preface this story with the fact that this probably was not the best patient to try this out on for two reasons: 1. She was in obvious distress (chest/abdominal pain/lactic acidosis) 2. She was a retired RN–so she wasn’t exactly your baseline audience.

Regardless, I entered the room introduced myself starting with my usual sphiel “My name is Danielle, I’m a Physician Assistant and I work with the medical service here at the hospital”.  Instead of stopping there I proceeded with “I work with the medicine team here and collaborate with a Physician to determine a plan of care and treatment”.  I wish I could say I had feedback, but it was pretty brushed over.  In her defense I would have brushed me over and demanded some pain meds too–she looked uncomfortable.

However, I think it is something worth continuing to do in my daily practice and to think about.  I hope that I get some opinions back on what this article means to other PA students and practicing PA’s out there!
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False Sense of Health?

I haven’t talked much about my personal life or what I do in my spare time. I like to lift heavy shit for time. AKA CrossFit.  I’m really into being healthy and personal betterment, whether it is intellectual, physical or whatever.  I was a personal trainer for a while before PA school, I’ve ran 10+ half marathons, I did one triathlon and played sports virtually all of my life.  You get it–it’s important to me.
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Being a health care provider can be somewhat frustrating at times for anyone who is health conscious.  Most of the people I see and treat are super sick.  They take 10-20 medications daily, have no idea what medications they are taking or purpose they serve. Most of you have probably experienced it on some level. I remember being super impressed with a 93 year old patient I had who could tell me when his last echocardiogram was and his ejection fraction.  I may have high fived him, he pretty much rocked.
I think the overall state of our health is rapidly declining. I also think patients do not have a clear understanding of what is occurring with their health. Seriously though–as a Nation we are in bad health. Why is this happening? I believe there are innumerable reasons and road blocks.  Some of which I am going to venture to explore today.  All of the reasons are too complex to mention in one post-I’m sure I will touch on a lot of them as time goes on, as for now, I’ll leave it to what I believe are the massive red flags.
I can’t help but wonder if a false sense health and wellness is being created.  What are the forces behind this potential false sense of health and wellness? Driving forces include health care providers, sensitivity and political correctness, the new average/normal health state of society, as well as screening tests and advanced technology inadvertently reassuring bad habits.
A substantial number of patients with chronic conditions that we know and treat are not improving.  In fact from my experience it can be the opposite.  Their diseases are getting more concerning, hemoglobin A1c’s are rising, ejection fractions are dropping and the number on the scale is going up.  Consistently on my rotations I watched providers ignore the BMI, edit out “obesity” on patients discharge summary or simply just add medications or increase insulin regimen without talking to the patient about what was going on or why it was happening. Patients begin seeing medication as getting rid of their illness as opposed to masking it.
imagePeople no longer think they are diabetic because they take insulin, or that they don’t have high blood pressure because they take metoprolol.  Instead of having important, difficult conversations with patients about their weight and other various aspects of declining health We slap medicine on it to fix the numbers. But, is the quality of life of our patients improving?
Now, let’s be clear I’m not shaming medical providers.  However, suggesting that we do have a small part in perpetuating the epidemic of illness. That small part entails not succumbing to a ridiculous level of political correctness that we neglect to broach difficult conversations with our patients.  We need to talk to our them about difficult topics and make sure explain that just because they are taking a medication doesn’t mean they don’t have a disease.  I know we are all short on time it’s hard to cram all this stuff into a 15 minute appointment.  What I do ask and suggest is that we don’t see it and brush it to the side because it’s “taboo” to help your patients hold themselves accountable.  Talk to that patient who has put on 15 pounds since their last appointment.  Tell the new patient who has a BMI > 40 that their weight is adversely effecting them, and if it hasn’t yet it will–warn them of the adverse effects. Heart disease, diabetes, stroke, joint ailments/chronic pain–all of which can lead to more damaging and expensive side effects.
Sick is the new standard.  Yea, kind of like orange is the new black.  Whether or not any of us want to admit it we are a culture that for most of us–we follow a general range of societal norms.  What is average is normal, and the more people who are a certain way the more normal it is therefore the more accepted.  When things are “acceptable” there is no sense of urgency to do anything to change.  Meaning that because having multiple chronic diseases have become the norm, it is becoming very acceptable to simply just life with these diseases.
Diabetes. According to the CDC in 2002 5.5 million people had diabetes.  In 2014 22 million people were estimated to be afflicted with the disease. The cost for diabetes direct and indirectly in 2012 was 245 BILLION dollars.  That absolutely blew my mind.  I asked my colleagues this same question and their responses were not even close.  Their guesses included 2 and 3 MILLION dollars.
Obesity. An estimated 34.9% aka 78.6 million adults are reported to be obese.  Ready for the cost annually?  147 BILLION in 2008.  Again yes, BILLION. We wonder why our country is in a ridiculous amount of debt—–a post for a whole other day.  The CDC reports that the medical costs for obese individuals are 1,429 higher per year than a person with a BMI WNL.  Anyways, this is not supposed to be about cost.
Heart disease. Kills 610,000 individuals annually.  Coronary Artery Disease (CAD)–which I swear every patient I admit has–kills 370,00 0 each year (for the love of god people take your Lipitor I don’t care if your muscles hurt–kidding kidding). Again, the modifiable risk factors that have the possibility of having a positive impact on patient morbidity and mortality if addressed are numerous.
Stroke.  800,000 hospitalizations in 1989 and that number is now up over a million.  Cost per year in 2008: 18.8 billion.
I have simply highlighted several diseases that were easy access on CDC and that I know from clinical practice are incredibly common.  The sad part about these diseases is that there are more modifiable risk factors as opposed to non-modifiable.  Physical inactivity, obesity, smoking, medication compliance (one could argue if this is truly “modifiable” or not).
My point is that the numbers of chronic diseases are rising at a ridiculous rate.  I would venture to guess that if you combined the category of overweight and obese individuals together they would comprise >50% of the population. I’m also willing to bet that >80% of hospitalized patients are either overweight or obese.  I can’t remember the last time I palpated an abdomen of normal size.  The madness needs to stop.  People need to get off the merry-go-round.  Providers need to start having difficult conversations.  Patients need to start having accountability and the iron armor of political correctness needs to be sloughed off.  I’m not saying bully people with chronic diseases.  I’m simply suggesting we attempt to become catalysts for change instead of simply allowing our patients to accept poor health standards.
So, we are now led to the point where we have all of these chronic diseases that have quite the laundry list of potential negative effects.  What do we do? Create a screening tool, which has positives and negatives.
Smoking for example. Smoking kills.  We all know this, there’s this thing called the surgeon general warning.  Because of this, in the health care field we have (and by we I mean the powers that be—The USPTF) decided that we should “preventatively screen” individuals 55-80 who have a minimum of a 30 pack year smoking history or have quit within the past 15 years. What we are doing for them is giving them a one time dose of low radiation CT scan to screen for lung cancer.  There are results that can be found on the USPTF website if you want more information on the study USPTF LDCT Lung CA Screening.  There are various additional  links on this page you can click to read more about the screening and evidence to support  this standard of care.
imageNow, my initial response was–what a great idea we can catch cancer early, less money spent on chemo, radiation and maybe show patients that yes–smoking does kill.  However, there was an article published in a recent article of JAAPA suggesting that perhaps we are giving smokers a false sense of “it is ok to smoke” because so few of these tests are turning out to be positive.  Meaning patients with a significant smoking history has the test completed and it comes back negative–what this translates to for a patient is this: ” Oh, well I smoke but I had my screening done and everything is ok so I guess I can continue to smoke”.  There is question being raised if we are have created a phenomenon of false security. FYI the USPTF is reporting that there is clinical significance to benefit patients from performing he LDCT.
On a related note, we have a lot of different sophisticated measuresimage these days that can track out calories, what we eat, how much energy we exert, etc.  I’ve developed this notion in my head and I’m not sure who else shares this proposition with me, that devices such as fit bits also contribute to a false sense of health.
DISCLAIMER: I know very little to nothing about these devices.  My extent of knowledge on them is that they electronically can track your steps, you can set up step goals, face off against your friends to see who does the most steps and that some of them claim to be a let o track sleep activity.  Here is my beef.  Say your step goal is 5,000 for the day and your work in a hospital. It’s very likely that you are able to get those 5,000 or more steps in your 8, 10 or 12 hour day.  However, taking this many steps throughout the duration of time previously mentioned is not the same as someone who goes out and continually moves/exercises for 30-45 minutes.  The person who gets their steps or activity in through 8-12 hours does not sustain an elevated heart rate to produce the same cardiovascular and metabolic benefits as someone who continually goes for runs, swims or does Crossfit, etc.
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I’m not suggesting take the elevator everywhere and that walking wherever and whenever you can to keep moving is a bad thing.  My point is that I don’t think it suffices to count for working out and I think a lot of people who use these devices can tend to be of the mindset that “oh I don’t need to go to th. gym/run/swim/Zumba or whatever it is you do because I walked 5,000 steps today”. I just cannot buy into this mindset and I think a lot of people do.
Why is this important? Less activity leads to more people being over weight and obese.  Obesity puts more people at risk for multiple chronic diseases, diseases which are leading to the acceptance of our current state of health as a nation.  We need to start with ourselves as providers by doing our best to institute change and provide support to our patients. In return hope that our patients are able to accept some sense of self responsibility, realize a change needs to be made and begin to take steps toward better health outcomes one person at a time.
I would love to hear what others think, drop a comment and let me know what you think!!

Is Your Patient Hypoxic? Oxygen Delivery Methods!

I don’t know about anyone else out there, but I learned minimal amounts of information regarding all of the different devices respiratory therapists use when we have a patient who needs oxygen support. Perhaps this is something I should have looked up sooner, but my guess is that it wasn’t a priority for boards so I ignored it unfortunately.

The other night I got a page that a patient on my list had O2 saturations in the mid 80’s on 31% 6L Venturi mask.  My literal response was: What in the world is  this and what do I do about it?  Literally. Hello?! I’m a licensed PA shouldn’t I know this?  I should tell you that before I was a PA I was a mental health therapist and that was my patient care experience–so my time in a hospital was well–nil.

Side Note: there has been a lot of talk on AAPA Huddle whether people with my background are prepared for PA school and to practice hospital medicine and whether programs should tighten their accepted health care hour experience–perhaps more on this on another day.  Interesting thought.

Let’s be real, there is only so much time to cover vital information during didactic year.  And I’m pretty sure my main thought during clinical year was “Dear baby Jesus please let me pass the PANCE”. This was just not one of those things we covered extensively–and if we did I totally zoned out (if we are being honest we all do it at some point).  So, I talked with the other PA’s that were working with me, we printed out some information for me to read and I started watching you tube videos.

The purpose of this post is to examine the most common types of oxygen delivery systems, a basic understanding of how they work and a general understanding of when to utilize each of them. I’ll also provide pictures, because I don’t know about you but I had no idea what half this stuff looked like.

Before I go into descriptions of each type of oxygen delivery, a reminder as to what the FiO2 is, because it’s important to understanding oxygen delivery methods. Different devices are able to deliver different FiO2. Thus, have varying effects on oxygenation.

  • FiO2: Fraction of inspired O2 being measured in space.  Naturally occurring in the atmosphere, you and I walk around breathing 21% FiO2.  So, when we place patients on supplemental oxygen, they are all requiring a higher FiO2 to maintain adequate oxygenation.  We can supplement patients all the way up to 100% FiO2.
  • The chart below is a summary of the devices I go on to describe, and the ability to effect FiO2.  I provided this information under each of the separate devices, but I realize that some people might like the condensed information (table found in the online ACLS manual).

image

Nasal Cannula

imageI think most of you know what nasal cannula is, but I will go through a
brief description.  Nasal cannula is a low flow delivery system, the regular good old tubing that has an opening for each nostril.  Generally speaking, NC is able to deliver anywhere from 21-40% FiO2 and is typically not run higher than 5L.  If you patient is at 5L and not reaching saturation goal, they probably need a higher level of oxygen delivery. In order to use nasal cannula the patient has to be spontaneously breathing on their own because how well NC works is influenced by breath rate, tidal volume and whatever the underlying pathophysiology.  It’s also not a bad idea to humidify oxygen as it can dry out the nares. A simple rule of thumb that I found by reading many articles and web sites is that for every liter/min of oxygen that you add you increase the FiO2 by 4%, starting with 1L.  So, it would look at follows:

  • 1L = 24% FiO2
  • 2L= 28% FiO2
  • 3L= 32% FiO2
  • 4L= 36% FiO2
  • 5L= 40% FiO2
  • 6L= 44% FiO2

Simple Face Mask

Not used commonly in a hospital setting, typically only when patientsimage are not tolerating standard nasal cannula.  It is a low flow delivery system and cannot accurately deliver a specific FiO2.  The FiO2 thought to be maintained through simple face mask is 40-60% at 5-20L/min. A minimum of 5L is absolutely required because. Anything less than this and the CO2 will not be removed from the mask. The simple mask also requires a patient who is breathing on their own and is influenced by respiratory rate and tidal volume.  Mostly used in a hospital setting when a patient is not tolerating nasal cannula due to irritation of the nares or epistaxis..

Venturi Mask

imageThe Venturi mask is considered a high flow oxygen device that has the ability to deliver various settings of FiO2 based on the attachment utilized.  So, that normal 21% FiO2 that we consume in the atmosphere– patients who require additional assistance getting proper oxygenation require a higher FiO2.  The various attachments which are pictured, provide the ability to deliver varying percentages of oxygen.  It sounds confusing— so it’s like this there is 100% oxygen being delivered to the patient via the special tubing and varying jet adapter devices that allow a certain amount of atmosphere air to mix with the atmosphere air–altering the FiO2 the individual is receiving.  The Venturi mask provides the most precise oxygen delivery. The one downside,  the potential for respiratory depression in patients with COPD when oxygen concentrations are high (>50%).

Non-Rebreathing Facemask

High flow delivery system, that also requires a spontaneouslyimage breathing patient. Settings here are 8-10L/min and greater than 40%FiO2 requirement of your patient. The non-rebreather mask as pictured, has a one way valve that inputs high FiO2 when the patient inhales.  When patient exhales there are two ports on the side where CO2 escapes.  All of the exhaled air in this situation escapes.  I did read that there are 3 one way valves and you can maximize the percent of oxygen your patient receives if all 3 are closed; however, because of legal purposes one of them always has to be open.  The bag attached acts as an oxygen reservoir, and should never become collapsed at any point to ensure possibility of 100% O2 delivery.  These can be uncomfortable so they are not appropriate for long-term care of hypoxemia; however, they are appropriate to utilize in the acute care setting.

Transtracheal Catheter

imageTracheostomies are performed for a variety of reasons. These obviously, do not require a spontaneously breathing patient. Individuals receive a tracheostomies for reasons such as obstruction, long-term ventilation requirement, weaning patient off vent, respiratory muscle paralysis (ALS).  It is exactly what it sounds like, a catheter a few inches long inserted directly into the wind pipe. There are all different types of trach tubes–which is beyond the point of this post. Know that trach cuffs with fenestrations are what allow patients to be able to speak with a tracheostomy.  Most of what I have seen of patients who are trached, are those who are in critical condition, came in because of a trauma,  being weaned off the ventilator, or have had obstruction due to esophageal cancer.  From my reading I have learned that it is easier to wean a patient off the vent with a trach as opposed to an ETT. Disclaimer: I know next to nothing about how to wean a patient off a vent.  Perhaps that is a discussion for another day.

NIPPV: Non-Invasive positive pressure ventilation

Although one could argue whether this fits in the “oxygen delivery method” section I didn’t think it could hurt to add a word or two about CPAP and BiPAP.  NIPPV refers to methods of assisting patients to properly oxygenate without intubation or trach (which would obviously be considered “invasive”).

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Continuous Positive Airway Pressure (CPAP)

Most commonly used in our patients with obstructive sleep apnea (OSA).  In order to use CPAP the patient must spontaneously breathe on their own.  It is typically used when someone is hypoxic despite other less invasive measures (ie nasal cannula, mouth pieces for OSA). Patients with OSA often require CPAP because of their body habitus and anatomy, they have a difficult time getting their breath past a collapsed upper airway.  The pressure that is continually delivered to the patient to help keep the alveoli in the lungs “popped” open to optimize the lungs surface area for ventilation.  There are various settings to CPAP machines in order to maintain appropriate O2 saturations.  Settings range between 5-20cm H2O pressure. Pressure put into airway keeps tongue forward and therefore airway = open.

Bi-level Positive Airway Pressure (BiPAP)

Used in a variety of settings, delivers inhale and exhale pressure, meaning  there is a generated inspiratory as well as expiratory airway pressures (IPAP and EPAP respectively).  Also used for COPD, ALS, CHF and Acute Respiratory failure.  Unlike CPAP you have the choice of two level settings for IPAP and EPAP.  Patient takes breath in: delivers IPAP.  Patient exhales: exhales against positive pressure–with bipap the airways don’t completely collapse so CO2 can be pushed out more effectively. To improve ventilation (meaning if you have high CO2) IPAP needs increased.  If oxygenation is low, increase EPAP.  Again, these are just basics that I have come across through my research for this post. The goal here for patients is to have an appropriate tidal volume and oxygen saturation.

I hope this was helpful to others out there who were in the same situation.  This is by no means comprehensive coverage.  There are other options out there and there is so much more related information I could have covered–but it would have been a snow ball effect that never ended.  Below are a list of resources I consulted to help my post!

Resources Helped to create this post:

ALCS Provider Manual

  • I believe it was the same manual you first get when you become ACLS certified.  Found a copy online and sifted through.

Respiratory Therapy Cave Blog

  • This is an endless site of information on anything related to what respiratory therapists do!  I absolutely loved what they had going on!

UpToDate

  • The same old UpToDate I’ve talked about before that mostly everyone knows about.  Super expensive if your institution doesn’t pay for it but an awesome resource.

YouTube: Critical Care Survival Guide by Department of Internal Medicine Indiana University

  • The first time I’ve used their channel but love, love, loved it!  The “surviving your ICU rotation” playlist looks awesome, definitely getting added to my resources page!

Merry Christmas, it’s a Neuro Kind of Night

Neurology has always freaked me out. It’s so meticulous and nitty gritty. Ugh. Last night I received an admission and on the chief complaint portion of our EMR it said “seizure, neuro says SCU”. I was up to do the next admission. I’m not going to lie, I’ve never previously done an admission for a seizure and I didn’t really deal with anything neurological in my first job. The closest I got to that was taking care of post op patients who had had lumbar or cervical laminectomies (aka not even close).

So, the first thing I did was pull out my iPad to read a little. Where I work the PA’s have a nice office and there is ample room to have your things that you need which is nice. So, not that I had NO CLUE how to approach a patient with a possible seizure (he ended up being more AMS as well but I’ll get to that)– but I didn’t want to miss anything.

I started by reading the neurology consult–which was helpful from a history standpoint, but it seemed to me like they just assumed he had a seizure becuase he had a history. Hey–they’re neurologists it is their job to look at the brain. I took a bit more broad perspective. But first, let me tell you about the patients background so you can get a bit more clear picture.

Pt was elderly, medical history of MR, schizophrenia, seizure disorder and hypothyroidism. I read carefully through his chart and once I had my bearings and an outline of a plan I went to the ED to see him. At this point he was unaccompanied (he had previously been brought in by a family memeber that helps to care for him). I tried to arouse him just by voice and he stirred a bit but couldn’t stay with me, if you will. I shook him a bit and he would open and close his eyes on and off–he couldn’t follow my directive to open his eyes in order to examine his pupils. I tried asking him a couple of questions and the most I got out of him were slurred noises (his head CT was clean by the way). His tounge was moving in odd patterns. Exam was otherwise insignificant. The most important information at this time came from the caregiver. She had left at this time, but I called to speak with her over the phone.
My interview with her revealed that the patient had not been acting like himself for approximately 10 days. Increased speech, talking to dead relatives and on the same day of admission 2-3 episodes of bowel and/or bladder incontinence. In addition to this information I also inquired about how the patient had been sleeping, eating, drinking, new medications or modifications, also if he took care of his own medications if he could have possibly taken too much of something (ASA, tylenol–or was he drunk–hey you can’t discriminate in medicine I ask 80 year olds all of the time if they do illicit drugs). I should also add that he had not been taking one of the seizure medications he was previously prescribed–we aren’t quite sure why–there’s a hole in the system somewhere. His other antiseizure medication level came back WNL (within normal limits). There were other things I asked in my HPI–but those are the most important.
The ED board originally made me think it was a slam dunk tonic-clonic seizure; however, at this time my ddx (differential diagnosis) was a bit more than just seizure. My ddx included seizure, toxcicity, CVA/TIA, retained CO2, elevated NH3, myxedma coma, dehydration and lactic acidosis. Basically your differential for AMS.
My work up included:
Head CT (which was already performed and negative for acute process)
UA- UTI in the elderly can cause what looks liek AMS or delerium
ABG for retained CO2
TSH/FT4–pt demonstrated subclinical hypothyroidism which means his TSH was elevated but T4 measure was normal (so basically its a big “whoop-de-do”
Urine tox screen
Tylenol level
Salicyilate level
NH3 level
Since the patient required assistance with medications first you never know what people can get into and just take a bunch of something–also as nice as the woman I talked to on the phone seemed I don’t necessarily trust anyone–I saw one too many lifetime movies and unsolved mysteries as a kid–so yes I considered poinsoning. Oh, I also checked ethanol and methanol levels as well. (FYI I’ve read that you can actually treat methanol toxicity with ethanol–not exactly how true it is but interesting concept that I need to look into more). And of course I also did a seizure work up including long term eeg monitoring, prolactin level, calcium level, neuro checks q2h. Oh, the last thing that I thought was strange and I need to look into this more is that my Attending Phsycian did disagree with one of my orders– not to provide prn ativan for seizure activity because they would want to catch it on the eeg monitor. However, obviously if he were to go into status treatment would be required and address at the time if that situation were to arise.
At this point his workup is still negative. I did place him on continual EEG monitoring which to my knowledge has yet to reveal anything. So, I’ll be interested to see what his workup shows and what the specialists have to say about his condition.
My post has several points: 1. I don’t like neuro. 2. Don’t trust what someone else says about a patient. Keep an open mind for your ddx just becasue someone else says it’s true doesn’t mean anything. 3. I hope you all learned something about the broad work up for AMS/seizure.
My second admission of the night was actually neurological related as well–I guess it was time for me to get comfortable with the uncomfortable. Continue reading Merry Christmas, it’s a Neuro Kind of Night