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sirI, MSN, APRN, NP Admin 71,279 Views

Joined Jun 24, '05. Posts: 99,853 (17% Liked) Likes: 26,100

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  • 6:43 pm

    And just as an aside...the new Medicare rules under ACA actually now allows CNM's to charge 100% of the physician billing fee.

  • 6:42 pm

    On the other hand, I think this is a legitimate question unlike the one the OP posted before in another thread.

    Consider the following scenario:

    A family practice physician sees a new patient to establish routine care of a healthy middle aged male with no prior histories. He performs a physical exam, checks vital signs, orders labs, and determines that screening diagnostic tests are required. He writes up a note on the patient and bills the insurance company for $100.

    An FNP sees another middle aged male with the exact same profile as the one the physician saw and performs the exact same procedure as the physician but can only charge the insurance company $85 or 85% of what a physician can charge because that's what the CMS rules state.

    If you look at it, both providers did the exact same thing. The argument against making reimbursement equal between physicians and NP's is that NP's offer a more cost-effective alternative to the care physicians offer by charging insurance companies less. That disparity, however, is also preventing NP's from having a level playing field with physicians.

    In some institutions and practice settings, physicians insist on billing services alone and not having the NP's on their team bill in order to capture the 100% reimbursement. This devalues the NP in states where a collaborative practice is required. There are good arguments on both ends of the debate.

    This is not about NP's asking to be allowed to perform the full scope of physician and surgeon practice. What it is is asking if NP's should be paid the same as physicians if they bill for the exact same CPT code. I'm also not excluding PA's in this argument.

  • May 24

    Why would you think it's better for her to "follow in my footsteps"? It's also simply not true the nursing and np education is better for women looking to start a family. No offense but I'm not sure where you get all this.
    I encouraged her to go to med school. Much less political crap to deal with.

    Quote from AAC.271
    Why is your daughter in med school? Wouldn't she be better to follow your footsteps? Also nursing and np education and route is better for women looking to start a family.

  • May 24

    Thanks all! The Ortho said we could let it heal without surgery and new bone will form to connect the two pieces, but she is 11 and I want optimal healing to she can use her arm normally for the rest of her life.

  • May 24

    I don't want to hijack the other thread but I wanted to update on my daughter's broken arm. We saw Ortho yesterday and she is having surgery tomorrow. They were not able to completely reduce it in the ER, it's still completely displaced. I'll TRY to add pix... I'm bad at it, apparently.

    Please cross your fingers for a smooth surgery and uneventful recovery!!

    Before reduction- That bone should not be pointing at her ribs
    Attachment 22291


    After
    Attachment 22292

  • May 24

    Several posts have been deleted in this thread as off topic - please stay on topic.

  • May 23

    Yes. They all do. The big vendors are NSO and Marsh/ProLiability.

  • May 23

    This was an excellent session and very informative.

    The presenter was kind enough to share the link to her slide presentation with us.

  • May 23
  • May 22

    Thank you

  • May 21

    And passed my two year mark, of course.

    Sky diving! - Album on Imgur

  • May 21

    I checked my email and saw the email from Duke Admissions about the timeline for interviews and decisions. I guess now we just wait.

  • May 21

    220k for charting vital signs 30 hours a week? Sign me up please! That would be a stress-free dream come true. I wish my job was that easy.

    Where I work there's no MDA to call to my aid. At 3 am, the paramedics arrive in the ED with a limp 3 week old they can't intubate. Who do you think the FP ER doc calls? I'm the only possibility of survival for that little girl. If I can't save her, there's no one else within an hour's drive that can. Do you think her mother is wondering if I'm worth my salary at that point? Do you think I ever have to justify my salary to the people I work with?

    Then there's the stat call to OB because of a rupturing uterus. Try being sound asleep, and 2 minutes later you're in OB hell, managing the Anesthesia for a 300 lb screaming mother. I have enough time to make sure she's not allergic to my anesthetic, and then I push a concoction of drugs that could possibly kill her. The whole room is in utter chaos. My heart is racing, but you'd never be able to tell from the calm demeanor in my voice and on my face. I then intubate what could easily be a difficult airway. At that point, the baby is already out. What seemed like 10 minutes, was only 30 seconds. MDA nearby to to help me with CV and A-lines? No? Maybe there's an intensivist? No? How about a neonatologist? Still no luck.. The fact is, I assume all those roles in that situation. But, you know who is in there with me? A circulating RN. An OB RN. A neonatal RN. A resp therapist. To that patient and her baby, everyone in that room, including the ob-gyn is worth far more than they make.

    Should I mention what I do during daylight hours in the OR?

    Honestly, the only time I ever think about this kind of bs salary crap is when I read something like this. I'm not trying to brag, and I certainly have nothing to prove. When I work, I'm thinking about how to best take care of my patient, period. I strive for the perfect anesthetic every time. I don't have time for pissing contests between MDAs, CRNAs, and AAs. All this bull $$$$ about who's qualified to do what, or supervise who, or is worth what salary just distracts from what's really important.

  • May 20

    And, of course the answer to that question is ... I can't tell you that. This is a joke that's floated around for years. But, HIPAA is very serious. Passed by Congress in 1996, The Health Insurance Portability and Accountability Act (HIPAA) is, in short, for the protection and confidential handling of protected health information. HIPAA is always lurking in the back of the minds of every Nurse: Does this violate HIPAA? I am being accused of violating HIPAA; will I be fired? Nurses everywhere receive education in their Nursing programs as well as from their healthcare employers. Are you HIPAA savvy?

  • May 20

    What Are We Looking At?

    There are four classes of drugs typically implicated in the rave culture. Stimulants and dissociatives are the two most commonly used agents.

    Amphetamines and stimulants:

    Methamphetamine (beanies, blue devils, chalk, CR, crank, crystal, crystal meth, fast, granulated orange, ice, meth, Mexican crack, pink, rock, speckled birds, speed, tina, yellow powder)

    3-4, methylene-dioxymethamphetamine (Adam, bean, blue kisses, clarity, club drug, disco biscuits, E, ecstasy, hug drug, love drug, lover’s speed, Mercedes, Molly, New Yorkers, peace, roll, white dove, X, XTC)

    Cocaine (blow, C, candy, coke, do a line, freeze, girl, happy dust, Mama coca, mojo, monster, nose, pimp, shot, smoking gun, snow, sugar, sweet stuff, white powder)

    Crack cocaine (base, beat, blast, casper, chalk, devil drug, gravel, hardball, hell, kryptonite, love, moonrocks, rock, scrabble, stones, tornado)

    ADHD drugs (Ritalin ©, Adderal ©, Dexedrine ©, Vyvance ©, Concerta ©: crackers, one and ones, pharming, poor man’s heroin, R-ball, ritz and t’s, set, skippy, speedball, t’s and ritz, t’s and r’s, vitamin R, west coast)

    Nicotine

    Caffeine!

    Dissociatives and anaesthetics

    Ketamine (bump, cat killer, cat valium, fort dodge, green, honey oil, jet, K, ket, kit kat, psychedelic heroin, purple, special “K”, special LA coke, super acid, super C, vitamin K)

    Phencyclidine (Angel dust, belladonna, black whack, CJ, cliffhanger, crystal joint, Detroit pink, elephant tranquilizer, hog, magic, PCP, Peter Pan, sheets, soma, TAC, trank, white horizon, zoom): may be mixed with marijuana or tobacco then smoked, or with other drugs in the rave drug family, such as MDMA, ketamine, LSD, mescaline or methamphetamine
    Lysergic acid diethylamide (A, Acid, black star, blotter, boomers, cubes, Elvis, golden dragon, L, LSD, microdot, paper acid, pink robots, superman, twenty-five, yellow sunshine, ying yang)

    Mescaline (beans, buttons, cactus, cactus buttons, cactus head, chief, love trip, mesc, mescal, mezc, moon, peyote, topi)

    Psylocibin (boomers, god’s flesh, little smoke, magic mushroom, Mexican mushrooms, mushrooms, musk, sherm, shrooms, silly putty, simple simon)

    Plant materials such as Datura stamonium (Hell’s bells, Jimson weed, locoweed) and Salvia divinorum may also be ingested via smoking, chewing, vaping or drinking as tea. The hallucinogenic effect depends on method of ingestion as well as purity of the product used.

    Users tend not to appear in ERs unless they engage in behaviour leading to accidental self-harm. The psychological effect of particularly vivid or frightening hallucinations may be severe.

    Depressants

    Gamma-hydroxybutyric acid (caps, cherry meth, ever clear, easy lay, fantasy, G, GHB, G-riffic, gamma hydrate, Georgia Home Boy, Grievous Bodily Harm, liquid ecstasy, liquid X, soap, sodium oxybate)

    Flunitrazepam (circles, forget-me pill, la rocha, lunch money drug, Mexican valium, pingus, R2, Reynolds, roche, Rohypnol, roofies, rope, ruffles and wolfies)

    Alcohol

    Synthetic Opioids

    Fentanyl (Apache, China girl, China town, dance fever, friend, goodfellas, great bear, he-man, jackpot, king ivory, murder 8, poison, tango and cash, TNT)

    Methadone

    1-(4-Nitrophenylethyl)piperidylidene-2-(4-chlorophenyl)sulfonamide (aka W-18) was originally developed as a potential analgesic by chemists at the University of Alberta in 1981. It was abandoned only to be resurrected by labs in China. 100 times as potent as fentanyl, it has been found in tablets sold as oxycodone; its lethality means even a microscopic dose could be fatal. It is not known if naloxone is effective to reverse the effects. 4 kg of it was seized in Edmonton in December 2015, and 1.3 kg were seized in Florida last August.

    What’s the Attraction? Enhancing the RAVE experience

    Stimulants produce euphoria, heightened sensations, altered sense of time, increased stamina, hypersexuality & psychedelic hallucinations; they may also produce tachycardia, hyperthermia, dry mouth, blurred vision, bruxism and dehydration. Onset of action is 30-45 minutes for oral ingestion, and duration is approximately 3-6 hours. Because of the slow onset of action, subsequent doses may be taken, which then produce a dramatic collapse.

    Dissociatives produce euphoria, analgesia, amnesia, hallucinations, derealisation & depersonalization; more noxious effects may include hypertension, nausea & vomiting – aspiration is highly possible – & psychotic emergence reactions. Onset of action depends on route; snorting or injecting produces rapid onset (seconds) while oral ingestion takes 2-5 minutes. Duration of the high is about an hour for ketamine; hallucinations may continue for several hours. Continued use may cause renal failure.

    Depressantsmay produce euphoria, hypersexuality, tranquility & a sense of well-being; hypotension, sweating, nausea, hallucinations, amnesia, somnolence, loss of consciousness (reported by 69% of GHB users) & coma are less welcomed effects and are potentiated by alcohol. Onset is rapid, 10-20 minutes following oral ingestion; duration may be as long as several hours and is dose-dependent.

    Synthetic opioids create relaxation, euphoria, analgesia & hallucinations; they also cause respiratory depression, nausea, vomiting, arrhythmia, seizure and coma. Onset of effect is seconds when injected or inhaled and 15-30 minutes when taken orally. Duration is relatively brief, 1-2 hours when ingested.

    The Ugly Side of Ecstasy

    Stimulant effect > dehydration, hypertension, cardiac and renal failure

    High doses > malignant hyperthermia, rhabdomyolysis, low cardiac output syndrome +/- cardiac arrest, cerebrovascular accident, seizure

    Chronic abuse > confusion, depression, sleep disturbances, drug craving, severe anxiety and paranoia, psychotic episodes, muscle tension, involuntary teeth clenching, nausea, blurred vision, nystagmus, faintness, liver damage, chills/fever or sweating, hypertension and tachycardia may occur even WEEKS AFTER LAST DOSE

    Long-term neurological damage > serotonin receptor destruction > impaired regulation of aggression, mood, sexual activity, sleep patterns, sensitivity to pain

    Comparing Ecstasy to Cannabis

    Recreational Ecstasy users are unimpaired in simple tests of alertness when under the influence while marijuana users are somewhat impaired.

    However, they perform much worse on more complex tests of attention, alertness, memory, learning and tasks reflecting general intelligence, whether they’re high or not. Cannabis effects on frontal attentional networks are generally not as significant as those of MDMA’s hippocampal and frontal cortex effects.

    Neurotoxic effects on cognition and executive function persist more often in MDMA-only users compared to cannabis-only users. Given that MDMA is rarely used alone, impairment in memory and complex thought processes may be additive.

    Signs and Symptoms of MDMA Abuse

    Chronic paranoid psychosis, flashbacks, anxiety, panic, confusion, suicidal depression, insomnia

    Gum-chewing (reduces the distressing effects of jaw muscle fasciculations), weight loss, exhaustion, jaundice, acute hepatotoxicity, hepatitis, irritability, chest pain, tachycardia, hyperkalemia, spontaneous intracranial hemorrhage, retinal hemorrhage, central serous chorioretinopathy, decreased libido, anorexia, amnestic syndrome, severe ataxia, urinary retention likely related to adrenergic effects

    PET shows decreased glucose uptake in caudate & putamen, which is more severe in those users starting before age 18

    Hyponatremia from SIADH and increased H2O intake > cerebral edema & death may be 2o serotonin uptake increase, as is priapism (painful but not fatal)

    γ- Hydroxybutyric Acid (GHB)

    First developed as a general anaesthetic but withdrawn due to unacceptable side effects. Xyrem (Sodium oxybate) approved in 2002 as tx for narcolepsy is a Schedule III drug requiring restricted access and intensive monitoring programs.

    The draw: euphoria, increased libido, sense of tranquility

    When mixed with ETOH it becomes a date-rape drug via amnesia and inability to resist
    Anabolic effects attractive to body builders for increased muscle mass and decreased body fat

    The Downside

    Acts on both GABAB and specific GHB receptors > CNS depression, stimulant and psychomotor effects > 95% hepatic metabolism, t1/2 30-60 minutes with only ~5% renal excretion which makes verification of ingestion very difficult. Urine levels are virtually nil within 24 hours and serum levels in as few as five hours.

    Sweating, LOC, confusion, headache, nausea, auditory and visual hallucination, exhaustion, clumsiness, amnesia > steep dose-response curve with onset noted within 15 minutes. May be implicated in the phenomenon of excited delirium.

    Overdose effects: respiratory depression – apnea or Cheyne-Stokes, acute respiratory acidosis, hypothermia, bundle branch block, bradycardia +/- hypertension, orthostatic hypotension, nystagmus, ataxia, vertigo, tonic-clonic seizure, aggression, impaired judgment, nausea, vomiting, aspiration > especially when combined with ETOH or other sedative-hypnotics

    Addiction - a Bit of a Puzzle

    Historically low levels in 8-12 grade population = 2 % or less

    Withdrawal symptoms are usually severe and require in-patient, medically-supervised treatment for 7-14 days. Amnesia may cause repeated re-addiction - they don’t remember they’ve taken it, or that they’ve been through a horrible withdrawal so they may resume using soon after rehab.

    Benzodiazepines should not be administered to any patient suspected of chronic use; they worsen withdrawal symptoms and increase risk of severe respiratory depression, coma and death. Treatment of intoxication in absence of confirmatory evidence is supportive. Naloxone and other reversal agents do not work. If polypharmacy is suspected, gastric lavage and activated charcoal may be in order.

    Baclofen may have role in tx withdrawal but is not FDA-approved (2014)

    If you're still reading along, here is the personal story I promised in the introduction.

    About 10 years ago on a Saturday morning, I got an alarming phone call from my daughter, who was away at university, The conversation went something like this:

    D: "Mom, I think somebody put something in my drink last night."
    M: <trying not to freak out> "Are you okay? Did anything happen?"
    D: "I started feeling really weird after only a couple of sips and I was scared. So I left and went home. So I'm okay, but I still feel weird."
    M: "Oh. Well. I'm really glad you went home." <practically breaking my arm patting myself on the back for educating her about evil things> "But if you're still feeling weird, you should go to the ED and get checked out."

    She went to the ED, they gave her some IV fluids and sent off blood and urine for drug screens. The serum came back "no illicit substances detected", but the urine tox screen was positive for GHB. She was SOOOO lucky! And I was so thankful that she was safe.

    Talk to your kids!

    We’ve now gotten some solid information about the effects, both desired and unanticipated, of these drugs. In Act 3 we’ll look at a couple of case studies that will bring the pieces together.

    Watch for Act 3, coming soon.

    Act 1: The Agony of Ecstasy in PICU and Other Tales… a Play in 3 Acts - NTI 2016 Session


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