LivingthePAdream

Family Medicine PA

[livingthepadream]

Me: hmm this patient still has an elevated A1c even while on metformin. He also has heart disease and elevated micro albumin. Let’s trial him on an SGLT-2

Insurance: sorry to qualify for that he has to have tried metformin and have an elevated A1c

Me: uhh yeah he does like I said before. But anyway here is your PA along with the extra proof of that.

Insurance: ehh still not buying that Imma need you to write a letter of necessity

Me: do you want to die

[redstonedust]

weirdest side effect of the pandemic is how many people i know who get sick and say 'but my covid tests are negative so i should be fine' like you know other illnesses. exist. right.

[dontmakemeturnthisuniversearound]

[livingthepadream]

patient: “my covid test is negative though”

Me: “you have pneumonia”

[livingthepadream]

X ray: incidental finding of AAA recommends CT

Me: orders CTA

Insurance: sorry we don’t see why the patient needs this even though the radiology report clearly states they do. Do a peer to peer and submit an appeal.

My office: submits appeal

Me: checks on status cause you know, AAAs can KILL people

Insurance: sorry we don’t even see that this case exist in our system start over

Me:

[livingthepadream]

Update

Hey guys,

I know I have been pretty inactive for a while but I still get a steady amount of followers and would love to continue giving advise or insights into the PA profession. I know tumblr isnt the main platform of content creators but I am definitely too private (and sensitive) to be a youtube content creator so I will stick to this format.

All that said. If anyone has questions or topics they want me to cover please let me know!

[livingthepadream]

More on call shenanigans

Caller: for the past month I have had on and off cold and flu symptoms

Me: ok do you have bad symptoms now

Caller: no but it worries me that it happens so often

Me: that’s understandable however I feel this complaint is more appropriate for an outpatient visit this is an emergency after hours line

Caller: but I need to talk to someone now to figure out why I keep getting sick

Me: ok have you had any outpatient appointments since you have felt this way

Caller: I made 2 but missed both cause I forgot

Me:

Ma’am please just make an outpatient appointment and go.

[livingthepadream]

This on call shift is breaking me. I honestly am at my limit. Omicron is devastating my patients and with full hospitals and >8hr wait times I feel completely helpless.

- a helpless primary care PA

[livingthepadream]

When you finally are able to to put in that 60 day notice

This job was not as toxic as my last for sure but it was definitely time

[livingthepadream]

I this is taboo to post right before thanksgiving. However, I refuse to believe I am alone in this.

Does anyone else work in healthcare yet feel that the system is set up for us to forgo our own well-being? How do you come to terms with this?

For context I need surgery and my job doesn’t offer short term disability and I overdrew my PTO because of my illness. Therefore I may owe my practice money…for being sick.

It’s just so disheartening to work my butt off 6 days a week in the middle of a pandemic for this.

[livingthepadream]

No lie it’s getting very exhausting treating covid patients. So many people will get tested at urgent cares, the ER, and mobile site but they don’t receive treatment for symptoms at these places and are told to come to primary care. It just overloads us I wish others would participate in symptomatic treatment, especially if the patient was seen by a provider and not just tested by nursing staff.

[depsidase]

[gunsandfireandshit]

I feel like this was probably originally a ketamine joke but here we are…

[populationpensive]

Emergency Burn Management

We have EM residents come on our service and I try to make it my priority to teach them what they need to know when they have a large burn come to their facility. More often than not, our big burns come from an OSH ED. There are some important things that ED providers should keep in mind when they get a big, unstable burn pt patient. Below, I’ll talk about ABLS based emergency management, things to look for, and what to do initially for burns > 20% TBSA. The initial care and tests are pretty much the same for all types of burns but there are some variances based on burn mechanism. Bear in mind, any burn can also co-exist with inhalation injury. 

Initial Presentation and Workup

ALL burn pts are TRAUMA pts. Complete your primary survey BEFORE addressing the cutaneous injury. Always. 

Evaluation of the burn is a part of the secondary survey

Use the rule of 9s to get a rough estimate of %TBSA affected

ONLY 2nd and 3rd degree burns count when counting TBSA (blisters, slough, skin that appears slick and shiny, skin that appears hyperemic or leathery)

Stick a foley in this patient. We will need to have accurate I/O for resuscitation.

Get a rainbow of labs: CBC, BMP, Mg, Phos, Lactic, ABG, EtOH, Utox

If the pt has additional trauma (broken limbs, etc), get appropriate imaging and work up for that. 

You don’t need an ECG for all burn pts. Electrical injury or ROSC pts ALWAYS need an ECG but generally, most don’t unless they have a cardiac history or electrolyte abnormality.

If the patient is so painful that you require fentanyl or morphine drips, the patient will need to be intubated secondary to iatrogenic respiratory depression. 

If intubating, do NOT use succinylcholine for induction. It carries a high risk of hyperkalemia in a burn patient, particularly electrical injuries with substantial muscle destruction. 

Large burns will continue to swell secondary to their pathophysiology and the amount of fluid they need. This means that the airway could be compromised. 

Do you have a chemical burn? - First, pH the skin, then aggressively decontaminate for 20 minute intervals. pH the skin until it is neutral. If there is chemical injury to the eyes, flush with NS via Morgan lenses. Repeat pH testing and continue to flush until neutral. BASES are much worse than acids. 

Do you have a child with a scald burn from tap water? Most states require this to be investigated. Get your social worker involved to begin this process. Any suspicion you have with any kind of burn should be investigated. 

Drips and Meds

Fluids: LR is the fluid of choice for resuscitation. Do NOT administer NS as the volume this patient will receive will likely push them into a hyperchloremic metabolic acidosis. Depending on the size of the burn, we will generally recommend a rate of 150-200 cc/h. Large burns may require fluids to be wide open. 

Pain Medication: For large burns, PO pain meds won’t cut it. We recommend fentanyl drips for the most part. It’s safe for people with renal disease (unlike morphine) and easily titrated. If the patient does not require intubation and pain can be managed by IV push medication, you can use dilaudid or morphine depending on renal status. 

Sedation: We usually recommend propofol. People with large, painful burns are best sedated. No one wants to be awake for that kind of injury. You should not need a paralytic unless the patient is SUPER unstable on the vent and requiring a paralytic for ventilator synchronicity. 

We do not give antibiotics prophylactically in burn patients. Please don’t start your large burn on an abx. 

Inhalation Injuries

Recall my previous post about inhalation injury. If the patient was NOT in an enclosed space for a period of time, your suspicion should be low. If the story fits, do the following:

Labs: Carboxyhemoglobin, ABG, VBG, methemoglobin. Not all facilities have methemoglobin testing, but most have carboxyhemoglobin. If the carboxyhemoglobin is >15%, suspect inhalation injury. If your facility has a cyanokit, administer it. A Cyanokit is essentially Vitamin B12; it acts like a mop for the cyanide in the body. Be warned, the urine will look like red wine. 

Vent/Airway Mgmt: 100% FiO2 on whatever setting the patient tolerates well. High oxygen concentration helps push carbon monoxide off hemoglobin binding sites. Our first setting we use is pressure control but honestly, vent management is a lot about what works for that patient. If the patient has facial burns, you’ll have to make sure that the ETT is SECURED well. The 2nd degree burns can make the skin very slippery and complicated tube securement. 

Wound Care

For a large burn, you should NOT worry about debridement or any kind of burn cream. We recommend that you wrap the patient in saran wrap to maintain moisture and send them to us. The most important thing you can do with a large burn is to keep the skin covered to preserve body temperature as these patients cannot thermoregulate. Pile on blankets and keep them normothermic. Warm fluids help. 

Referral

I have a post about referral to burn centers. Any burn over 10% needs to be referred. My facility will fluid resuscitate at 15% TBSA but the ABLS criteria is 20%. I think there is wiggle room here depending on the patient, their PMH, and status at the time of assessment. When you receive a burn that is a potential referral, call your nearest burn center once you have your workup done. Send us images of the burns so that we can assess severity. Not all burns have to be air lifted. Though, generally, >30% TBSA we have a big risk of fluid and electrolyte imbalances, so those pts should take priority for air lift. The burn center you talk to will recommend the best transport. 

PEARLS

Make sure copies of lab results go along with the rig or chopper. This is helpful to us when monitoring patients. 

If you and the burn center do not have the same EMR or have a “care everywhere” share function, make a copy of recent medical records and send them. We are most interested in a summary page with diagnoses, meds, and surgeries.

If you have a chemical exposure, please give us the MSDS information if you have it. 

Depending on how long the patient is with you, you need to make sure that they are making urine - goal is at least 30 cc/h (1 cc/kg/hr in kids). You likely will not end up doing any Parkland based fluid resuscitation as most patients are transferred to a burn center soon enough. If there is going to be a delay of some kind in transport, use the Parkland formula (adults) or Galveston formula (kids <30 kg) to calculate fluid needs.

Burns of any kind are intimidating injuries. Large burns coming to a facility with little experience can be completely overwhelming. Breathe, treat this pt like any other trauma pt, and call your nearest burn center. Keep the pt warm and give them fluid. I wouldn’t initially worry about giving too much fluid unless they have a history of CHF. We end up diruesing pts after resuscitation is complete. 

Good luck, y’all!

[populationpensive]

Slight correction to this post:

#1 removed statement about paralytics and APRV. You CANNOT paralyze a patient who is on APRV/bivent.

#2 added statement about intubation induction. Tldr don’t use succinylcholine.

[livingthepadream]

So this happened while trying to give education and and clarity about covid and the vaccine. Compassion fatigue is real and warranted yall protect your mental health at all costs and carry on

[livingthepadream]

We call patient to tell him he has arthritis in his knee

He is on dialysis so he is limited in terms of medicine

He tells he has orthopedic doctor and will follow up with them. We also have him PT referral. Patient demonstrated understanding.

Also this patient: makes a walk in appointment with me for knee pain

I don’t know what else to tell you my dude maybe actually go to ortho instead of your jaded pcp who has already told you she has tried everything she can possible do.

[mamoru]

okay, let me start out by saying that the whole shooting fireballs from your hands thing is awesome as hell. thanks for showing it to me. but, just so you know, this is way outside of my specialty as a gastroenterologist. if you want to make your fireballs stronger, you should schedule an appointment with a rheumatologist.

[mamoru]

rheumatologists specialize in inflammation

[livingthepadream]

Had a moment today where a patient made me cry. so I locked myself in my office and cried then remembered who the fuck I am.

PSA we are all stressed working during this pandemic and unfortunately assholes still exist. It’s ok to have emotions and not always be strong as a provider. Just take time to yourself, let it out, then remember you are #thatbitch for getting through school and continuing to help people everyday.

[livingthepadream]

Seeing my patients have access to the vaccine before me well, how can I say it, sucks

[livingthepadream]

Fellow Healthcare Workers

We can still be excited for the covid vaccine but still be critical about how our government and health systems still aren’t vaccinating based mainly on actual proven exposure and seemingly on wealthy hospital systems and high ranking positions.

So proud to see those of you who have gotten the vaccine but there are so many of us on the front lines who haven’t even been told when the vaccine is available to us even though we see a proven high number of cases daily. Urgent cares, independent primary care offices, etc are left in the dust yet again but we will still fight the good fight until help arrives. God speed!