Co-founder and organizer of #PAblr on tumblr. Currently working in critical care. Formerly in burn medicine Crafter. Rabbit lover. Avid reader. See FAQs for questions - if not answered, ask away! This is a medical blog which details MY journey to becoming a PA-C, as well as a platform to connect with other people interested in the profession. Though, there are *some* pics of bunnies. Or science puns. You get it. ;-) **I do NOT give medical advice** I do write educational content for other providers and students. HOWEVER, I am more than happy to answer GENERAL health related questions or questions about my job/specialty/etc. Just don't ask me if you should see your provider for that mole on your back or something- if you are asking, you should go.
This is, admittedly a month belated. In March, I officially entered into year 7 of clinical practice as a PA. Looking back at past reflections, it is always interesting to see what sort of headspace I was in.
New things for me: more administrative duties related to several parts of my department & having to choose between the PANRE-LA or the normal PANRE.
I chose the PANRE-LA and started my questions in January.
I really had a hard time with this, mainly because I feelt like even thought the longitudinal assessment is more in line with adult learning theory and better supports continuing education, I still feel like I have to sit for a 5 hour exam.
In all fairness, the boards recertification as a PA is absolute shit unless you work in primary care. I haven't cared for a kid in 5 years. Pediatric exanthems? LOL.
Working in adult critical care since 2021, there isn't a ton of detailed stuff related to my specialty. Hence copping out and just doing the LA. Why add stress to my life when I can just do the longitudinal assessment and be done with.
This year, I have mentoring a new hire PA staight out of school. We have a lot of similar interests and a similar personality. We've gotten coffee outside of work and just hang out. She is a reminder of how far I've come. In the ever famous words of Lorde, "it feels so scary gettin' old."
I definitely have a comfort level with my knowledge and that is the kind of thing that can get a little tricky at times. I don't want to get into a rut where I assume I know things.
I am doing a little more hyperbaric medicine and have a conference in Mexico in May. Going with some work people - should be a good time. :-D
Overall, I feel pretty satisfied where I have come and where I am going. Critical care is still an emotional toll. It has impacted my health negatively and I've needed to prioritize self care. A surgeon buddy of mine and I will go to yoga a few times a month --that's been helpful. Though, I think I am mostly just hoping I am putting in good cosmic karma for my next life where I have a stress free job (or none at all) and just paint and make music. :-D
But, in all seriousness, I don't regret a single thing about pursuing PA school and becoming a PA-C. Best life decision I have ever made besides marrying Mr Poppen and adopting our fur children.
Unfortunately, this feeling will come again. It’s a strange place to be in - having the technology and resources available to literally throw a hail Mary in the name of simply living but knowing that, in certain situations, those efforts are fruitless.
I can honestly say in my 4 years of medical practice that my colleagues and I have done things so fruitless to avoid the appearance that we “didn’t care” or “didn’t try”. Even if I’ve discussed with family the shear fruitlessness of an intervention. And trust me, even when I gently but firmly educate about the truth of a situation, I’ve been told once or twice that I’m “giving up” on their loved one.
I absolutely HATE the phrase - giving up.
No.
There is a big difference between doing something FOR a patient and doing something TO a patient. The biggest regrets I have in my medical practice are situations in which we put people through something we knew they could not tolerate and they died suffering.
We took oaths to DO. NO. HARM. Yes, preserve life, but only in so far as it will do no harm. Every patient of mine that has been denied a death with dignity lingers with me because I felt I let them down in this way.
So how do we move on?
I think we need to look at each patient that faces this and think about what we did as individuals to preserve that dignity. Whether is was giving pain medication or strongly advocating with their families - we have to hold on to those things to keep sane.
You know when someone from your past pops up in your head and the thought of them came from absolutely nowhere. You’re sitting there, minding your own business, when all of a sudden this person emerges. You might not have even thought of them for several years.
This happened to me today, when I randomly thought of the therapist that I used to have who helped me significantly when I was in the process of changing from teaching to becoming a physician assistant. This individual was instrumental and helping me realize my potential and calm my excessively negative self talk.
Like any normal human, I googled her and regrettably found out that she passed away two years ago. It’s strange how these people pop up and even stranger still that they could be so easily forgotten. I don’t think I have thought about her for at least eight years probably closer to a decade.
But for whatever reason, I did think of her today. And I’m reminded of how lucky I was to cross paths with her when I did. It made all the difference in my life. 
I have a side hustle as a hyperbaric medicine provider and I am here to give you the down and dirty!
Sometimes referred to as HBO (hyperbaric oxygen), hyperbaric or dive medicine is a specialty that utilizes oxygen at high pressure to treat a variety of conditions, primarily things involving wounds. We place a patient in a chamber, deliver 100% oxygen to them, pressurize the chamber, and keep them in there for about 120 minutes. Since oxygen is the number one thing you need to heal a wound, we use a lot of it to try and speed up the process.
The Basics
Wait - what? HOW? Try not to have PTSD from your days in chemistry, but remember these?
The treatment physiology of hyperbarics relies on gas laws. Recall that it takes a lot of pressure to dissolve a gas into a liquid.
We use pressure to force oxygen into the blood stream at high rates to facilitate wound healing. For reference, most of your oxygen content is bound to hemoglobin (~98%). You do have dissolved oxygen in your blood, represented by your PaO2/PvO2 in a blood gas. However, this makes up a fraction of O2 content (~2%: if you want a clinical soap box, you should hear me talk about blood gases to students lol). A normal ABG would have a PaO2 of 65-100. An ABG acquired during hyperbaric treatment would be well over 2,000.
As an aside, recall that ambient air is 21% oxygen. Also, as a reminder, we exist at 1.0 ATA of pressure (one atmosphere).
How is it done?
Delivering oxygen this way requires delivery of a lot of pressure. We utilize dive chambers for this purpose. There are two types of chambers:
Monoplace: literally looks like a class coffin. Holds one patient and delivers oxygen at pressure through the entire chamber. These are very popular at wound centers.
Multiplace: literally looks like a submarine. Holds 2+ patients and delivers oxygen at pressure to individual patients hooked up to hoods or masks. These are found at tertiary care/academic medical centers.
Literally, the multiplace hoods make you look like a silly space person.
The reason oxygen is delivered this way in a multiplace chamber is to reduce the risk of fire. Oxygen at pressure can go boom. Having an entire chamber full of O2 is a big risk. So, we deliver the gas individually to each patient.
How did it start?
Dinking around with gases at pressure has been a thing for 400 years. However, it didn't become a more focused endeavor until the first dive suits started to be a thing in the 1870s. The specialty itself is relatively new, developed in the 1930s due to advent of decompression illness with divers. Things really progressed in the 1950s.
One pivotal study was "Life without Blood" in 1959. Dr. Boerema proved that he could keep a pig alive with HBO alone. The ethics of this experiment are questionable but he exsanguinated a pig under hyperbaric conditions (3.0 ATA, 100% FiO2). Plasma was left behind. By doing this, he proved that, at pressure, an organism does not need hemoglobin to live. Kind of a radical thing to prove! Don't worry, the pigs did get their blood back and recovered without issue.
What is treated with HBOT? (hyperbaric oxygen therapy)
Anything related to wound healing can be treated with HBOT. We also treat carbon monoxide poisoning, air gas embolism, and decompression sickness with HBOT. I'll start with those since they are (imo), the most clinically interesting. ;-D
Carbon monoxide poisoning: The physiology of using HBOT to treat CO poisoning is based on the binding affinity of CO to hemoglobin. CO has 200 x the binding affinity for hemoglobin than O2 or CO2 does. Because the binding sites are taken up by CO, hemoglobin cannot pick up O2. It also can't offload whatever O2 is already bound. The goal with HBOT is to bombard the blood with massive amounts of O2 to force CO off.
For reference, it would take about 6 hours for CO to offload on its own from hemoglobin on room air. It would take half as long at 100% FiO2 delivered at standard air pressure (1.0 ATA). CO is rapidly forced off within 30 minutes with HBOT. With very severe CO poisoning, particularly in cases of LOC, this is vital for limitation of hypoxia and neurological sequelae of exposure. Treatment is 1-3 "dives" depending on clinical context. The patient is treated at 2.8 ATA (60 feet of sea water) for about 120 minutes.
Air gas embolism: This occurs when gas is accidentally introduced into circulation. It can either be venous or arterial. The venous system has much more flexibility in tolerance for air bubbles. 15 cc or less of gas introduction is probably not going to result in symptoms. Higher volumes go to the lungs and can result in local lung infarction.
The real danger with this is air introduced into arterial circulation. Depending on where it is introduced, it can go directly to the heart causing an MI, or to the brain causing a stroke. Any volume of air introduced into arterial circulation is bad news bears. Treatment is usually 1 "dive" but could be more based on the context. The patient is treated at 2.8 ATA for 30 minutes and then the ascent is extremely slow. The whole dive takes about 5 hours. Why so long? If we ascend too quickly, the air bubble will reform.
Decompression sickness: This occurs primary with scuba divers who ascended too quickly. Scuba divers generally breath mixed gas, most commonly air (21% O2, ~79% N2) or nitrox (35% O2, ~65% N2). As someone is diving, the nitrogen they breath is also dissolved into their blood since they are at a pressure greater than 1.0 ATA. If a diver ascends too quickly, the nitrogen dissolved in the blood will rapidly reform air bubbles in the blood. We just mentioned how that is problematic.
Since air bubbles can go everywhere in circulation, the symptoms are variable ranging from headache, vertigo, nausea, joint pain, chest pain, stroke symptoms, loss of bowel/bladder function, etc. The treatment for this is to recompress the patient and very slowly ascend in the HBO chamber. Treatment is usually 1 dive but could be more based on the context. The patient is treated at 2.8 ATA for 30 minutes and then the ascent is extremely slow. The whole dive takes about 5 hours. Why so long? Again, if we ascend too quickly, the air bubble will reform.
Wound related conditions: there are roughly 15 approved diagnoses for HBO by Medicare in the USA. This is important to mention because if a condition is not covered, paying out of pocket is extremely cost-prohibitive. Insurance is billed $6,000 per treatment! Some of the most common conditions treated are osteoradionecrosis, soft-tissue radionecrosis, irradiation cystitis with hematuria, and refractory chronic osteomyelitis. Wounds created from radiation exposure have the best evidence to support the use of HBOT. These are considered outpatient conditions so patients come to be treated Monday-Friday. We dive to 2.4 ATA for 120 minutes. At minimum, patients are prescribed 20 dives but most treatment protocols for radiation induced injuries is at least 40 dives.
As you can see, this is a HUGE commitment for the patient. One dive is not enough for these wound related conditions. As a hyperbaric provider, I can say that we have patients with such significant symptom relief from HBO. For example, irradiation cystitis with hematuria is extremely debilitating. Patients are fatigued from chronic blood loss, deal with painful bladder spams and pelvic pain, pain with urination, and increased frequency. The blood can clot and obstruct their urethra or foley catheter. Symptoms like this limit quality of life. HBOT makes a huge difference for them.
Benefits
Anyone who has barriers to wound healing can benefit from HBO. Barriers include vascular disease, CKD, COPD, DM, heart failure, and immunocompromised status. The goal is symptom resolution/improvement or healing of the wound. Some patients get approved for far more treatments than we typically do. Usually the maximum insurance will cover is 60. However, in some situations, the clinical benefit of continued treatments is recognized by insurance and treatment is extended.
As a provider, I get to know these patients pretty well. They show up every day that I am staffing in HBO and it is rewarding to see them improve. Compared to my critical care role, this is a nice change of pace.
Adverse Reactions and Risks
There are risks and side effects to HBO. The most common are barotrauma, pneumothorax, seizure, temporary worsening of cataracts/vision, and abdominal distention.
Barotrauma of the ears and sinuses is by the most common issue we face in HBOT. If patients are not able to clear their ears as they descend ("pop" their ears), they can rupture their ear drums. Patients that cannot descend without extreme pain may need myringotomy tubes (ear tubes) to assist with equalizing pressure.
Seizure is a risk of HBOT and that primarily comes from oxygen reducing the seizure threshold. We mitigate this with "air breaks". These are 5 minutes intervals of the treatment where the patient is receiving air rather than 100% O2. Example, we treat at 100% for 30 minutes, have a 5 minute air break, repeat x 2. Obviously the people at highest risk are those with epilepsy or taking seizure threshold reducing medications.
HBOT can worsen cataracts and vision temporarily. The mechanism of this is poorly understood but we know it is reversible. Distance vision is affected the most.
Contraindications
The only absolute contraindication to HBOT is an untreated pneumothorax. There are many relative contraindications that require a risk benefit analysis. An example of this is pregnancy. HBOT has not been thoroughly studied in pregnancy and is not recommended EXCEPT in cases of CO poisoning where we know that the CO concentration is higher in fetal circulation than maternal. Always treat a pregnant person with CO poisoning.
Other potential contraindications include use of certain chemotherapy agents, COPD with blebs/bullae, severe heart failure, epilepsy, sinus/HEENT disease, claustrophobia, certain implanted devices, or active infection.
With certain chemo agents, they can lower the seizure threshold putting patients at higher risk of seizure in the chamber. People with COPD and blebs are at risk of those blebs popping under pressure and causing acute respiratory distress. People with heart failure can experience flash pulmonary edema after an HBO treatment. If people are claustrophobic, obviously spending time in a monoplace chamber can trigger panic attacks. At my center, we sometimes have people referred to our multiplace chamber for exactly that reason.
Most implanted medical devices are HBOT compliant. Generally, pacers and other devices are tested at 4.0 ATA of pressure. We double check with the manufacturer that the device is compliant. If it isn't, we cannot safely treat and have to deny the consult.
Obviously, if someone is sick, we don't want them in the chamber. Particularly colds, severe allergies, fever, or anything that is affecting HEENT. People with acute sinus infection are unable to clear sufficiently to dive. Even if they can clear, they feel miserable. No need to go through that.
Safety Issues
I mentioned that high O2 environments are at risk for explosion. Safety is the number one concern with any chamber. The goal is to reduce risk of fire by removing fabrics that create static (anything synthetic), removing electronic devices that are not HBOT approved, and going through multiple levels of safety checks for patients and for chamber preparation.
At our chamber, only 100% cotton is allowed in the chamber. All patients have special scrubs that they wear during treatment. No electronic devices can be brought in the chamber which includes phones, tablets, laptops, e-readers, watches, pagers, etc. We do have HBOT approved IV pumps and radio headsets that we use. These have been tested at 4.0 ATA. The radio headsets are for the attendant (staff member) who is in the chamber and this is also for safety purposes. Since we have a mulitplace chamber, a staff member is always in the chamber with the patient(s).
One thing I do want to address is that some people are concerned about putting a patient with active cancer into the chamber. There is concern that the high O2 environment will "feed" the cancer. There is simply not data to support this. Active cancer is not a contraindication to HBOT.
And there you have it! The down and dirty of HBOT! Hopefully you learned something cool. If you think you have a patient who would benefit, find your local HBOT provider. We are always happy to talk with you about the process. If you care about a soapbox of how insurance companies suck, see below. :-D
Soapbox: I will say, I have definitely been frustrated with insurance companies. They are the gatekeepers of this treatment. You can have several providers supporting the use of treatment and an insurance company can still say "no". Very frustrating.
A prime example of this are patients who have avascular necrosis that is steroid or chemotherapy induced. These are often younger patients (late teens, early 20s) who have/had leukemia of some kind. They end up having necrosis at a joint, usually the femoral head, that will likely result in complete joint replacement at a young age. No orthopedic surgeon wants to replace joints on a young person. It comes will all kind of problems and always needs revision later in life.
Insurance companies will say "we only cover radiation induced necrosis" because that is what the literature supports. Yes, they are correct that the vast majority of studies support HBOT for radiation induced injury. However, the pathophysiology of the tissue destruction, while a little different, ends up with the SAME problem. There are studies that support HBOT use in these situation but not nearly as many as radiation induced injury. The result is that patients suffer, get a joint replacement they could have avoided (or postponed until they are fully developed), and generally are shafted.
2025 was.... a year. I, like many people, found myself a tad overwhelmed with the events around the world and here in the US.
2026 seems to be shaping up similarly with its bullshit.
I am still in the ICU, though I am doing more HBOT these days. I have an administrative gig as well which added some new responsibilities. One of those tasks was formalizing our fellowship curriculum as our program seeks accreditation. That teaching degree is coming in handy!
I am fast approaching 7 years as a PA-C. I registered for the PANRE-LA and that was just...mind boggling. It my head it was further off. I suppose it isn't.
I'm in a relatively comfortable place in my career. I know what I don't know and I know what I know. I have great professional relationships and my work is fulfilling.
I will say that I haven't done a great job of dealing with all that I compartmentalize from work. I see a lot of sad, depressing shit. I can compartmentalize that VERY well. Unpacking those boxes later is a little problematic. I am hoping this year I will appreciate the process of unpacking so that it positively impacts my health and life.
The most mind-blowing moment, not only for De La Mata but the scientists too, came when they managed to actually record the sounds that she heard in her ears – which now appear as ‘Left Ear’ and ‘Right Ear’ which begin sides A and B on the album – and in doing so opened up questions about the nature of tinnitus itself. “The NHS definition is that it’s a phantom sound that your brain is creating, that it isn’t something ‘real’, so you should try to ignore it.” By having De La Mata place her ear into an anechoic chamber, with an ultra-sensitive microphone perched in her ear canal, they were able to provide significant evidence to the contrary. “After the first recording of it, it was ‘There’s no way, this isn’t possible.’” They tried again with her breath held, and again with her tensing her ears, and again with other members of staff, but each time it became apparent that yes, the noises De La Mata hears are seemingly something physical.
Children shouldn’t be a “stage” in life that everyone is obligated to fulfill; childrearing is not for everyone. More importantly, children shouldn’t be state-enforced punishments for “irresponsible” sexual behavior.
Children are people with thoughts and feelings just like the rest of us. They are conscious of the way people treat them. And they can certainly tell when they are unwanted and/or resented.
This. Children are only infants for a year, and only toddlers for couple of years after that. Before you know it, they are inquisitive school kids, challenging teens and independent adults.
They will be in your life long after you are legally responsible for them.
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