tinkle tinkle...

This post is a quick notes version regarding cystitis/pyelonephritis:

DYSURIA with vaginal irritation correlates with a > 90% diagnosis of cystitis. This can occur with a NORMAL urinalysis.

Yeah, I know there are dipstick tests and what not, and the overall specificity and sensitivity is okay, but if you have a patient that gives a correlating history it's still cystitis.

cystitis vs. pyelonephritis, what's the difference?
Classic S/Sx of pyelonephritis:
fever
n/v
CVA tenderness

Remember, PYELONEPHRITIS A CLINICAL DIAGNOSIS!!! You can have a patient who is afebrile, non-toxic appearing that complains of flank pain, positive U/A. You can diagnose as pyelonephritis.

U/A (catheter specimen if female on menses). Let's narrow down on the pertinent results:
1) Urine RBC
2) Urine WBC
- Pyuria (the most specific finding!)
- must be >10
4) Urine Leukocytes
- size of WBC, doesn't mean much.
3) Urine Nitrites
- Positive nitrites is HIGHLY specific!! Odds are you have Pseudomonas, Enterococcus, or Acinetobacter.
4) Squamous Epithelium
- Squamous epithelium....so annoying. If you have any concerns of pyelonephritis, get a catheter specimen.
5) Urine Bacteria
6) Urine pregnancy

DO NOT FORGET TO SEND THE URINE FOR A CULTURE. 

Renal Function to r/o acute renal failure:
BUN/Cr
GFR


CBC r/o sepsis:
WBC
H/H


REMEMBER, think about urine in the ELDERLY with a fever of unknown origin, or altered mental status.

Literature states asymptomatic catheter associated UTI do not require treatment.

What about incidental findings? asymptomatic bacturia (no fever, suprapubic tenderness) is only treated during PREGNANCY!!

Differential:
PID- Unfortunately suprapubic pain will warrant a pelvic exam.
vaginitis
urethritis

If the patient continues to have symptoms after 48 hours of antibiotic treatment, CT ABD/PELVIS to r/o anatomic anomalies, obstructed stone, papillary necrosis, abscess.
If there is hematuria and flank pain, get a CT ABD/PELVIS. 

Treatment:
Simple cystitis (no concerns for pyelonephritis, no pyuria)
TMP-SMX (Bactrim)160/800mg BID x 5 days if a good first choice for simple cystitis (no concerns for pyelonephritis).

Nitrofurantoin (Macrobid) 100mg BID x 5 days is another good choice for simple cystitis (and for asymptomatic preggers!)

Complicated cystitis/pyelonephritis (fever, pyuria, CVA tenderness, known anti-biotic resistance, patient already being treated 48-72h):
Ciprofloxacin 500mg BID x 10 days for D/C medication.
Rocephin 1gm IV OR Levaquin 500mg IV once in ED
Remember this is the ED, the mindset will be assume the worst.

Side note: I highly suggest you look at your nearest medical center's antibiogram before giving antibiotics. You'd be surprised what you find.

When to admit:
Altered mental status
intractable vomiting
pregnancy
Sepsis, shock, acute renal failure, blah blah blah.

References:
Cline, D.M., Ma, O.J., Cydulka, R.K., Meckler, G.D., Handel, D.A., & Thomas, S.H. (2012). Tintinalli's Emergency Medicine Manual (7th ed.) McGraw Hill Professional: Columbus, OH.

Hooton, TM, Gupta, K. Acute Uncomplicated Cystitis and Pyelonephritis in Women. In: UpToDate, Basow, DS (Ed), UpToDate,Waltham, MA, 2012.

Hooton, TM. Acute Complicated Cystitis and Pyelonephritis. In: UpToDate, Basow, DS (Ed), UpToDate,Waltham, MA, 2012.

Poop, part 2

soap suds enema seems to work best for me. I'm not a fan of Enemeez®....let the nurse do the rest. You don't have the time to be picking away at the bedrock of stool when you have all these other patients that require your attention.

Pediatric constipation:

It happens, more often than not it isn't Hirschsprungs.

I. do a rectal temp, sometimes that's all you need
II. stick your pinky in there to confirm the stool is soft.
III. sorbitol-containing stuff
   A. Sorbitol 1-3mg/kg/day
   B. Lactulose
   C. prunes, peaches, pears, etc.
IV. Glycerin suppositories
V. Osmotic laxatives

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN). (2006). Clinical Practice Guideline: Evaluation and Treatment of Constipation in Infant and Children: Recommendations of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition. Journal of Pediatric Gastroenterology 43:e1-e13.

References:
Cline, DM, Ma, OJ, Cydulka, RK, Meckler, GD, Handel, DA, & Thomas, SH (2012). Tintinalli's Emergency Medicine Manual (7th ed.) McGraw Hill Professional: Columbus, OH.

Ferry, GD. Treatment of Chronic Functional Constipation and Fecal Incontinence in Infants and Children. In: UpToDate, Basow, DS (Ed), UpToDate,Waltham, MA, 2012.

Ferry, GD. Prevention and  Treatment of Acute Constipation in Infants and Children. In: UpToDate, Basow, DS (Ed), UpToDate,Waltham, MA, 2012.

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN). (2006). Clinical Practice Guideline: Evaluation and Treatment of Constipation in Infant and Children: Recommendations of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition. Journal of Pediatric Gastroenterology 43:e1-e13.

What's in a Criteria?

To scan or not to scan, that is the question....
One of my attending physicians made a good point, everything that we do is about risk stratification and playing the odds. There are no definitive answers.






New Orleans (applies ONLY if GCS 15). If positive for just ONE of these, CT!
1) Headache
2) Vomiting
3) >60 y/o
4) Drug or alcohol consumption
5) persistent anterograde amnesia
6) visible trauma above clavicle
7) seizure

Subdural

Canadian (applies to GCS 13-15 after LOC, amnesia to event, or witnessed disorientation from trauma). If positive for just ONE of these, CT!
1) GCS less than 15 at 2 hours post injury
2) suspected open or depressed skull fracture
3) any sign of basilar skull fracture (racoon eyes, battle sign, hemotympanum)
4) >2 episodes of vomiting
5) > 65 y/o
6) retrograde amnesia of 30 minutes or more
7) "dangerous mechanism" (i.e. auto vs. pedestrian, fall > 3 feet or five stairs)

Subarachnoid

PECARN
Pediatrics is the tough one, as the risk for radiation induced malignancy increases as age decreases (roughly 1:1000/5000).  This applies for suspected head trauma less than 24h old:

Check out Dr Michelle Lin's blog for some great info, or
Click below to get calculations of exposure:

References:
Ebell, MH. Computed Tomography after Head Injury. Am Fam Physician 2006 June 15; 73(12): 2205-7. PubMed PMID: 16836038

Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. Epub 2009 Sep 14. PubMed PMID: 19758692.

Poop, part I

Ohhh emergency medicine...the good, the bad, the stinky

1) Why? It's all in the HPI!
- new drugs? (narcotics, anti-psychotics, anti-histamines)
- H/O constipation?
- weight loss? changes in stool (colon cancer!)
- passing gas?

2) What's going on in there? Rectal exam: gives you an oppotunity to rule-out other diseases (i.e. hemorrhoids, anal fissures, abscess).
 - can you palpate stool? masses?
 - soft? hard?

3) Further work-up?
- if you can find out the cause, this may not be necessary
- is the abdomen distended? vomiting? Think obstruction, get a KUB/Abdominal Series
- is constipation the only complaint? maybe you want to check the thyroid too
- concerns for 



Here are tools of the trade (funny how we have so many for constipation)
I) Fiber
   A) bran muffin, oatmeal, prunes, etc.

II) bulk forming laxative
   A) Psyllium (Metamucil®)
   B) wheat dextran (Benefiber®)

III) Stimulants (also known as anthraquinones)
   A) bisacodyl (Ducolax®)
   B) senna (Senokot®)

VI) stool softeners

   A) Docusate sodium (Enemeez®, Colace®)

   B) Glycerin suppository

V) Osmotic agents
   A) Lactulose (Enulose®)
   B) Sorbitol
   C) polyethylene glycol (GoLyteLy®, Miralax®) - 17g PO
   D) saline laxative
      i) Milk of Magnesium -15-30mL/day)
     ii) Magnesium Citrate -240mL PO once)

VI) enema
   A) Enemeez® (see above)
   B) mineral oil 
   C) soap suds (1500mL PR)
   D) phosphate (Fleets®)
  
Treatment:
Lifestyle: dear lord please drink water!!, eat some fiber (20-25g/day)!

Analgesics:
If they're on pain meds, please give them something extra... I think all the elderly should get something if on narcotics. In my surgery rotation is was routine to give Colace with Norco, but is that enough?  Dr. Orman from ercast.org notes that giving colace does nothing but leave soft stool in the colon. This does not help get the stool out, adding a stimulant like senna will improve gut motility.Unfortunately, this will add to the number of pills they will take. So I like the GoLYTELY combination:

POLYETHYLENE GLYCOL (17g/1 glass of water) PLUS SENNA (15mg/daily) WITH ALL NARCOTICS


next, the fecal disimpaction.....

Negotiations

1) Practice
  A) other PAs? Are you the only midlevel, will you be interacting with other midlevels?
  B) who are your supervising physicians? are you PA for a single physician or the group?
2) Experience with PAs. Are you going to be the first PA they hire?
  A) orientation program in place?
  B) Delegation of Services Agreement
3) Salary
  A) hourly vs. salary
  B) vacation time
  C) CME reimbursement. While you are on the subject, might as well ask if they will pay uniform and DEA stuff.
  D) re-evaluations? every 6 months? 1 year?
  E) Are you an employee or a partner?
  F) profit sharing?
  G) loan repayment? And if so, what is the time committment?
4) Orientation
  A) is there a transition period to give you time to learn? Have realistic expectations for yourself but keep your employer in mind. It would be a good idea to have 1-2 months of orientation before you start seeing patients for yourself.
5) EMR. Odds are that you will need some sort of training on this.
6) Hospital privileges?
7) Expectations
  A) what are they expecting from you? Are they expecting you to see 20, 30 patients a day? Are you expected to do preliminary readings for imaging? What about hospital admissions?
  B) patient load?
  C) on-call schedule?
8) Malpractice
  A) who is the carrier?
  B) what is the coverage?
  C) how much?
  D) tail-coverage?

This is just an outline of what to expect. There is considerable variances, depending on if you'll be in surgery vs. dermatology. I think the most important thing as a new graduate is to take a look at the work environment, a good indicator is how the other medical staff is being treated. If the MAs look disheveled and unhappy, odds are that you will too. Be realistic about your productivity and make sure you can communicate with your employer and supervising physician. If you can't talk to them because they keep blowing you off, what's going to happen if you have a sick patient and need advise?

The Transition

I was so excited when I graduated from my program..freedom from CDMT and Harrison's.

I couldn't wait to relax and party.......



but the truth is, the end of the road is CLOSE!
Here's a checklist of what's next:

1) PANCE
2) state license
3) NPI
4) DEA
5) Credentials
6) BLS, ACLS


1) PANCE. cost $475
   http://www.nccpa.net/Pance.aspx

2) state license (I only included CA and NV, each state varies!)
  A) California Department of Consumer Affairs. cost $225-274.
        1) Notarization. cost $10-25
        2) LiveScan fingerprint. cost $20-40
http://www.pac.ca.gov/applicants/applicant_faqs.shtml

  B) Nevada. cost $300
       1) registration fee $400
       2) background fee $75
       3) REQUIRES A SUPERVISING PHYSICIAN FOR STATE LICENSE.
       4) REQUIRES EVIDENCE OF MALPRACTICE FOR STATE LICENSE.
       5) Notarization. cost $10-25
http://www.medboard.nv.gov/New_OtherForms.htm

3) National Provider Identification. This is your unique identifier when billing medicare.
  A) requires state license
  B) notarization. cost $10-25
https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do

4) DEA. cost $731/3 years
http://www.deadiversion.usdoj.gov/drugreg/reg_apps/onlineforms.htm
  A) controlled substances course (CALIFORNIA ONLY). cost $180-310 (OPTIONAL)
http://www.capanet.org/Conferences/Controlled-Substances-Education-Course/

5) Credentials. If you will be doing any inpatient care, you will have to apply for privileges at that medical center. This is a long process, anywhere from 2-4 months. cost $100-400.
  A) Background check. cost $75-100

6) By know your BLS has expired, and you'll need to renew. Depending on what position you take, ACLS may be required.
  A) BLS/ACLS. cost $85-250.


Total cost...at least $1731.
Being a physician assistant, priceless.


Now this is variable, some providers will help you pay for somethings. You may end up in outpatient and won't need hospital privileges. Others will reimburse after a period of employment....Your mileage will vary
This isn't intended on scaring you, but it's a reminder that you will still have costs when school is out.
Please plan accordingly because there may be a lag-time between getting hired and jumping through all the loops to get all the legal stuff out of the way to practice medicine.

Blood Transfusion Consent

Remember the "10/30" rule?

Tips on what to cover when obtaining consent:

1) Discuss Risks:
           HIV   1:2,000,000
           HBV  1:300,000
           HCV  1:2,000,000
          HTLV 1:2,000,000

2) Type and cross to prevent complications such as acute immune hemolytic reaction.

3) Some patients may experience a fever/chills and dyspnea. Most times it is a benign cause, but it is something we monitor (fever, non-hemolytic transfusion reaction).
Tx: stop transfusion, saline bolus, maybe ASA.

4) Transfusion Reaction: this can range from hemolysis, anaphylaxis, transient hypotension, fever, acute lung injury. It can also take up to 24 hours for reactions to present themselves.

References:

Kleinman, S, & Carson, JL. Indications for rec cell transfusion in the adult. In: UpToDate, Basow, DS (Ed), UpToDate,Waltham, MA, 2012.

WikEM

The fine folks down at UCLA have created a wonderful wiki site dedicated to all things emergency medicine. It's a great tool when you start seeing patients and want to double-check your differential diagnosis. Just click the image above ↑

I highly recommend you check it out. They even have apps for your smartphone, and it's FREE!

Ooowweeyyy

Pain control: it'll preserve your hearing, along with your sanity.

© Fox

™ Sony Pictures Television

Now I know what you're thinking, we're just fueling the fire for all those with opioid dependency. However, pain is pain. It is a subjective matter and passing judgement on your patient does nothing other than hurt the patient-provider relationship. Besides, you'd be surprised who the bad ones really are…





So let's figure out what we can do to really help those in pain: Here are the players:
I.   acetaminophen (Tylenol®)

II.  non-steroid anti-inflammatory drugs
     A. Ibuprofen (Motrin®) 
     B. Ketorlac (Toradol®)

III.  hydrocodone/acetaminophen (Vicodin®, Norco®)

IV.  oxycodone/acetaminophen (Percocet®, Roxicet®)

V.    morphine (MS Contin®)

VI.  hydromorphone (Dilaudid®)
    A. 10mg inj morphine = roughly 1mg inj.hydromorphone

VII. oxycodone (oxyCONTIN®)

VIII. meperdine (Demerol®)

IX.  fentanyl (Sublimaze®)
    A. 100x stronger than morphine, but an rapid half-life

There’s a lot more, but I’m no pharmacist (I don’t think I could even play one on TV)…so let’s look at these patient populations:

MINIMUM dosing for morphine is 0.1mg/kg IV! (children and adults)
If you have a 300lb. female who presents with abdominal pain, 4 of morphine just isn’t going to cut it. In fact, 1mg of hydromorphone may not either…

300lb/2.2= 136kg x 0.1mg/kg= 13.6mg morphine

hydromorphone- 0.0125 mg/kg IV
300lb/2.2= 136kg x 0.0125mg/kg= 1.7 mg hydromorphone
Children
Acetaminophen- 15mg/kg PO
Ibuprofen- 10mg/kg PO
Intranasal fentanyl- 1-2mcg/kg 
Intranasal fentanyl is a great way to take the “edge off” if you need to do a procedure on a little kid. Give a lil’ spray in each nostril, stick a lollipop in their mouth, and call it a day (personally I'm 0/2).

Another option is intranasal midazolam (Versed) 0.5mcg/kg (maximum dose 10mg/kg)

Adults
Avoid Ibuprofen if concerns for GI bleed/diverticulitis/ulcers (think elderly)
Acetaminophen has concerns for hepatotoxicity in doses greater than 4g/day

RUQ pain
I added this section as a little reminder, there are concerns with giving morphine and spasm of the sphincter of Oddi. This MIGHT exacerbate pain for someone with biliary colic/gallbladder disease or pancreatitis. In the end it’s your clinical decision, and I’ve seen providers give morphine without problems. Try D/C home with ibuprofen 400mg PO for pain, Vicodin® for severe pain.

Alternatives:
Meperidine 50-150mg slow IV push (Beware: serotonin syndrome!)

Ketorlac (Toradol®)- 30-60mg IM

hydromorphone- 1-2mg IV

Don’t forget to make these patients NPO and hydrate!

Angina
morphine has been considered standard treatment for chest pain (remember M.O.N.A.?) for two reasons:

Step 1: Treating pain will decreased anxiety. Decreasing anxiety will calm patient down and reduce catecholamine secretion.
Step 2: Decreasing catecholamine secretion will lower heart rate and blood pressure. This will allow for improved blood flow and help maintain perfusion in a heart may have been damaged by infarction.

2-4mg IV q5-15 mins., can increase 2-8mg until pain relief.

Methadone
So anyone on methadone has been dealing with chronic pain for some time now, and hopefully pain management is following. Methadone has a long half-life.These people are going to be in pain! The standard algorithms for pain management DO NOT APPLY (I learned the hard way, my poor patient. it took 4mg dilaudid). Talk to your patient; how much methadone are they on? For how long?

You can give a 100lb. patient 2mg Dilaudid without breaking a sweat, but discuss this with your attending/supervising physician first!

Side effects:
Please don’t forget nausea/vomiting is a common complaint, especially for the opioid naive. Anti-emetics should routinely be dosed with narcotics:

Ondansetron (Zofran®) 4-8mg ODT (avoid in those with arrhythmia)

Metoclopramide (Reglan®) 10mg inj.(great for those with gastroparesis, constipation. Beware dystonia)

Promethazine (Phenergan®) 12.5-25mg inj. (Beware x 2! for dystonia)

Sedation, monitor your patients. Please don't turn them into respiratory depression...


Pain scale:

Ketorlac→  Morphine →   Hydromorphone → Lorazepam (Ativan®)

Allie Brosh

I hope this helps as you attempt to provide some pain relief for all your patients flooding in the ED:






There’s also the topics of conscious sedation, but that is beyond me and I would refer to your attending/supervising physician.


References:
 
http://www.med.umich.edu/1info/FHP/practiceguides/pain/dosing.pdf
UptoDate®
Cline, D.M., Ma, O.J., Cydulka, R.K., Meckler, G.D., Handel, D.A., & Thomas, S.H. (2012). Tintinalli's Emergency Medicine Manual (7th ed.) McGraw Hill Professional: Columbus, OH.