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  1. core0

    Struggling NP student

    Another thing that might help is to have a A/P for every system. One of our attendings teaches the residents to have a diagnostic and a therapeutic differential for each system. For example if you have a patient in shock you would list what the differential in and then what tests you would do to rule in or out the differential. Then for treatment you would list what the different treatment options for the differential are. This allows you to think about the different processes going on with the patient. Also some of the differential may already be done so you can include that but state the test is already done and what the results are. For example shock. MAPs 50's. Diagnostic differential - hypovolemic vs cardiogenic. DDx - Echo yesterday showed EF 65 percent with normal wall motion. Check if patient is volume responsive. CVP is 12. Vigeleo placed for SVV. Then SVV 20 with CO 7 CI 2.5 showing adequate cardiac function. Therapeutic intervention Bolus with NS to so SVV Even if you can say its not a particular process this method forces you to think why its not or what piece of information you have that rules it in or out. Then if someone asks you a question you can discuss the process intelligently. As far as notes, we are using a hybrid note. Our PE is system based but our A/P is problem based. This is strictly a billing issue. Our coders want the notes to have a problem based system. They were getting claims rejected because the problem billed on was not spelled out for the insurance companies. I still present the problems in a system based approach, I just write the A/P in a problem based format. I'm a PA in a tertiary SICU.
  2. core0

    Terms used to describe APNs - what do people call you?

    Our center uses affiliates which I dislike because it sounds like the greeters at Wal-Mart. We generally use PAs and NPs. The problem with physician extender and mid-level is that they lack definition. As Nomadcrna points out it also implies that the care we give is less than that of a physician. Despite the fact that legally it has to be equivalent. There are also a host of other professions that crowd into the area. For example are WOCNs are obviously not "basic-level" providers (whatever that is). Does that make them mid-level providers? If you have to lump people together the term Non-physician provider (NPP) is defined by Medicare as a PA, NP, CNS (in states with advanced practice privileges) and CNM who has the ability to bill Medicare. Its got a legal definition and a finite number of people that it covers.
  3. core0

    Organ donation: cardiac death v. brain death

    Donation after cardiac death is done is cases where the patient does not meet the formal criteria of brain death but there is no chance of recovery. I don't know exactly what the OPO was doing but the donor is not rushed to the OR. Instead the donor is taken to the OR, prepped and draped and then life support is discontinued. If the patient has a non-survivable rhythm (ie cardiac death) for 5 minutes within one hour of discontinuation of life support then death is declared and the procuring team procures the organs. If death does not occur within one hour then the patient is brought back to the ICU and end of life care is started. The management of the patient and pronouncement of death has done by a physician not associated with the transplant. Here is a powerpoint from Oschner that describes the process and the background: http://www.lopa.org/Downloads/Donation%20After%20Cardiac%20Death.ppt
  4. core0

    Benzocaine-induced methemoglobinemia

    The PI says .1-.2 mg/kg which is the pretty standard dose. We use doses up to 2 mg per Kg in refractory hypotension so anything in that range should be OK.
  5. core0

    Hospital based NP--useless with image interpretation.

    We had a 4 hour class in this each week. You can look at some of the state and national conferences. I don't know about NP conferences but most of the PA conferences have a CXR boot camp class. Also if you work in an academic center see if you can come in for a 1/2 day with one of the radiologists looking at chest xrays. My problems with CXR usually are around the lousy quality and/or lousy monitors. Learning how to use the contrast brightness controls on your PACs will help you with line and tube placement.
  6. core0

    compensation for new grad emergency medicine fellowship

    Thats in the ballpark for PA post grad programs. Most pay between $40k and $60k per year.
  7. core0

    Not licensed yet

    Actually this is correct and incorrect. For Medicare and Medicaid the only first assists that can bill are physicians, PAs, NPs, CNS and CNM. RNFAs cannot bill Medicare and Medicaid. "Medicare will make payment for an assistant-at-surgery when the procedure is covered for an assistant and one of the following situations exists: The person reporting the service is a physician. The person bears the designation of PA, NP, nurse midwife or CNS. Physicians are prohibited from billing a Medicare beneficiary for assistant-at-surgery services for surgical procedures deemed non-covered for an assistant." For other insurances its going to depend on the insurance contracts the hospital, physicians or RNFA has. Some of them follow Medicare guidelines others follow their own guidelines. There are 7-8 states that require Non-medicare insurance companies to reimburse RNFAs. YMMV
  8. core0

    Whats the most blood products you've given in a shift?

    136 units of product in a 12 hour shift. Portal vein came unhooked. Patient walked out of the hospital.
  9. core0

    Need some Precedex advise

    I'll give my perspective after using it for about a year. First it seems to have a binomial distribution. It either works or it doesn't. Unlike Propofol where you can increase the dose until you get an effect, some patients will never calm down on Precedex no matter what the dose. Also it takes longer to work (we don't use loading doses). So if you expect it to work right away you are going to be disappointed. Bradycardia is a problem but its relatively uncommon (10-15% at a guess). Its just a flip side of hypotension you see with propofol. Its a great drug if you use it correctly, but its not the be all end all. To me its definitely my go to drug in two specific areas. The post surgical patient you are planning on extubating in the next day or two who is still snowed from surgery. Turn it on and by the time they wake up its to full effect. The other place is the patient who is agitated on their SBT. Keep the propofol on, titrate the Precedex up and then turn off the propofol. SBT on Precedex then extubate on precedex. Once extubated turn of the Precedex. Works great. As far as RSI with Precedex - wow, just wow.
  10. core0

    Forensic Nurse Practitoner ??

    New York City uses PAs and NPs as medical legal examiners: http://thename.org/index.php?option=com_content&task=view&id=758&Itemid=27 There are other states that also use PAs in this role. I am not as knowledgeable about NPs in other states.
  11. core0

    'PA anesthetist'?

    Thats the way that its written but its never been implemented. The forms available are for primary care (PAs) and anesthesia (AAs). The problem is that they tried to define medicine by primary and critical care when what they probably meant was primary and specialty care. For example if I do dermatology obviously I'm not part of primary care but equally obviously I'm not in critical care. Hence the lack of forms.
  12. core0

    Clinical Experience

    For me it largely depends on where the student is in their training. If this is their first rotation I would expect them to watch for a day then start to see some patients. You should definitely sit down with the preceptor and talk things about how things are going to work operationally before you start. When I worked in an office based practice, I would poke my head in, introduce myself and "ask" if it was OK if the student came in and saw them before I came in. Since these were mostly patients who I had a long term relationship with it was almost always OK. Its all in how you phrase the question. Usually I would go and see another patient while the student was in their and then have the patient present the patient and go see them. I would point out any interesting exam findings etc. When I did my FP or peds rotation I would see one of four patients and work my way up to ever other one and in FP on the final day I saw all of them prior to the PA. This was the progression that was expected. Where I am now in the ICU I usually orient the student the first day and then have them watch whats going on. I have them pick out one patient that will be "theirs" for a while. They are expected to write the note and present the patient to the attending. When they do well with one patient I have them pick up another and so on. I also like to have them do an admit to see what its like. All of this under the weather eye of the RNs and myself. If they are further into training I would expect them to get more patients quicker. Basically your program should have some goals for the rotation. Discuss this with your preceptor. Open communication is the key to a good rotation.
  13. core0

    RNs to write Diagnoses for medications?

    My question is why are you doing this at all? Is there some rule that requires every medication to have a diagnosis attached to it? Where I work in the hospital the MAR just has the medications no diagnosis attached to it. I would agree with the NP. The administration of the MAR is within the domain of nursing. If someone in nursing has decided that the MAR has to have extraneous information on it how is that the physicians responsibility? On my side I am responsible for reviewing all the medications that the patient takes every day and deciding if they are still appropriate. The only time that I would see the need for a diagnosis is on a PRN drug. Technically it doesn't have a diagnosis, its an indication for administration. David Carpenter, PA-C
  14. core0

    Billing For Nurse Practitioner Services

    Two different questions. Medicare: Office - 85% of physician fee for the same service (100% for incident to) Hospital - 85% of physician fee for same service (100% for shared billing) OR - First assisting is 13.6% of the surgeons fee (85% of the first assist surgeons fee of 16%). It has to be a covered surgery. Take a look at the AAPA brief on first assist for surgery (basically it applies to NPs also) http://www.aapa.org/advocacy-and-practice-resources/reimbursement/medicare/892-first-assisting-at-surgery Private insurance is completely different. Its going to depend on the contract that is negotiated with the insurance carrier. Even within a particular insurance carrier may reimburse differently for different policies.
  15. core0

    Surgical first assist as NP?

    Medicare is a Federal program. It applies to all states and most (or all) Medicaid (a joint federal state program).