On a recent shift, I had a 4yo kiddo with a nasty pneumonia who was having increasing work of breathing despite being on treatment for a few days, so they returned to the ED as advised when they started antibiotics.
As part of this reassessment, I brought my POCUS learners to do a lung scan to rule out a pleural effusion/empyema as the reason for worsening respiratory status despite therapy. My learners for this block are less experienced with POCUS, so it takes them a bit longer to get oriented and obtain their images. This little guy was initially very cooperative and chill during the assessment, but of course, once it hit the 5-minute mark or so, he began to get restless. Queue the distraction techniques: MineCraft was pulled up on the Child Life iPad.
At first, this bought us maybe 3-5 more minutes of me slowly coaching my learners through the lung scan, optimizing their techniques and saving their images, talking them through findings, etc. Unfortunately, little dude was getting quite antsy... the longer the scan went on, the more wiggly he got.
"Hey bud, we're almost done! Are you building a house right now on MineCraft?"
"No!" he pouted. "I have no building materials or weapons and it's gonna be nighttime soon. Will you help me?"
So I sat with him, asking him to "teach" me how to play the game while keeping an eye on the POCUS process and offering pointers between questions about the different pixelated animals our patient was encountering in the game. At some point, we had to lift each of his arms to get the lateral views and while he had one hand on his head as instructed, he was directing the sightline of the character while I was physically moving the character around.
Of course... this is when nightfall actually occurs in-game and so half my attention is spent dodging monsters spawning all over the place and the rest of my attention is spent helping my learners complete their images and interpretation.
...Well, in the end, we got the images we needed and my little friend and I only died 4 or 5 times to the scorpions 😅
(I had to review all the images outside the room after to actually get our clinical interpretation... much easier when you aren't being chased by skeletons shooting arrows at you...)
Can't say I expect my adult EM POCUS colleagues to have much experience juggling MineCraft with scanning hahahaha
Had a frankly ridiculously cute 14-month-old bean come in who had a complex cardiac surgical history (read: very high risk for big badness). Kiddo was just having multiple episodes of intraoral and central cyanosis (i.e. went blue in the mouth/lips and to his belly) multiple times a day, correlating with sustained desaturations on his home oxygen monitor down to the 50′s when his baseline for his specific cardiac physiology was 70-79%.
The family told us they called cardiology on-call and were instructed to come straight to our cardiology unit for admission; predictably, they were told “that’s not how admissions work” and were sent down to the ED.
(Keep reading for the rest of the story and a rant on being a generalist in a specialist-dominated institution)
We assessed little bean with his adorable round cheeks that were ever-so-slightly flushed pink and his giant blue eyes. I squished his face a lot. He desaturated for us, too, and when his sats stayed down in the low 60′s for over 3 minutes continuously we applied a little supplemental O2 and he came right back up.
So here’s where stuff gets odd: I called the cardiology staff on-call, as is our protocol for kids like this, and they were rather short with me.
“Hi, I’m calling from the ED about this patient, who you may be aware of because the family already contacted the on-call person for your service and they were instructed to come in.”
“Okay, so what?”
“Oh, well, this is the clinical history and given there are clear desaturations, this child was understandably told they needed to be admitted. The thing that was a bit confusing for us, however, is that the on-call person instructed them to go straight to the ward, so I was wondering if perhaps you knew anything about that since it’s not our usual protocol.”
“No, obviously this is an indication for admission. I don’t know if you’re aware, but our hospital doesn’t do direct admissions from home.”
Now I paused, because I mean, I work in the McFreaking Emergency Department, I am pretty darn familiar with how admissions work and also that this cardiologist was actually incorrect--we DO have some services that will admit straight to their service and bypass the emergency department in specific circumstances, including but not limited to when they call a child into their clinic, do their assessment, and admit them from there. It seemed like some unnecessary passive-aggressiveness, but this is what I’ve realized tends to be the norm at this institution so I’m not quite sure why I would be surprised.
“Yup, as I just said, the instructions the family received were not in keeping with the usual protocol for assessment for admission, hence why I wanted to touch bases with you, the service that the family contacted and received the instructions from.”
“Okay, listen, I don’t know what the family heard, but let’s just be clear that we’re on the same page here--these desaturations are an indication for admission for this child. Got it?”
I bit my tongue.
“Got it.”
“I’ll send my fellow to assess this patient for admission.”
“Sure. We are going to get a chest X-ray for this child; given their lack of any other localizing findings, is there anything else you’d recommend we do while they’re here?”
“No, just wait for my fellow.”
I’m annoyed by this whole interaction, but I have other patients to see, so off I go. Fellow assessed the patient then told me to discharge the kid home. After the whole song and dance I just went through with his staff, I was gobsmacked.
“Did you review this with your staff? They told me in no uncertain terms that this was an indication for admission. Please let me know what has changed since your evaluation.”
“...I’ll review with my attending.”
In the end, it took another attending-to-attending discussion to find an appropriate discharge plan for this patient, because what the fellow did not care to express to me was that there was a whole comprehensive outpatient investigation plan for this child if they were to be discharged home, which is very different from me just sending them back to the exact same situation with the instructions to “come back to the ED if it happens again”.
At the very least, little bean was very content throughout his encounter with us, and tolerated me smooshing his little face with this same contentedness.
Unfortunately, this is what it feels like to be in a subspecialty that specializes in, well, general-ness. At my current institution, most of our other subspecialty colleagues that chose one organ system or procedural focus speak to us and treat us like we are very much beneath them in intelligence, expertise, and qualifications... sure, our area of expertise may not be every obscure familial neurodegenerative disease, but my area of expertise IS to weed through all the other possible reasons this child is presenting with episodes of losing consciousness and be able to differentiate the neurologic from the not-neurologic as well as the acute (i.e. the entire reason I’m calling you rather than putting in a referral for later) versus the non-acute. Your dismissal of my expertise just reinforces the public perception that generalists of all stripes--acute care, critical care, and primary care--are less than, and we are simply “too stupid” to possibly do what you do, when in reality, we are all just different cogs in the same machine and if we didn’t do our job, you wouldn’t be able to do yours.
And let’s face it--when you have a kid admitted to your service who acutely decompensates and you don’t know why because it doesn’t seem to be related to your organ system, it’s the acute care generalist (i.e. me, or our PICU/PCCU colleagues) that you’re calling for help. If you enjoy the peace of mind that we will help you out when you are in dire straits, I’d love to feel like you are willing to help my patients when they need you, too. We are all spread very thin, but if you are annoyed by the number of patients I need to call you about from the emerg, at least try to remember that there are scores of patients that I was able to divert from your workload because I could identify that they were not appropriate patients for your service.
(Just a last little rant: I find it especially frustrating when I encounter a lack of collegiality from my fellow generalists in general pediatrics and general emergency medicine, because hello, when your patients deteriorate and you feel out of your depth, you are asking me for advice, sometimes immediately after you’ve alluded to me being less competent than you as a physician...)
...Can we all just be kind to one another please? We’re all in this together. The patients will continue to need us all and that’s why we’re here, isn’t it? Don’t let the patients down because of something as silly as pride.
I'm at the point pre-exam where I oscillate between compulsively trying to make everything into a table or diagram, panicking about studying, and procrastinating by doing literally anything that catches my attention.
Fully board certified in two fields, with the option to pursue fellowship training in either (or both) after residency. Adult cardiology? Peds cards? The ultimate Med-Peds cards?? Go for it.
The 2013 American Academy of Physician Assistants Salary Report, A Review
It's important to stay updated on the salary of a PA, specifically PAs in the field you plan to go into. This can have positive or negative effects on your future and could eventually enable you to single out the speciality, subspecialty, or practice setting you choose for yourself. This salary report also helps PAs ready to go into practice negotiate the best compensation package, hourly rates, salary rate, bonus packages, productivity measures, and benefits packages available. But this salary report isn't all about salary, it also talks about schools, coursework, and other information about becoming a PA you might find useful along your journey. Remember, this is just a review, so I'll just highlight a few that I think are cool and important, but if you want to see more, you'll need to purchase a membership. Lets get started!
The first part of the Salary Report is on PA Facts - this is basic information not regarding salary you might find useful.
Table 1. Table featured in AAPA Annual Survey 2013. This
particular table features the area of medicine and surgery
PAs work in by percentage.
The average PA program takes 26 months to complete; nearly all award master's degrees
93,000 certified PAs work in every medical and surgical setting across the country
37.5% practice in a hospital setting
38.1% work in a group practice or solo physician office
24.4% work in community health centers, freestanding surgical facilities, nursing homes, school or college based facilities, industrial settings, or correctional institutions
Each year, a PA treats around 3,500 patients
A PA writes approximately 2,600-5,200 prescriptions each year. [That's about 50-100/week!]
Salary Report
This report was collected by a voluntary survey released online to AAPA members and non-members between March-July 2013. An astonishing 18,000 PAs responded, reporting valuable information about those working more than 32 hours/week for their primary clinical employer. The information is also presented in such a way that divides PAs into two categories: PAs with a base salary only and PAs with bonuses in addition to their base salary.
PA base pay is 75% salary, whereas 22% of PAs are paid hourly and 3% of PAs are paid based on their productivity.
54% of PAs receive a salary ONLY, while 46% of PAs receive a bonus in addition to their salary
78% of those who receive bonuses say they are based on productivity
12% of those who receive bonuses say they quality improvement metrics are the prominent drive of their bonuses
PAs in surgery and other specialities are earning substantially more per year than their counterparts in primary care
Table 2. This table indicates the average salary of PAs based on specialty including those with salary only and those with salary and bonuses.
How Much Does It Cost?
The report is FREE for members, or about $500 for non-members.
$75 for current PA students (lasts entire PA program length) and pre-PA students (lasts 12-months).
$275 for currently practicing PAs (lasts 12-months).
$75 for non-practicing or retired PAs (lasts for 12-months).
To download your copy, visit www.aapa.org/salaryreport
Although Cardiologists care for the heart, Gastroenterologists care for the stomach and intestines, and Dermatologists care for the skin, Hospitalists don’t care for the hospital. Rather, they care for hospitalized patients.
The first physicians who dedicated their practice to caring for non-ICU hospitalized patients started in the mid-1990s. Today, although not officially recognized as a specialty, about 30,000 Hospitalists staff about 70% of U.S. hospitals.
While the first Hospitalists were Family Medicine or Internal Medicine physicians, they now include about 15% of all practicing Obstetricians, as well as many Neurologists, Orthopedic Surgeons, Dermatologists, and Acute Care (including Trauma) Surgeons. The growth of these subspecialists has been pushed by those clinicians who no longer want to work in a hospital gladly turning their patients over to those who do.
As of now, relatively few training programs exist that emphasize Hospitalist Medicine. That is bound to change. The reference at http://bit.ly/17iIQAd describes the current training situation.
