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Liver transplant

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  1. core0

    Ok TEXAS NP's, wake up and smell the coffee!!!

    You have a dramatic misunderstanding of what happens in medicine and are missing the entire point of this rule. 1. The rule does not say a radiologist must read the xray simply a physician. So a Family practice physician who has minimal training in xray can read and interpret an Xray but an FNP cannot. If the regulation said only a radiologist can read and interpret a radiological study then I would agree. But it doesn't its simply an anti competitive measure to try to ensure physician primacy. 2. The road to hell is paved with good intentions. This is especially obvious in an acute care setting. Specifically:  The problem is with number 2. If I look at an xray and see a problem such as a pneumothorax, I can't act on it until its read by a physician. Even in an tertiary care hospital it regularly takes several hours to get reads on x rays. I can't imagine what its like in a tertiary hospital. For example, I'm asked to look at a KUB for feeding tube placement. I notice that not only is the feeding tube in the lung but there is a pneumothorax on the same side. I put in a chest tube on that side and get a CXR which shows resolution of the pneumothorax. Three hours later I get a call from radiology that there is a pneumothorax. Just sayin.
  2. core0

    Can't get ACNP job

    They are fairly competitive depending on when you apply. Emory takes 6-8 per year in two classes and gets around 50 applications total. So fairly competitive. But when you count in the fellowships in heme/onc, cardiology and transplant there are a lot more. Also there are fellowships at Piedmont in a number of specialties.
  3. core0

    Can't get ACNP job

    I will add something else. At 2 years without practice is something else you have to think about. Its one thing if someone with years of experience takes a year or so off. But you never practiced after school. If you are given the choice between someone with fresh learning and experience and someone who's learning and experience is two years old who would you choose? I would strongly consider an ANCP residency. Both Piedmont and Emory have a number of NP residencies. Some come with attached jobs and this will address your lack of experience.
  4. core0

    Medical billing and coding for NPs

    You could also look at this one: https://store.sccm.org/SearchResults.aspx?searchterm=integrating&searchoption=ALL Although I have an authors bias.
  5. core0

    "A Case of Bad Blood"

    This also points out a problem if you work at a tertiary medical center. These are the hospital that gets the oldest blood. We turn over our blood bank every few days. On the other hand a small hospital may turn it over every few weeks. So when the local blood bank sends out blood the oldest units (closest to expiration) go to the places with the highest turnover. We see TRALI about 1-2 times a month throughout the hospital. There are probably a couple other cases that get missed because they resolve quickly.
  6. core0

    "A Case of Bad Blood"

    It can happen to anybody. The hard part is distinguishing it from pulmonary edema or ARDS. In a case like Juan's its more straight forward. When someone has been in the hospital a while it could be PNA >> ARDS. It could be volume overload leading to pulmonary edema. Teasing that out can be difficult. Its really a diagnosis of exclusion. Finally, its more associated with FFP and PLT than blood. From a clinical perspective Hgb and crit are basically the same thing. Most of the studies on when to transfuse use Hgb so that's what we use.
  7. core0

    "A Case of Bad Blood"

    I think the real take home here is don't give blood products that aren't indicated. Clearly in the absence of coagulopathy the FFP was never indicated. I would be willing to bet the PRBCs transfused the patient well over hgb of 7 also. The fundamental problem is that providers regard blood products as just another colloid when they have long and short term deleterious effects.
  8. 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.
  9. 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.
  10. 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
  11. 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.
  12. 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.
  13. 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.
  14. 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
  15. 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.