Post-Brain Tumor Resection





The American Association of Neuroscience Nurses put together this awesome 40pg document: Guide to the Care of the Patient with Craniotomy Post–Brain Tumor Resection,

AANN Reference Series for Clinical Practice. Some of it is more relevant to nursing than PA practice, but I've found the majority of it VERY helpful in getting a general idea of what's going with tumor resection patients (especially as a new graduate). Of course, each institution is a bit different, but this is a great start.



Image:

http://medicalxtourism.com/wp-08/Top-Brain-Cancer-Treatment-Centers-Abroad.gif



Billing and Coding. Who Cares?

Reimbursement? Who cares? In short, YOU should.

Scenario 1:

It is time for your annual review and you've been working hard all year. You've stayed late to see extra patients and come in occasionally on your days off to cover the shifts of sick co-workers. You decide that you are going to ask for a raise based on the extra efforts that you've put in, but when you do the office manager states that everyone has been working hard so that alone does not justify a raise. Where do you go next? Your next step should be to present objective data. You should be prepared with not only the number of hours that you have put in this year, but also with your revenue (which you get from your billing records!) If you are able to show that you have increased your billings by a significant percentage, you're more likely to get something extra than if you just say you've been "working extra hard". Know what you are being reimbursed - check your billings bi-weekly or monthly to stay on top of it.

Scenario 2: 

You are working for a small family medicine practice with a couple physicians. You are the only PA. The family practice employs a billing and coding specialist to bill for all visits and procedures completed at the practice. You don't know much about billing and coding so you leave it up to the "specialist" to take care of all that. After all, you care about is seeing patients, right? This year, Medicare decides to audit the practice that you work for and they find several fraudulent mistakes in your billing. You have apparently been upcoding* several office procedures and double billing for some office visits. You are now facing criminal charges for defrauding the federal government and are facing jail time and a $300,000 fine. You try explaining that you never actually did any of the billing yourself, but in the eyes of the law, you are still at fault. Know what codes are appropriate. This is a two-way street. Don't overbill, but don't under bill either. Under-billing can be misconstrued as favoritism toward certain patents or it can just hurt the bottom line of your business. Its a Goldilocks and the three bears thing... not too much, not too little... but just right.






Both of these scenaios are real and they show the importance of understanding reimbursement/billing/coding. You've worked really hard to become a PA, don't lose it all because you didn't want to be bothered with the paperwork of billing. 















*upcoding = adding additional codes so that you are paid more money than you should get

Pic: http://www.tormont.com/en/Products-in-English/English-Products/GOLDILOCKS-AND-THE-THREE-BEARS/102518-118-1042.aspx

6 Salary Negotiation Strategies

This entry is a repost from the PRSA Job Center. I thought it was relevant and worth a repost- It makes a lot of the same points that I stated in another one of my entries earlier (Negotiations 101).

Six Salary Negotiation Strategies

Navigating the salary negotiation process can be tricky. You don’t want to overplay your hand, but you can’t afford to sell yourself short either. Many job seekers shy away from negotiating out of fear they’ll blow the deal.

But here’s a little secret: Most employers expect to engage in some back-and-forth discussion at the bargaining table. In fact, more than one-third of executives interviewed by Robert Half said they’re more willing to negotiate salary with top applicants than they were one year ago. Only five percent of hiring managers are less willing to negotiate.

Consider the following six tips for negotiating with finesse:

1.   Understand your market value. Savvy salary negotiating doesn’t involve throwing out a ridiculously high figure and hoping the employer says yes. The best negotiators are well-informed.

Do your homework and support your request with concrete numbers from reputable sources. Review current compensation standards for PR professionals in your area and at your experience level by consulting publications such as The Creative Group’s 2013 Salary Guide. The Occupational Outlook Handbook from the U.S. Department of Labor’s Bureau of Labor Statistics is another valuable resource.

2.   Look at the whole picture. Remember to consider all aspects of the deal, not just pay. An attractive healthcare benefits package, bonus opportunities, a retirement savings plan and perks such as tuition reimbursement or relocation assistance can make up for a lower base salary.

Also, don’t overlook the intangibles when doing your cost/benefit analysis. For instance, flexible scheduling, remote work options and a shorter commute can improve your work/life balance.

3.   Research the firm. Before you start plotting your negotiation strategy, get an idea of how much wiggle room there is. Learn about the organization’s financial standing by reviewing its website and searching for relevant news stories in business and trade publications. If it’s a public company, look at the most recent earnings statements and annual reports.

Ask members of your professional network what they know about the organization, too. If you discover the firm or agency recently announced layoffs or a salary freeze, you’ll probably want to recalibrate your expectations.

4.   Keep it friendly. Always manage negotiation discussions tactfully. You can make a strong case without issuing ultimatums or threatening to walk away if your demands aren’t met. Remember: You’re negotiating with someone who could be your future  boss, not haggling with a used car salesperson you’ll never see again.

Be poised and pleasant, not adversarial. And be a straight shooter. Candidates sometimes falsely claim to have a more lucrative job offer from another company only to have the misguided bluff called and end up with nothing.

5.   Ask to revisit the issue. If the company can’t quite meet your desired salary, ask if the hiring manager would be willing to re-evaluate your compensation in six months. The firm could be in better financial standing by that time, and your manager will have had an opportunity to see the value you provide firsthand. It never hurts to ask, and now’s the time to do so.

6.   Get it in writing.  If your salary negotiation is successful, make sure to get a contract detailing all aspects of the agreement. This includes compensation and any special arrangements (such as a signing bonus, extra personal days or early salary review) you’ve settled upon.

                                                               
Finally, if you decide to turn down an offer, do it with class. Go out of your way to be gracious and appreciative. It’s best to give the employer the courtesy of a phone call rather than a quick “thanks, but no thanks” email.

The bottom line is that you want to do everything possible to leave the door open to future contact. Just because you weren’t able to come to an agreement for this particular position doesn’t mean there won’t be a more desirable or suitable opportunity at the company down the line.
                                                           
The Creative Group is a specialized staffing service placing interactive, design, marketing, advertising and public relations professionals with a variety of firms. More information, including online job-hunting services, candidate portfolios and TCG’s award-winning career magazine, can be found at creativegroup.com.

Become Great At Knot Tying

Several months back during my surgery rotation, my preceptor and chief resident (Dr. Smith*) gave me some great advice becoming better at surgical knot tying so I thought I would share.

• Learn the square knot and be able to tie it by perfectly and quickly (by hand and instrument). There are lots of surgical knots to learn, but the square knot will get you through most situations. 

• Practice tying everyday. You often see medical students/residents walking around with string hanging from the tie their scrub pants or to a loop in their white coat.... this is because they are practicing tying in their down time. I started doing it and it is amazing how much practice you can get during the day - on the elevator, during rounds, on the T on the way to work. Dr. Smith said he still practices tying 100s of knots a day and he has been doing so since his first day of residency four years ago.

• Make it second nature. When you first start you will need to look at the string/thread and concentrate... however the goal is to be able to tie and tie well while doing something else. Dr. Smith recommended practicing knot tying during your favorite show at home while sitting on the couch. If you don't have scrubs on - place a coffee mug between your knees and use the handle of the mug as an anchor. 

• Materials. Since suture packs are expensive and I doubt the hospital would appreciate you snagging a bunch of $4-5 brand new suture packs to *practice* tying - there are other options. 1) after each of your OR cases, ask the scrub nurse if there are any opened, unused sutures left that you could have to practice with - if not, they get thrown away and 2) go to a sporting goods store and buy your own. Fishing line (mono filament and braided) are remarkably similar to suture material and you can buy 1800 yds of mono filament line for about $8 and 100 yds of braided for about $6.

This is the brand of braided line that I use. It is similar to "string ties". Purchased it at Dick's Sporting Goods for $6.

Using the arm of a mug as an anchor works great if you don't have scrubs on.

*Dr. Smith is a fictional name.

Free Book for Your Surgical Rotation

Scribd is a great resource for free textbooks (and not just the cheap ones). You can buy a subscription to have total access (Premium) or you can upload non-copyrighted materials and get a Premium membership for free.

I found this surgical book written for students on their surgical rotations. It is pretty awesome and comprehensive. A snippet from the table of contents is below.

Surgical Techniques: Textbook for Medical Students

Cardiac Surgery Made Ridiculously Simple

Cardiac Surgery Made Ridiculously Simple is a good resource if you are heading into a Cardiac rotation. Below are some additional resources listed on this site:

A good reference is: Cardiac Surgery in the Adult 

by L. Henry Edmunds, Jr., MD which is available online http://www.ctsnet.org/book/

An online reference text “Cardiothoracic Surgery Notes” for residents 

is available at http://www.ctsnet.org/residents/ctsn/

An online Johns Hopkins Cardiac Intern Survival Guide is available at http://www.ctsnet.org/doc/2695

http://www.nhrmc.org/heartsurgery

Free GI Textbook

First Principles of Gastroenterology, 5th Edition

"It was over ten years ago that we identified the need for an introductory gastroenterology textbook that would be useful to students, residents, family physicians and specialists. We decided this textbook should be relatively concise and readable, with appropriate figures, tables and algorithms, providing a logical and practical approach to patient management. It should cover the pathological basis of gastrointestinal and hepatobiliary disease, provide a list of learning objectives and be well indexed. We intended the book would not replace the standard encyclopedic tomes or excellent in-depth reviews, but would instead present a complementary first step to the vast and exciting field of gastroenterology. We also recognized that there was a place for important topics such as the clinical trials that form the basis of much of our modern practice and the crucial new area of molecular biology as it applies to clinical practice and patient care. We also thought it important that such a tribute to Canadian gastroenterology be made available in both official languages, English and French. And we considered it essential to bring out such a text- book in a timely manner and at a modest cost."

This is a FREE textbook.  

Preparing for PA School Interviews

'Tis the time for interviews at many PA schools and quite a few pre-PAers have emailed asking how to best prepare. Each interview process is slightly different so I would encourage you to reach out to current PA students at the school that you are interviewing at to ask them specific questions. PA school is difficult to get into - so don't waste the opportunity - PREPARE!



Below I have listed some generalized advice to help you prepare for your interviews:

• Know the history of the profession. Even if they don't ask you about it directly, try to incorporate it into an answer or two. It shows that you've done your research.
• Have a good (and genuine) answer of WHY you want to be a PA. I have heard many "generic" answers and those are boring and don't set you apart from anyone else. Be able to say not only why you want to be a PA, but why you don't want to be a nurse/MD/radiology tech/etc.
• Come up with good questions for your interviewers. Remember, you are interviewing them too. Why *this* and not another school? 
• Ask what their pass rate for the PANCE is and how they prepare their students to pass - after all, that's the goal of your education!
• During the group session - assert yourself, but don't be too pushy. You need to be remembered.
• Know about some of the changes in healthcare. Be able to speak intelligently about the role of PAs in national healthcare law as well as state.
• Be aware of any recent legislation in your state affecting PAs (visit your state chapter website for more info)
• Be able to answer the "standard" interview Qs: what are your strengths/weaknesses, tell me about a difficult encounter with a patient or boss, etc
• Wear a suit. 
• Be able to explain any weird parts of your resume (if you have them) - for example, if you got a "C+" in biology or you took 2 months off to backpack around Europe - come up with a good REASON why, not an excuse.
• If you had a medically relevant job/career prior to applying to PA school - mention it.
• Bring several copies of your resume. If no one asks you for it, no big deal - but you don't ever want to be asked (even once) and not have one.

Pic: http://www.snellingnj.com/blog/bid/53533/The-Characteristics-of-a-Great-Interview

Tips on Finding a Good Elective Rotation

One thing that I have learned from being involved in so many PA and PA student activities is that all PA programs are very different. They all need to meet ARC-PA standards, but the ways in which they meet them varies. For example, some schools have elective rotations, some don't. Some help you set them up, some don't. I have had a few people email me and ask me how to go about setting up their electives, but each program varies so much it is difficult advice to give. Below are some general tips to consider when trying to set up your elective. These tips are helpful only if you know what you want your elective to be - if not, see one of my earlier posts (Choosing an Elective Rotation) to help narrow it down.

1. Check with your program director. Most program directors have been around the PA profession for a while and have made a multitude of contacts over that time. Much of this is about who you know.
2. Network, network, network. Attend any and all PA events that you can make it to and don't be a wallflower! Reach out and say hi to people. If you make a connections, get their contact info and follow up.
3. Join the PA organization for whatever field you are interested in pursuing. You can find most on Facebook or with a good Google search. Some of these organizations are better/more organized than others, but make the effort to reach out to them. They may have a list of mentors that are willing to take students. The cardiovascular PA group is fantastically organized and has offered free student membership in the past.
4. Check with your state chapter. They may have a mentor program for student members as well.
5. Contact the department directly. I only suggest this if it OK'd by your school. Some schools do not allow students to directly contact potential sites so... ASK FIRST.
6. Do your homework on the institution. It is important that you know what type of rotation you are signing up for since your elective is likely something you may seek employment in in the future. Big, teaching hospitals are great because you see a high volume of patients and often see rare/unusual cases, which can be super exciting! The downside is that these large institutions generally have residents and medical students that are fighting for these cool cases as well. These means that you may not get as much hands-on time as you would like - especially in the OR. If you want lots of hands-on experience, you may want to look at a mid-size or small hospital. The down side to this is usually a smaller patient load with more "bread and butter" cases - but you will likely get to participate more and have more responsibility. These are not the exact scenario at every hospital, but are things you consider and ask about before committing your one elective to it.

In the end, hopefully you are successful in getting the elective of your dreams. If not, learn as much as you can from whatever elective you end up in and don't be discouraged. If you weren't able to find a "Trauma" rotation, that doesn't mean that you will never work in trauma. Where there's a will, there's a way.




Pic: http://www.whatsnextblog.com/2008/09/whats_the_best_advice_you_ever_got/

Approach to Volume Disorders, Part 3

Fluid Replacement Therapy

 I have also attached a chart that should be helpful in understanding when to give which type of fluid.

Approach to Volume Disorders, Part 2

Assessing Volume Status

http://cutcaster.com/photo/100023974-IV-Drip/

• Track ins and outs (Is & Os) - this is not an exact science because you can't exactly measure insensible losses, but it will give you an idea of the volume status
• Normal urine output of an adult = 1mL/kg per hr 
• Skin turgor and mucous membranes are difficult to assess and are not always reliable
• Daily wts are a good way to assess volume trends
• Don't lose sight of the BIG PICTURE. What is the overall health of your patient?
• Pts with: fever, burns, open wounds have a higher insensible loss
• For each degree over 37 degree C, estimate an increase in loss of 100mL/ day
• Pts with CHF may have pulmonary edema so pay close attention to their volume status
• Pts with end stage renal dz are prone to hypervolemia
• Pts with hypOalbuminemia tend to "3rd space" fluids out of vasculature and are therefore total body hypervolemic, but intra-vascularly depleted

Source: Step up to Medicine (Agabegi and Agabegi)

Approach to Volume Disorders, Part 1

Volume disorders are tough. They haven't come easily to me, but I hope once I start practicing the experience will help me along. I will do a 3 part series on the approach to volume disorders.

Fluid Compartments (Normal)

Assessing Volume Status

Fluid Replacement Therapy

Hopefully they will help you in your basic understanding.

Fluid Compartments:

• Men and women are different. Men: TBW* = 60% of body weight, Women: TBW = 50%
• % of TBW decreases with age and increases with obesity (Why? Fat contains little water)
• How is water distributed?
• Intracellular (ICF) = 2/3rd of TBW (the largest proportion of TBW = skeletal muscle mass)
• Extracellular (ECF) = 1/3 of TBW
• Interstitial fluid = 1/3 of ECF
• Plasma = 2/3 of ECF
• Water exchange:
• Intake (normal) = 1500mL PO fluids, 500mL in solids/oxidation PER DAY
• Output (normal) = 800-1500mL in urine daily is normal
• 600-900mL per day is from insensible losses (variable bases on fever, trachs, hyperventilation, etc)
• 250mL lost in stool
• MIN OUTPUT per day = 500-600mL assuming normal kidney function
• Fluid shifts are based on hydrostatic and oncotic pressures (pull out your physiology book for a refresher in this)

TIPS:
For the fluid compartments think 60-40-20!
TBW is 60% of body wt (50% for women)
ICF is 40% of body wt
ECF is 20% of body wt

What are 3 reasons for oliguria?
1. low blood flow to kidneys
2. kideny problem
3. post-renal obstruction (need a Foley cath!)





*TBW = total body water




Source: Step up to Medicine (Agabegi and Agabegi)

Interested in Global Health?

This video/ppt by Kaiser.edu is Global Health 101 in less than 15 minutes. If you are interested in working as a PA in the global market this is a perfect introduction to help you get a better idea of what's going on outside of the United States.

2011 PA Salaries

Advance for NPs and PAs in a site/magazine that puts out salary data each year for NPs and PAs based on surveys. It is a good way to gain general knowledge about salaries in your area, but keep in mind the numbers are based on a voluntary survey.

These salaries can seem inflated or even below average because it is largely dependent on how many people answer the survey. If one plastic surgery PA answered the survey and stated that s/he made $200K, it would look like plastics PAs were some of the best paid - when in reality, this is not true. Also, if 10 family practice PAs answered and most of them were around $85K, but 2 only make $70K that would drop the average even though those 2 might be anomalies.

Take home: Look at the data. Consider it. Don't consider it the end all be all. The best way to get an idea of salaries in your location and specialty is to ask people that work in the field. I don't recommend walking up to a PA and asking them what they make. You won't make many friends that way. But you can ask them what they think the salary range would be for a new grad working in their department with your skill set.


Source: http://nurse-practitioners-and-physician-assistants.advanceweb.com/Web-Extras/Online-Extras/The-2012-National-Salary-Survey-of-NPs-PAs.aspx

Secrets of the Social Media Trade

I have received quite a few emails over the past few weeks asking me how I keep up with all of my social media outlets. I'm on Twitter, Facebook, Linked In, and obviously ...blogging. The secret is Hootsuite. Hootsuite is one of many free social media dashboards available today. I haven't tried any of the other ones so I'd be interested to hear if you have.

Why is Hootsuite the secret to my success? Because it allows me update ALL of my social media outlets at the same time. I can input a message once and send it to all outlets with one click. In addition, Hootsuite allows me to schedule messages to go out at any time in the future. This enables me to sit down once or twice a week and set up the majority of my postings for the week. This is an enormous time saver.

If you are looking for a way to save time, but keep all of your social media outlets up-to-date or if you are just starting up your social media endeavors- check out Hootsuite or another dashboard. 

Post-Grad Advice

It has been 3 months since I graduated from PA school. I still haven't started work and I'm not in the minority of my class. I write this entry as a "heads up" for soon-to-be grads. Our class was told that it could take 4-6 weeks to start working after graduation, even if you were already offered a job! I think that time frame is a good minimum to think about. You should plan for about 2-3 months without an income just to be safe. If you start working prior... great! but if not, you will have a bit of a cushion for things like rent, bills, loan payments, and your licenses.  Getting all of your national/state stuff for credentialing will cost you around $1500. Even if your institution says they will pay, it is typically in the form of reimbursement - that means you need to have the money upfront.

Tips to Start Working Sooner

• Fill out as much as you can on your state license application and state controlled substance application right after graduation. You won't be able to do everything, but having it ready to go so that as soon as you get your NCCPA ID you can finish it up.
• Request official transcripts from your previous institutions. You will need them for your state license and often this is the step that holds up the process. Some school can take 5-7 days to mail out official transcripts.
• If possible, hand deliver the documents to the offices instead of putting them in the mail. If it isn't possible, think about expedited delivery.
• You will need your supervising physician to sign paperwork. Depending on your relationship with that individual and their schedule, think about scheduling an appointment soon after graduation because they can fill out their sections completely prior to you getting your PANCE results.

With all of this being said, even if you do everything ahead of time - you still might not start work for 2-3 months because some of the process is out of your control.

• Some hospital credentialing boards only meet once a month, so even if all of your stuff is in if you've missed that month's meeting then you will likely have to wait til the following month.
• Your hiring department may not be able to on-board you right way, especially if they hired several new grads. They may stagger your start date with other new grads for training purposes.
• Stuff gets lost in the mail. It happens.

Take home: Be organized and get as much of the application process done ahead of time as possible. Plan for 2-3 months without an income and be sure that you have $1400-1500 "extra" money to pay for your licensing. 

Family Practice Notebook

The FPNotebook site is a wealth of information - unfortunately- much of it is buried. They have changed their site a bit and added more advertisements which makes everything a little harder to find, but on there is still a lot of great info (especially under the tabs such as Derm and Nephrology).

Interested in Becoming a Surgical PA?

If you are interested in becoming a surgical PA - you should definitely check out the American Association of Surgical PAs (AASPA). Their website if a wealth of information for all types of surgical PAs - trauma, CT surg, burn, head and neck, and neurosurgery - just to name a few. If you click on the subtype that you are interested in, a fairly generic job description will pop up along with job qualifications and general duties and responsibilities. These contain good "buzz" words when it comes time to spruce up your cover letter and resume.

What else does the site contain?

• Student Scholarship! $1,000
• Surgical PA Residency Programs 
• Tips and Techniques  (small section - I hope they expand it soon)
• Professional Organizations
• How much to become a member?

Fellows = $150/yr (PA-C/graduates only)

Residents = $80/yr

Students = $75 (good for your entire time as a student!)

• Student Opportunities for Leadership (sit on the AASPA Board)

Disclaimer: I was not asked to promote this group nor do I receive compensation for doing so.

Note Taking on Your iPad

I must confess upfront that I am a Mac-o-holic. If I'm not on my iPhone or my iPad, then I'm working on my MacBook. I've had several people ask me how I use my iPad to take notes - and until recently I didn't have a great answer. I primarily used it to read text books and articles - but now that I've discovered Notability, I also use it to take notes.

Notability is a pretty wonderful app with good ratings and I haven't been disappointed with it yet. Now, of course, every app has it's flaws... but for what I use it for - I love it. It allows you to write out your notes on a "sheet of paper" and create a PDF or email it to yourself. You can also import PDFs (great for note taking on PDF'd ppts that you get in class. With the current version you can only import PDFs, but they are working on adding .doc and .ppt files to the mix soon. It also syncs with Dropbox to back up all of your notes or import files.

I have added some screen shots below. I'd love to hear if anyone has found something better out there - shoot me and email or add a comment.

And best of all, as of now, the app is only 99 cents!

There are several customizable features - pen and highlighter color and thickness as well as the addition of voice notes.

The mini window allows you to write smaller notes, thus getting more on each page (this will come in handy if you wish to print out your notes).

Disclaimer: I was not asked to write this review, nor do I receive anything if you buy it. Just wanted to share!

2C + 2MB = 4P + 4MO

Cranial nerves. I found this "equation" that helps me to remember where the cranial nerves arise from:

2C + 2MB = 4P + 4MO

The 1st 2 cranial nerves [Olfactory (I) and Optic (II) nerves] originate in the Cerebrum, the next 2 [Oculomotor (III) and Trochlear (IV)] cranial nerves arise from the Midbrain, the next 4 [Trigeminal (V), Abducens (VI), Facial (VII) and Vestibulocochlear (VIII)] cranial nerves arise from the Pons and the last 4 [Glossopharyngeal (IX), Vagus (X), Accessory (XI) and Hypoglossal (XII)] cranial nerves arise from the Medulla Oblongata.







Source: Problem Based Neurosurgery by Sam Eljamel

Gov't Loan Forgiveness: Do You Qualify?

You qualify for loan forgiveness based on public service if you work for the state, federal gov't, or a non-profit hospital. Get the details here: Loan Forgiveness Document

Also see the Federal Student Aid website for more information.

http://www.begincollege.com/the-benefits-of-the-public-service-loan-forgiveness-program/

Mnemonic Site

Board Mnemonics Site. Some are super helpful. Some are ridiculous. Enter at your own risk.

Mnemonic: is any learning technique that aids information retention. Mnemonics aim to translate information into a form that the human brain can retain better and even the process of applying this conversion might already aid the transfer of information to long-term memory.




Source: http://en.wikipedia.org/wiki/Mnemonic

Financial Aid, Handling PA School Debt

Financial Aid packages for PA school are rarely the bearers of good news. There are some students that get their education paid for through various avenues, but the majority of students take out loans. It is scary to think about being in debt, in some cases, more than $130-40K. At some point it feels like Monopoly money, you just keep signing on the dotted line and the "owed" amount just keeps growing and growing.

I'm not sure how all PA schools handle this, but mine gave a few talks on potential scholarships or loan repayment options - but no one really sat us down and had a "money management" talk with us. Financial aid services make you fill out an Exit Interview for the loans you borrowed, which is helpful - but I always wanted to know more. What are my repayment options? Should I consolidate? What are the pros/cons of consolidating? What happens when I get my first job - should I start saving for retirement and investing in my 401K or should I pay back my loans first? How do I save for a house/kids with a large loan payment per month? Should I hire a financial advisor?

I had (and still have) so many questions about the process. I found this site created by the Association of American Medical Colleges (AAMC) and it helped to answer many of my questions. They created a section called "FIRST" which stands for Financial Information Resources, Services, and Tools. On the left-side bar there are options for you depending on your stage of the process. This is geared primarily toward medical student, however, most the information is extremely relevant to PA students. They also have a section called FIRST Videos that contain videos and podcasts on important questions you may have regarding financial aid. The only way you can handle the enormous debt of PA school is to understand how to handle it. Knowing is half the battle... 

http://www.millionaireplayboy.com/mpb/index.php/tag/gi-joe/

Surgical Tubes & Drains

Tubes and Drains. Most of the time you don't go over these in PA school. People just keep referring to "JP drains" and "NG tubes" - but if you've never worked in a hospital - you probably have no idea what these are. I will go over some of the more common tubes and drains. If you see one on a rotation and aren't sure what it is or what it does - ask!

Jackson-Pratt (JP) drain:

• used to drain surgical wounds and keep bacteria/blood from building up
• usually attached to suction bulb
• if you are asked to "strip" these tubes - it means you need to pull along the length of the clear tube filled with blood [this prevents clotting]

http://www.ghorayeb.com/jpdrain.html

Blake drain:

• similar to a JP drain
• has a more narrow internal section so it is less uncomfortable for the patient when pulled out
• has a blue line along the tube (this is how you can tell the difference between a JP and a Blake)  

http://www.studyblue.com/notes/note/n/dressing--drainage/deck/975474

Penrose drain:

• yellow-colored tube used to drain large abscesses
• no suction

http://www.cantaertaxel.be/dokters/overzicht.php?cat=1&page=11400

Nasogastric Tube (NG Tube):

• tube leading from nasopharynx to the stomach
• used to drain stomach of fluids

Gastrostomy tube (G-Tube):

• goes from the stomach to outside of the body
• kind of like a permanent NG tube
• used for feeding pts with obstructions or ileus

http://flickrhivemind.net/Tags/gtube/Interesting

Jejunostomy tube (J-Tube):

• primarily used for feeding

http://milainternational.com/ca/products/small-animals/enteral-feeding/jejunostomy-tube.html

GJ Tube/Moss tube:

• has 2 ports (1 to stomach, 1 to the jejunum)
• acts like 1 G-tube and 1 J-tube
• often used for pts at high risk for aspiration

http://www.mosstubesinc.com/gdiagram.html

T-Tube

• a biliary tube shaped like a "T"

http://www.pssjournal.com/content/3/1/19/figure/F4?highres=y

Source: First Aid for the Medical Student

Is Twitter Worth it?

Great blog post on Academic Life in Emergency Medicine, topic = Twitter! How can Twitter help you as a PA student? Why bother getting involved in it? Is it a waste of time? Check out this blog to find out: Mini-Guide to Twitter: Why Should I Join?

You can find me on Twitter: @B_Belcher


Photo source: http://technmarketing.com/web/11-things-to-avoid-when-using-twitter/

Hypoparathyroidism, The Signs

Hypoparathyroidism. It is on the NCCPA's list of diagnoses on the PANCE exam. Two signs associated with hypoparathyroidism are Chvostek's and Trousseau's Signs. Chvostek's sign is a twitching of facial muscles in response to tapping over the area of the facial nerve. The Trousseau's sign is hand/finger spasm that results from ischemia, which can be induced by pressure applied to the upper arm from an inflated BP cuff.

As I was looking through this week's NEJM email I came across and article with videos of each of these signs. Watch it! Once you see it, you won't forget it. I would also read the case, it is very short. That plus visualizing the "signs" will help it stick.

NEJM Video

Photo source: http://www.medicinenet.com/hypoparathyroidism/page2.htm
Source: http://www.nejm.org/doi/full/10.1056/NEJMicm1110569?query=TOC

Vasculitides

Vasculitides

Definition: immune-mediated inflammation of blood vessels
Classifications: by size of the vessel, anatomical location, and immunological findings

Large Vessel Vasculities

• Giant cell arteritis 
• usually > 50 yo
• inflammation of the temporal, vertebral, or ophthalamic arteries
• increased ESR
• histology = segmental
• Takayasu arteritis
• inflammation of the lg arteries branching from the aortic arch
• downstream ischemia causing blindness
• undetectable pulse in upper extremeties

Medium Vessel Vasculities

• Polyarteritis nodosa
• segmental nectrotizing inflammation of any vessel (most often kidney, heart, and liver)
•  affects young adults
• Kawasaki disease
• acute vasculitis
• primarily coronary vessels
• Thromboangiitis obliterans
• aka Buerger's disease
• acute and chronic inflammation
• inflammation that can spread to veins and nerves

Small Vessel Vasculities

• Wegener granulomatosis
• either acute or necrotizing
• prominent lung involvement
• Churg Strauss Syndrome
• necrotizing granulomatous
• affects vessels and surrounding tissues (usually heart and lungs)
• numerous eosinophils
• Microscopic polyangiitis
• usually affects the skin
• most caused by immune responses  

Photo source: http://www.wegenersgranulomatosis.net/5_autoimmune_vasculitis.php
Source: Hardcore: Pathology, Carter Wahl

Gross Anatomy Videos

University of Michigan Medical School has a wealth of medical resources online. One of the ones that I used most throughout school was the dissection videos. 

Medical Gross Anatomy - Dissection Videos

PA-C, Finally

So I graduated, took the PANCE, passed... and now I'm a PA-C. Some how "Physician Assistant, Almost There" was no longer an appropriate title for my blog. I thought long and hard before changing it to "Physician Assistant, Finally There" and decided to make the change subtle because I don't really want much to change about my blog now that I'm a certified. I hope to keep the blog alive as the same resource it has always been. I'm always seeking new websites/apps/books that will increase my medical knowledge and I will always have a desire to share them with YOU, my future colleague.

Thanks for all of the continued support and emails. I hope that this blog can continue to be a great resource for all that visit.

Have You Backed Up Your Data Lately?

Have you backed up your computer lately? If you are like me, the majority of your "PA life" is on your computer... notes, e-text books, audio recordings, resume, cover letters, fun pics documenting the year, etc... What would you do if you couldn't turn on your computer tomorrow? Personally, I'd cry. I bring this up because it happened to a couple of my classmates in PA school and I felt horribly for them. I think it only makes it worse when people say after the fact that they should have backed it up. Ha. Hindsight is 20/20. SO, here is my pitch to you to back your stuff up NOW.

If you have a Mac - life is easy. You just need an external drive that is bigger than your hard drive and Time Machine does all the hard work. You just need to remember to plug it in! It even reminds you every 10 days that you haven't backed up in a while.

Pro of Time Machine: it backs up your entire computer, including your operating system
Con of Time Machine: you are reliant on an external hard drive - if that fails - you're out of luck

If you have a PC or would like an alternate to Time Machine there are some online back up systems available. Carbonite, Mozy, Centurylink are a few of the more popular ones. I suggest Googling them to see which one fits your needs/budget.

Pro: Runs in the background and constantly keeps things up to date. File accessible from iPhone/iPad, etc.
Con: Cost. Carbonite runs about $153 for a 3 year subscription. Security. Each of these companies say that their information is super secure, but it is alway a little weird to give all of the information from your computer to an outside entity.

The last alternative is to back up your most beloved files on a CD or DVD.

Pro: Cheap.
Con: Limited space unless you use lots of CDs/DVDs to back up. Can be wasteful if you are changing your files regularly.




I am in no way, shape, or form receiving financial reimbursement from any of the online storage companies that I mentioned in this blog. Just some suggestions.

PANCE REVIEW: Train Your Brain

Here are some more Word-Associations for your PANCE studies... I'll add any tricks that I have found or come up with to remember them. Remember, these are meant as a study tool. Read the entire question and use your clinical know-how to determine your final answer. These are in no particular order:

Retinal Artery Occlusion = cherry red spots [When I think artery, I think RED]
Retinal Vein Occlusion = blood and thunder

Hordeloum = Hurt (painful)
Chalazion = painless

Viral conjunctivitis = preauricular lymphadenopathy + bilateral + watery discharge
Bacterial conjunctivitis = purulent discharge

Macular degeneration = drusen deposits/central vision loss

Rinne/Weber - Conduction/Sensorineural 

Epiglottis = thumb print sign/tripod/drooling

Oral white patches
Candidiasis = uncomfortable/Can be scraped off
Leukoplakia = painless/cannot be scraped off (Left on)

HypOparathyroidism = + Chvostek's sign/Trousseau's sign [due to low Ca+]
Hyperparathyroidism = "bones, stones, abdominal groans, psychiatric moans, and fatigue overtones"

Essential tremor = can temporarily gets better with ETOH

Eczema = flexor surfaces
Psoriasis = extensor surfaces

Actinic Keratosis = sun exposure/pre-cancerous!

Seborrheic Keratosis = greasy/ "stuck on"

PANCE REVIEW: Pesky Vertigo

I can never keep these straight. Every practice exam I'm cursing myself when I get these wrong - so I finally decided to make a chart and learn them.

A couple tips to narrow it down:

*Those with the red circle are SUDDEN onset
*Those with blue circle involve hearing loss - so if it is sudden with hearing loss... you're down to Meniere's!

Source: AAPA and PAEA book

My Blog, the Mobile Version (New)

The new mobile version of this blog is up and running! Bookmark it!

PANCE: Buzz Words

When studying for the PANCE it is difficult to "know it all" - sometimes you need some helpful hints to jog your memory or lead you in the direction of a likely answer....  The following list contains some word association stuff that may help for which organisms in pneumonia are most common in particular populations. Word association is no substitute for knowing and understanding the clinical scenario, but it may help you narrow down the options.

I will put a list here... quiz yourself (see below for answers):

Which pneumonia organisms would you match with the following patient populations or buzz words?

1. ETOH 
2. COPD
3. Air conditioners/cooling systems
4. Cystic fibrosis
5. Asplenic
6. College
7. Leukemia
8. Kids < 1 yo
9. Kids > 2 yo

 Answers:

1. ETOH = Klebsiella
2. COPD = Haemophilus influenza (H.flu)
3. Air conditioners/cooling systems = Legionella
4. Cystic fibrosis = Pseudomonas
5. Asplenic = encapsulated organisms (strep pneumo/H.flu)
6. College = mycoplasm pneumo or chlamydia pneumo (longer prodrome, sore throat, hoarseness)
7. Leukemia = fungus
8. Kids < 1 yo = RSV
9. Kids > 2 yo = parainfluenza virus

Delirium vs. Dementia

Source: PSYCHIATRY for Medical Students and Residents Nabeel Kouka, MD, DO, MBA (available for free online)

PANCE REVIEW: Jones Criteria

Is it rheumatic fever or not? You need to know the Jones Criteria to make the determination.

Source: AAPA/PAEA Exam Review Book, PANCE review lecture by Janice Herbert-Carter, MD, MGA, FACP

Difference Between OCD and OCPD

What is the difference between Obsessive-Compulisive Disorder (OCD) and Obsessive-Compulsive Personality Disorder? Here is a chart that I found that explains the differences in an easy to understand manner:

Source: PSYCHIATRY for Medical Students and Residents Nabeel Kouka, MD, DO, MBA (available for free online)

Free Ophthalmoscope App

"The Virtual Ophthalmoscope is a free, educational resource for the clinical ophthalmologist. The Virtual Ophthalmoscope features a library of more than 50 clinical cases with high-quality, zoomable images and commentary from a leading consultant ophthalmologist.  Available on iPad and iPhone

This app is provided as an educational service by Alcon UK. It is intended for healthcare professionals only. Not for patient use."

iTunes Link

PANCE REVIEW: Dyslipidemia Drugs

Excellent (FREE) Resource for Rotations

I love resources that make my life easier. I love them even more if they are free. The University of Washington put out something called The Turkey Book - which is basically a truncated resource for your clinical rotations as a student. Lots of "need to knows", charts, answers to potential pimping questions, and a good variety and I highly recommend taking a look at it before you begin your rotations.... and keep looking at it during your rotations! It has everything from EKG tips to family medicine to pediatrics to OB/GYN to radiology. It offers help on presenting a patient and writing your notes.