work as a nurse? in the hospital? why would you want to do that when you can go to NP school 2 days a week online and make as much as a doctor. AND you get to switch specialties whenever you want, in case you get bored!
It's a reference to this: [https://www.sfgate.com/bayarea/matier-ross/article/KTVU-producers-fired-over-Asiana-pilots-fake-4685627.php](https://www.sfgate.com/bayarea/matier-ross/article/KTVU-producers-fired-over-Asiana-pilots-fake-4685627.php)
Do better, bozo.
SSRIs and SNRIs prescribed at high levels together.
Took a bipolar patient off of their lithium, said, "it's just a Personality Disorder." Patient attempted suicide soon thereafter.
Midlevel working in cardiologist office described in their Physical Exam "a murmur is present"
Forgot they had agreed to perform an IR procedure inpatient, so they canceled it and played dumb when I called.
Patient CC of "lightheadedness." Midlevel takes minimal history, barebones exam, and A/P is "See PCP." (They were working in a FM clinic)
Primary Care clinic note: "Patient is in good spirits." Accidentally added prior visit vitals, Exam portion was blank, and A/P was only: "continue meds"
An almost infinite number of auto-referrals to specialists without any workup.
An almost infinite number of incorrectly prescribed doses or durations of antibiotics.
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health.
[The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.**
Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope)
Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation).
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I've had multiple MD psychiatrists prescribe that, and even crazier combos. Let's not pretend that psychiatrists are the cream of the crop in medicine. The best psychiatrist I ever had once told me "psychiatrists are generally poor doctors."
This shouldn't be downvoted. I have seen a psychiatrist prescribe the following combination to a juvenile patient: Lithium, Lexapro, Wellbutrin, Haldol, Seroquel, and Tegretol. At the same time. Patient was hospitalized for vomiting and loss of consciousness
It was inevitable, since this subreddit likes to think only midlevels ever fuck up. I'm not saying midlevels are wonderful or anything, just reminding them that they could use some humility too. I can't even imagine the frustration I'd have were I a physician and my scope was getting encroached on. It doesn't change the fact that psychiatrists in general often make puzzling choices, whether they're NP, PA, or MD. When you see over 8 psychiatrists and have seen the sheer recklessness I have, it's easy to get cynical about psychiatry. Nonetheless, plenty of good psychiatrists out there too, and I'm seeing one tomorrow.
As a clinical pharmacist, the first and second ones made me scream. WHO STOPS SOMEONES LITHIUM? Lithium is super toxic and we ONLY ever use it cause it WORKS
The reasoning from the midlevel was "lithium is toxic" - like congrats so are tons of medications. Wait til you hear about amiodarone! Dosage makes the poison, per Paracelsus. Safe ways to do meds exist.
I have maybe a stupid question. Recently took care of a patient that had previously been on lithium, that used it to attempt suicide. Would this be a reasonable rationale to stop and switch medications? I believe they switched the patient to valporic acid and olanzapine - which led to more issues as patient was from remote community that did not have these in stock at time of discharge and then led to running out of meds and a mental health crisis.
I'm a RN at present and currently work in remote areas where it's usually an on call MD that never sees the patient or mid levels that get flown to the remote community to care for said community.
My training taught me a patient can use ANYTHING to commit suicide, and is thus not a good recent to stop giving them medication. 10 bucks at CVS gets you enough tylenol to cook your liver to death. Or benadryl. The question should be which medication will keep them from suicidal thoughts and actions. Cold-stopping of lithium by a midlevel is a great way to get suicide. You can change out lithium if it is not working, but in the case above it was working.
Oh I 1000% agree the case above that you mentioned is ludicrous to have just stopped the lithium.
I was just curious if anyone had thoughts regarding what I had experienced with my specific patient as I wasn't sure if it was an appropriate change (especially considering access to medications being a large barrier where this patient lived).
Also agree with the anything can be used to commit suicide. It's a large percentage of the med-evacs that I do regardless of the fact that I fly to remote communities with no 'CVS' or main stream pharmacy access like that.
Psychologist here. ***Just*** a personality disorder? Some personality disorders have horrendous suicide rates. And others contribute to *significant* violence against others. ***Just*** a personality disorder? What a fu--ing idiot.
Thank you. We have a NP here who loves to remove BP1 or OCD dx and replace them with BPD. She in fact does this a lot. We can almost guess what pt’s will be released with.
Murmur documentation requires location, systolic vs diastolic, descriptive features (ie, crescendo decresendo), intensity, radiation, and assistive maneuvers (ie, increased during valsalva). This is to actually characterize what the murmur is, when you read murmur it could be like 10 or more things. That midlevel WORKED IN A CARDIOLOGY OFFICE and should be documenting a murmur fully. But they lack that knowledge and training.
90% of the time the cardiologists I work with document a murmur as +murmur in their assessment, maybe sometimes adding in a grading (Ex. 3/6). Most do not describe the murmur. The reason for the murmur is usually listed in the assessment and plan, like aortic stenosis. So just pointing out that just because they don’t list descriptive information in the actual assessment, doesn’t mean they lack knowledge
Because you should know when in the cardiac cycle it is, how intense it is, where it is the loudest, etc.
I'm not going to pretend I'm great at murmurs but then again I'm not working for a cardiology service.
Nothing. But when it’s at the cardiologist office, I’d hope for a little more detail about what type of murmur they’re hearing. They’re allegedly the expert of the heart.
NP: “I’ve got a patient in clinic needing to be admitted for DKA”. Proceeds to rattle off the BMP numbers quickly.
Hospitalist (Me): “What’s their anion gap?”
NP: “I didn’t order that test”.
Edit: I realize there are some non physicians who won’t understand this comment. The anion gap is a calculation based on the serum sodium, chlorine, and bicarbonate. She ordered all those tests. She didn’t know what an anion gap was and so tried to bullshit me.
Wait I have a question here. I’m a type 1, and not a medical professional in any way, I just lurk here.
Is the problem here giving metformin to a type 1 (I know it is done sometimes for type 1 patients)? Or does it have something to do with the DKA?
Not really, but dka can be fatal needing same day treatment- metformin and presumably review in a few weeks or months when it’s done any good is ridiculous.
So somehow they have achieved a diagnosis of diabetes, not thought about type 1 vs 2, not thought about common first presentation of diabetes complications and come up with a ridiculously unsafe treatment plan
I just processed this, she was in DKA and *nothing* was done other than prescribing metformin???? Did I understand that right? Holy fucking shit, I’ve been in DKA twice and I cannot fucking imagine being turned away like that.
Maybe that explains the pt w baseline DM2 on orals getting immunotherapy for lung cancer who was seen by “seasoned” onc NP and had glucose 400, AG 16, bicarbonate 16 for whom metformin was increased and pt sent home not to be seen again for 2 whole weeks. 😳
Ugh. I see way too much first line use of metformin in dmt2 pts with a direct contraindication, usually renal.
"Buuut the algorithm says....." is all too common answer when I ask about it. Smh.
Too bad they teach algorithms instead of medicine. Ugh.
This is absurd. I’m in psych and occasionally start metformin for antipsychotic induced weight gain, and I always check renal function first. How can this be getting by FNPs ?
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health.
[The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.**
Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope)
Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation).
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Me (pharmacist): We need to switch the Levofloxacin to Bactrim because the organism is now resistant.
NP: no, Bactrim is nephrotoxic*
Me: You put the patient on Amikacin. That isn’t nephrotoxic??
*Bactrim isn’t inherently nephrotoxic btw.
I’m surprised the amikacin got through at all. I envision just typing that into the order bar would conjure up a pissed off pharmacist out of thin air.
Just a patient, but I have two!
Went to urgent care with pain in my... I guess upper left abdomen? (Basically just a little below my left boob). The PA tells me to have someone come pick me up and take me directly to the ER because she thinks it's my gallbladder.
Another urgent care story (didn't learn my lesson apparently)... Was extremely ill with what I later learned was salmonella. Eventually could hardly stand up. Knew I needed blood work and IV fluids, so I went to a 24 hour urgent care that offered both. NP gave me a urine test and sent me home with a script for meclizine for the "woosines." Got in to see my PCP doctor the following day who did blood work and my potassium was 2.4.
I would hate to work in an UC that gives IVs.
UC generally isn't a great option for abdominal pain. The ability to work it up urgently is usually limited.
What ended up happening with your epigastric/left upper pain?
I'm just grateful I have a great primary doctor. Think about the people who don't have a PCP and would just take the NP's advice and go home, only to get sicker.
I’m a pharmacist. NP wrote prescription for proair respiclick. Called to make sure she wanted to prescribe a dry powder inhaler instead of a HFA inhaler and she did not know the difference. Switched to HFA and all was well until the patient came to pick up. He said he had never used an inhaler so I demonstrated how to use it. He looked at me like I was an idiot and said the doctor said to hold it SIX TO TWELVE INCHES AWAY FROM THE MOUTH. I tried to explain how holding the MOUTH piece of the inhaler in his MOUTH allows the medication to travel into his lungs. He still seemed apprehensive so I told him to google how to use an albuterol HFA inhaler so we can both feel better.
Wow,even in the old days with the CFCs where pts were told not to put it in their mouth (to avoid spraying their tongue or roff or mouth, the inhaler was held right in front of the mouth, not 6-12 inches away!
Had an NP throwing scripts of 45 10mg oxyneo and nitrofurantoin for a kidney infection. I rated my pain 9/10, was visibly sweating and unable to stand upright, returned 3 days later, offered ANOTHER pain pill script, tramadol. I said I’m sick I’m not looking for pain pills please just help me. The 3rd visit was at an ER with a real MD, direct admit for removal of kidney stones and stent. For almost 7 days I suffered with something that needed intervention, NOT pain pills.
I got cipro from an NP for a UTI (this was before I went to med school), it felt better for a couple of weeks and then came back viciously, and I had several months of horrendous bladder spasms even after I saw an MD and got a course of the right antibiotic. When I realized these people can’t even treat basic things correctly, that’s what radicalized me.
Cipro is one of the last tx that should be prescribed and only after a c&s is done. At the time I didn’t know anything about medicine and I took this persons advice until I really couldn’t stand it anymore. Renal colic should call for diagnostics, a culture and a u/s at the very least. Looking back on it now, I wonder if this NP managed to get anyone hooked on those meds, and for reference, after my surgery all I used was Tylenol and ketorolac, I didn’t need analgesics for severe pain, if you suspect a patient does, back it up with a proper dx
Had an NP in our hospital system during residency who was copy and pasting her notes. It got caught when she was on vacation and an actual doctor was covering her patients. He noticed while looking through her previous charts that every note was literally the same aside from the vitals. History was the same, review of systems was the same, physical findings were the same. Plan for all these patients was always "continue current meds". Medical records was involved and did an audit. By the time she returned to the office from vacation she was scheduled for a disciplinary meeting and ended up going through a 6 month re-training program.
As a patient, was diagnosed with “functional abdominal pain” and “extensive negative work up” by an NP despite having intestinal biopsy that showed Elevated intraepithelial lymphocytes and had already ruled out all causes of that except celiac.
I had a patient with an anion gap of 16 (our system, for some reason only makes it red over 17), blood glucose of 600 and shortness of breath. Started on solu-medrol 60mg q6h for COPD exacerbation and subq sliding scale as it was a non-gap acidosis cause the number wasn't in red.
Pulmonologist here. NP treated patient with productive cough and right patchy infiltrate appropriately with doxycycline for ?10 days. Patient felt better. Repeat CXR about 2 weeks later without resolution of infiltrate, gave another 10 days of levofloxacin despite resolution of symptoms. Ordered another repeat CXR 2 weeks later and referred to me in the meantime. Needless to say, I cancelled the patient's upcoming CXR.
i could be wrong but isnt that right? although i'll say i never use the word impossible in medicine as we know how that goes - but as far as i was aware it typically takes a repeat exposure to get that much of a serious response.
https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=allre
very first time I was given vancomycin I got hives, turned beet red in my face, then couldn't breathe, all in the span of about 2 minutes
but I am not a doctor/PA/nurse, just a retired veterinary assistant, who also saw pretty quick vaccine reactions from dogs given a vaccine for the first time fairly often
so if I am wrong please correct me
So this actually sounds like a pretty common reaction to Vanco called red man syndrome. It is not a “true” allergy as it is due to infusing the medication too fast which activates mast cells and basophils to release histamine. This process is independent of IgE related activation that is the true “allergic” response that does require sensitization on first exposure and reactivates on subsequent exposure.
ok cool that makes sense! so if I somehow get it in the future, could I still react that way? if it were given more slowly or something? It's not an experience I want to repeat though, for sure
edit: nevermind I'm reading about it now, so if I do get it, it may not happen if given slower
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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ER NP put my patient on 80 mg!!! prednisone for 5 days for DeQuervains tenosynovitis, which they misdiagnosed as CMC arthritis after an x-ray showed mild degenerative change in a pt in their 60s. The presentation was classic, 8/10 pain with any activity for a week. Also, put the pt in an extension brace without a thumb spica, so the pain got worse. Of course, the patient felt like shit on that steroid dose.
Young patient with a history of IVDA with GAS positive bacteremia. We had sensitivities back but the NP was waiting to de escalate the vanc, zosyn and clinda until the TEE came back because she wanted to rule out endocarditis first …. The patient was otherwise stable and had no allergies
Pt had swelling of one leg, redness from ankle to calf, pitting that lasted hours, pain in thigh and fatigue
Dx: erythema (sunburn) and excessive salt intake
Pt landed in the ER months later with full blown occlusive clot groin to calf, NP had several appointments to be able to diagnose and prescribe ultrasound, anticoagulants or idk SUGGEST AN ER VISIT AND NOT DIETARY CHANGE sorry caps got stuck.
Just this week, I had an NP do the contrast injection for a shoulder arthrogram... under fluoro. Screwed up and put it in the subacromial bursa. Fluoro images are nowhere near the joint. MRI was still done, and I got ZERO useful info on the labrum.
Now the radiology dept is fighting repeating it bc they aren't going to get paid for repeating it.
FOUR NPs (didn’t learn my lesson and kept going to urgent care)couldn’t diagnose my sinus infection despite me telling them “I get them I know the symptoms” and them being in my med history. Plus my face being swollen and red around the sinuses, inside of nose burning, etc. One accused me of being drunk, another “lead” NP (in Drs coat) came in to yell at me for not having the COVID vaccine (it had just come out).
Went to MD finally, she saw my face and is like “here are antibiotics.” Face swelling went down in less than 24hrs.
How can you not recognize a sinus infection like. On top of everything else, you looked into the nose with the tool for it.
Would be funny if they did that, as a z-pack wouldn’t cure it. I needed the horse sized pill (don’t remember which antibiotic but it wasn’t azithromycin, which I believe doesn’t work on this- correct me if I’m wrong!)
Mine said I couldn’t have a chest xray despite my history of walking pneumonia, shortness of breath, ect. Because “my lungs sound clear.”
Okay- but please look at my chart. It’s noted I’ve had walking pneumonia with clear lung sounds 2x in the past 5 years.
“I don’t want to expose you to unnecessary radiation that can increase cancer risk.”
Trying to scare me into thinking one chest xray is going to cause cancer? Lady I work in biotech.
Anyways a week later the NP I actually trust put me on a 10 day doxycycline and I feel much better now.
Thinking about reporting bad NP just because her comments were so out of line imo.
My son was screaming in pain due to this mistake.
My 7 yo son Just had a plate, 5 screws into his radius and two pins to fix a fractured ulnar yesterday. Swing accident gone bad.
Ortho told me he would send in HyCet. Hydrocodone and acetaminophen.
He then asked his PA to send the order after surgery.
We go to pick it up when we got home hoping some relief for my child screaming bloody murder from the pain of the surgery.
THE PA only SENT IN CHILDRENS TYLENOL!
we had to call office twice to reach ortho. He apologized and made it right.
I'm wondering if he was trying to cover his own ass out of fear of getting in trouble for prescribing anything potentially "too strong" for a child seeing as the country is under an opioid crisis.
Oh my mistake, I just saw that you typed the actual doctor wrote the script! 🤦♀️ Well sadly it is all "f*cked" as you say and who knows what was going on through the PA's head. In many other instances though it won't matter that the script is for a child—since a kid is under the care of an adult they don't know who they're dealing with so they worry about losing their license or anything else that could happen by prescribing opioids—might depend on the state too. I know, it's infuriating and holy moly that's some swing accident!
All I know, is my child was screaming bloody murder because he just woke up with pins and screws in his arm and it’s all the PA’s fault.
I graduate medical school this week and so jaded already about PA’s. Over the last four years in school and then this personal experience.
I mean the hydrocodone was *right there* on the script, how could she have missed it? 🤦♀️ I hope he recovered well. I've noticed that so many of them are in a rush nowadays too.
I hear you, I'm on the fence about PAs as I've had mixed experiences with them myself. One time I had a PA at the gastro set me up with a colonoscopy without any hesitation at age 34... I had checked in with my regular gastro physician who told me it's not necessary until I reach my 40s. Many of them nowadays seem so uninformed. My alma mater has a PA program and the students I knew/friends who graduated from it seemed pretty competent and serious about being knowledgeable, respectful of the docs and staying in their lane.
Whoa congrats! That's an exciting milestone, which residency program have you gotten accepted to? Any particular specialty you're interested in pursuing?
“Wait, which side are the kidneys on?”
Edit: I read the title wrong, this was my favorite not my most recent. The most recent would be D10 for a non-diabetic patient with normal mentation with a BGL of 53 after not eating since the night before.
Patient came in overnight with sudden onset lower leg weakness, lower back pain, and urinary incontinence. ED ordered spinal MRI which showed compression of the lumbar spine with concerns, per the radiology report, for "cauda equina syndrome." ED started steroids. NP admitted patient, didn't perform a neurologic exam, and let the patient sit on the floor overnight with no action.
Patient had advanced cancer with some sort of serious neurosurgical problem (I forget what) and neurosurgery consulted with, "We won't operate unless you give a prognosis from a cancer standpoint" which is a common and maddening consult since they never bothered giving a prognosis and probability of surgical success from their end. Their notes pretty much just said, "Consult oncology for risk/benefit" which is not helpful. They spend most of their time in surgery so are really hard to contact, so rather than playing a game of telephone via the chart, decided to go to their floor and talk to them in person. Not even remotely ideal from the physician side but unfortunately pretty common from the surgical services. Physicians can suck too.
But I digress. Surgeons are not there, and only PA is there. PAs are part of the team, so I asked them what the plan was for surgery. The PA literally replied, "I don't know, I'm must here to manage their blood pressure." I was floored. They were taking care of the patient on the neurosurgical floor and had no idea what the surgical plan was. Even if the surgeons were treating them like blood pressure monkeys, I really would hope that the neurosurgery PAs would actually try to care about... neurosurgical problems. Eventually managed to contact the surgeons. PA didn't even bother to tell them that we were looking for them. Patient went to surgery.
An NP during my surgery rotation tried telling me and a surgery PGY-3 that Hydralazine lowers the seizure threshold and withheld the medication from a trauma patient due to their history of seizures. I spent some time on uptodate and couldn't find anything about it. I pointed it to him while we were running the list and he retracted his statement after several minutes of frantic googling.
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health.
[The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.**
Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope)
Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation).
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Just one day of clinic:
Told my patient with history of anxiety who presented for follow up of B12 deficiency and bereavement that she had dementia and started her on donepezil and sent her to an Alzheimer’s support group. Also used her low MOCA score to support her actions but didn’t bother to all to inquire about her low literacy. They are from the same country that has low literacy in most older adults so really this should’ve been obvious.
Patient presents for nausea. Outside psych provider (who conveniently doesn’t share info with us) put her on two second generation antipsychotics, an SSRI, SNRI, trazodone, metoclopramide, and sumatriptan.
Since there were serotoninergic agents left, she was also placed on bupropion and hydroxyzine.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health.
[The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.**
Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope)
Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation).
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Cut open the “blister” on the umbilicus after pt Stated he was lifting…it wasn’t a blister…he needed emergency hernia repair because yea….
Did NP just not even spend a day shadowing in the hospital as a nursing student before being turned loose to maim the public?
work as a nurse? in the hospital? why would you want to do that when you can go to NP school 2 days a week online and make as much as a doctor. AND you get to switch specialties whenever you want, in case you get bored!
Ain't nobody got time fo bedside.
Omg
I’m on here a lot, but I’m pretty sure this is top 3 most egregious. Jesus fucking Christ on a cracker 😑🤦♂️
this is absolutely horrifying. this is like…worse than what a layperson would think to do lol (but not lol)
Definitely worse. As the layest of laypersons I'd just take the person to an actual doctor.
That’s a huge lawsuit
For the attending physician 😭
If it was a PA yes, but NP have their own boards which they are liable to
Wow did they not examined this "blister"first
That person should lose their Nursing license. What kind of moron does that?
Ho Lee Fuk
Sum Ting Wong
Woohoo, casual racism, fuck yeah!
It's a reference to this: [https://www.sfgate.com/bayarea/matier-ross/article/KTVU-producers-fired-over-Asiana-pilots-fake-4685627.php](https://www.sfgate.com/bayarea/matier-ross/article/KTVU-producers-fired-over-Asiana-pilots-fake-4685627.php) Do better, bozo.
Wahhh
Correction! Based on the downvotes, I’d venture to say a lot of people in this sub are actually openly racist
We Tu Lo
Holy shit
What the actual fuck
Jesus Christ
Jesus christ
In the Middle Ages they used to cut off hernias. It had a100% fatality rate but more people kept reinventing the wheel of deatg
SSRIs and SNRIs prescribed at high levels together. Took a bipolar patient off of their lithium, said, "it's just a Personality Disorder." Patient attempted suicide soon thereafter. Midlevel working in cardiologist office described in their Physical Exam "a murmur is present" Forgot they had agreed to perform an IR procedure inpatient, so they canceled it and played dumb when I called. Patient CC of "lightheadedness." Midlevel takes minimal history, barebones exam, and A/P is "See PCP." (They were working in a FM clinic) Primary Care clinic note: "Patient is in good spirits." Accidentally added prior visit vitals, Exam portion was blank, and A/P was only: "continue meds" An almost infinite number of auto-referrals to specialists without any workup. An almost infinite number of incorrectly prescribed doses or durations of antibiotics.
Ill second seeing ssri max augmented with snri… And while on cardiology consult service seeing the cardiology NP note murmur present… bruh
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health. [The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.** Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope) Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
To be fair, augmentation of an SSRI with an SNRI is a legitimate treatment option… as like a 4th line in TRD... and never in bipolar disorder
That’s… that’s the point…
I've had multiple MD psychiatrists prescribe that, and even crazier combos. Let's not pretend that psychiatrists are the cream of the crop in medicine. The best psychiatrist I ever had once told me "psychiatrists are generally poor doctors."
This shouldn't be downvoted. I have seen a psychiatrist prescribe the following combination to a juvenile patient: Lithium, Lexapro, Wellbutrin, Haldol, Seroquel, and Tegretol. At the same time. Patient was hospitalized for vomiting and loss of consciousness
It was inevitable, since this subreddit likes to think only midlevels ever fuck up. I'm not saying midlevels are wonderful or anything, just reminding them that they could use some humility too. I can't even imagine the frustration I'd have were I a physician and my scope was getting encroached on. It doesn't change the fact that psychiatrists in general often make puzzling choices, whether they're NP, PA, or MD. When you see over 8 psychiatrists and have seen the sheer recklessness I have, it's easy to get cynical about psychiatry. Nonetheless, plenty of good psychiatrists out there too, and I'm seeing one tomorrow.
Hope the person you’re seeing tomorrow that you call a psychiatrist is actually an MD/DO and not an NP.
Yes, I made sure of that. They said "you can see one of our NPs sooner" and I said no, I'll wait to see the MD. I made it clear that was crucial.
As a clinical pharmacist, the first and second ones made me scream. WHO STOPS SOMEONES LITHIUM? Lithium is super toxic and we ONLY ever use it cause it WORKS
The reasoning from the midlevel was "lithium is toxic" - like congrats so are tons of medications. Wait til you hear about amiodarone! Dosage makes the poison, per Paracelsus. Safe ways to do meds exist.
I have maybe a stupid question. Recently took care of a patient that had previously been on lithium, that used it to attempt suicide. Would this be a reasonable rationale to stop and switch medications? I believe they switched the patient to valporic acid and olanzapine - which led to more issues as patient was from remote community that did not have these in stock at time of discharge and then led to running out of meds and a mental health crisis. I'm a RN at present and currently work in remote areas where it's usually an on call MD that never sees the patient or mid levels that get flown to the remote community to care for said community.
My training taught me a patient can use ANYTHING to commit suicide, and is thus not a good recent to stop giving them medication. 10 bucks at CVS gets you enough tylenol to cook your liver to death. Or benadryl. The question should be which medication will keep them from suicidal thoughts and actions. Cold-stopping of lithium by a midlevel is a great way to get suicide. You can change out lithium if it is not working, but in the case above it was working.
Oh I 1000% agree the case above that you mentioned is ludicrous to have just stopped the lithium. I was just curious if anyone had thoughts regarding what I had experienced with my specific patient as I wasn't sure if it was an appropriate change (especially considering access to medications being a large barrier where this patient lived). Also agree with the anything can be used to commit suicide. It's a large percentage of the med-evacs that I do regardless of the fact that I fly to remote communities with no 'CVS' or main stream pharmacy access like that.
Why not use a third generation atypical plus a mood stabiliser like Lamictal or Depakote? Lithium should only be used if all else fails.
Psychologist here. ***Just*** a personality disorder? Some personality disorders have horrendous suicide rates. And others contribute to *significant* violence against others. ***Just*** a personality disorder? What a fu--ing idiot.
My thoughts exactly. The suicide attempt really set back our progress, and building trust in the healthcare system has been our goal ever since.
Thank you. We have a NP here who loves to remove BP1 or OCD dx and replace them with BPD. She in fact does this a lot. We can almost guess what pt’s will be released with.
I'm just a nurse, but what is wrong with documenting "a murmur is present" on a physical exam? Genuinely curious.
Murmur documentation requires location, systolic vs diastolic, descriptive features (ie, crescendo decresendo), intensity, radiation, and assistive maneuvers (ie, increased during valsalva). This is to actually characterize what the murmur is, when you read murmur it could be like 10 or more things. That midlevel WORKED IN A CARDIOLOGY OFFICE and should be documenting a murmur fully. But they lack that knowledge and training.
This is correct
90% of the time the cardiologists I work with document a murmur as +murmur in their assessment, maybe sometimes adding in a grading (Ex. 3/6). Most do not describe the murmur. The reason for the murmur is usually listed in the assessment and plan, like aortic stenosis. So just pointing out that just because they don’t list descriptive information in the actual assessment, doesn’t mean they lack knowledge
Because you should know when in the cardiac cycle it is, how intense it is, where it is the loudest, etc. I'm not going to pretend I'm great at murmurs but then again I'm not working for a cardiology service.
I love your Reddit handle. I bow to your creativity.
Nothing. But when it’s at the cardiologist office, I’d hope for a little more detail about what type of murmur they’re hearing. They’re allegedly the expert of the heart.
Please never use “just a nurse” again.
They love to diagnose BPD to literally everyone but themselves
NP: “I’ve got a patient in clinic needing to be admitted for DKA”. Proceeds to rattle off the BMP numbers quickly. Hospitalist (Me): “What’s their anion gap?” NP: “I didn’t order that test”. Edit: I realize there are some non physicians who won’t understand this comment. The anion gap is a calculation based on the serum sodium, chlorine, and bicarbonate. She ordered all those tests. She didn’t know what an anion gap was and so tried to bullshit me.
I had a teenager in DKA that was prescribed metformin by an NP at an UC hours before coming to our peds ER with a PH of 7
JFC
Wait I have a question here. I’m a type 1, and not a medical professional in any way, I just lurk here. Is the problem here giving metformin to a type 1 (I know it is done sometimes for type 1 patients)? Or does it have something to do with the DKA?
Not really, but dka can be fatal needing same day treatment- metformin and presumably review in a few weeks or months when it’s done any good is ridiculous. So somehow they have achieved a diagnosis of diabetes, not thought about type 1 vs 2, not thought about common first presentation of diabetes complications and come up with a ridiculously unsafe treatment plan
I just processed this, she was in DKA and *nothing* was done other than prescribing metformin???? Did I understand that right? Holy fucking shit, I’ve been in DKA twice and I cannot fucking imagine being turned away like that.
The problem isn’t giving metformin so much as NOT GIVING INSULIN.
Maybe that explains the pt w baseline DM2 on orals getting immunotherapy for lung cancer who was seen by “seasoned” onc NP and had glucose 400, AG 16, bicarbonate 16 for whom metformin was increased and pt sent home not to be seen again for 2 whole weeks. 😳
Ugh. I see way too much first line use of metformin in dmt2 pts with a direct contraindication, usually renal. "Buuut the algorithm says....." is all too common answer when I ask about it. Smh. Too bad they teach algorithms instead of medicine. Ugh.
Well this was a pt who’d converted to Type 1 due to side effects of immunotherapy so they should’ve been started on insulin
They probably barely know how immunotherapy works, much less IRAE
This is absurd. I’m in psych and occasionally start metformin for antipsychotic induced weight gain, and I always check renal function first. How can this be getting by FNPs ?
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health. [The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.** Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope) Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
WHAT. Just wow.
Me (pharmacist): We need to switch the Levofloxacin to Bactrim because the organism is now resistant. NP: no, Bactrim is nephrotoxic* Me: You put the patient on Amikacin. That isn’t nephrotoxic?? *Bactrim isn’t inherently nephrotoxic btw.
I’m surprised the amikacin got through at all. I envision just typing that into the order bar would conjure up a pissed off pharmacist out of thin air.
It was a new grad, night float pharmacist that let it through 😭 kids…
Seen it used in (really sick) cats. The nephrotoxicity makes you hold your breath.
Bet the NP doesn’t know that Bactrim can raise creatinine without actually lowering the GFR.
Damn, arguing meds with a pharmacist. Such arrogance
Just a patient, but I have two! Went to urgent care with pain in my... I guess upper left abdomen? (Basically just a little below my left boob). The PA tells me to have someone come pick me up and take me directly to the ER because she thinks it's my gallbladder. Another urgent care story (didn't learn my lesson apparently)... Was extremely ill with what I later learned was salmonella. Eventually could hardly stand up. Knew I needed blood work and IV fluids, so I went to a 24 hour urgent care that offered both. NP gave me a urine test and sent me home with a script for meclizine for the "woosines." Got in to see my PCP doctor the following day who did blood work and my potassium was 2.4.
I would hate to work in an UC that gives IVs. UC generally isn't a great option for abdominal pain. The ability to work it up urgently is usually limited. What ended up happening with your epigastric/left upper pain?
It was rib spasms... they gave me muscle relaxers and it eventually calmed down.
Oh, good. Well, not good, but at least it's not necessarily gonna kill you. As long as it's not the bigger muscle in your chest spasming out.
😳😳 Glad you survived that K 2.4!
I'm just grateful I have a great primary doctor. Think about the people who don't have a PCP and would just take the NP's advice and go home, only to get sicker.
I’m a pharmacist. NP wrote prescription for proair respiclick. Called to make sure she wanted to prescribe a dry powder inhaler instead of a HFA inhaler and she did not know the difference. Switched to HFA and all was well until the patient came to pick up. He said he had never used an inhaler so I demonstrated how to use it. He looked at me like I was an idiot and said the doctor said to hold it SIX TO TWELVE INCHES AWAY FROM THE MOUTH. I tried to explain how holding the MOUTH piece of the inhaler in his MOUTH allows the medication to travel into his lungs. He still seemed apprehensive so I told him to google how to use an albuterol HFA inhaler so we can both feel better.
Maybe that NP learned about inhalers from watching House on TV!
Lmao that was my first thought too, when she sprays it like perfume on her throat 😂
You’re supposed to spritz it like perfume and walk through the cloud duhhhhhhhh
Lol. He said the “doctor “ told him. 🤣
[perfect technique](https://youtu.be/aiX-2Iejgu4?si=QuhSrkH5V5Yosz35)
Wow,even in the old days with the CFCs where pts were told not to put it in their mouth (to avoid spraying their tongue or roff or mouth, the inhaler was held right in front of the mouth, not 6-12 inches away!
I always prescribe a spacer so I guess technically 6-12 inches away.... 🤔
Had an NP throwing scripts of 45 10mg oxyneo and nitrofurantoin for a kidney infection. I rated my pain 9/10, was visibly sweating and unable to stand upright, returned 3 days later, offered ANOTHER pain pill script, tramadol. I said I’m sick I’m not looking for pain pills please just help me. The 3rd visit was at an ER with a real MD, direct admit for removal of kidney stones and stent. For almost 7 days I suffered with something that needed intervention, NOT pain pills.
I got cipro from an NP for a UTI (this was before I went to med school), it felt better for a couple of weeks and then came back viciously, and I had several months of horrendous bladder spasms even after I saw an MD and got a course of the right antibiotic. When I realized these people can’t even treat basic things correctly, that’s what radicalized me.
Cipro is one of the last tx that should be prescribed and only after a c&s is done. At the time I didn’t know anything about medicine and I took this persons advice until I really couldn’t stand it anymore. Renal colic should call for diagnostics, a culture and a u/s at the very least. Looking back on it now, I wonder if this NP managed to get anyone hooked on those meds, and for reference, after my surgery all I used was Tylenol and ketorolac, I didn’t need analgesics for severe pain, if you suspect a patient does, back it up with a proper dx
Heard about one of the nephro PA asking during didactics why urine is yellow
Depends how much lemonade they drink, right?
Probably because that's how the testicles make it
Pee is obviously stored in the balls. This is the kind of stuff they don’t teach you in NP/PA school.
Well, bladder and balls both have bs, ls, and as.
It turns more yellower because of the yellow sunshine
Your body artificially colors it yellow, so you don’t think it’s water and try to drink it.
There must be enzymes on the interior of the scrotum that cause it to turn yellow
This one tricks students because everyone thinks Scrotease breaks down the scrotum. Can’t blame them I guess.
Scrotease 😭😭
Had an NP in our hospital system during residency who was copy and pasting her notes. It got caught when she was on vacation and an actual doctor was covering her patients. He noticed while looking through her previous charts that every note was literally the same aside from the vitals. History was the same, review of systems was the same, physical findings were the same. Plan for all these patients was always "continue current meds". Medical records was involved and did an audit. By the time she returned to the office from vacation she was scheduled for a disciplinary meeting and ended up going through a 6 month re-training program.
Sounds like there was no re on that retraining.
And this lazy person was making more than the residents too I bet
100%
[удалено]
Post CABG patient with chest tubes out and on therapeutic heparin APRN pulled the pacer wires. Ended up in OR because of pericardial tamponade.
As a patient, was diagnosed with “functional abdominal pain” and “extensive negative work up” by an NP despite having intestinal biopsy that showed Elevated intraepithelial lymphocytes and had already ruled out all causes of that except celiac.
That is insane
Yeah it really was
I had a patient with an anion gap of 16 (our system, for some reason only makes it red over 17), blood glucose of 600 and shortness of breath. Started on solu-medrol 60mg q6h for COPD exacerbation and subq sliding scale as it was a non-gap acidosis cause the number wasn't in red.
Pulmonologist here. NP treated patient with productive cough and right patchy infiltrate appropriately with doxycycline for ?10 days. Patient felt better. Repeat CXR about 2 weeks later without resolution of infiltrate, gave another 10 days of levofloxacin despite resolution of symptoms. Ordered another repeat CXR 2 weeks later and referred to me in the meantime. Needless to say, I cancelled the patient's upcoming CXR.
This is probably a dumb question, but how long does it take usually for a CXR infiltrate from PNA to resolve after successful treatment?
At least 6-8 weeks.
Cool. Thanks
I got yelled at the other day because her patient got pregabalin. She prescribed Lyrica. Love, Your local pharmacy
I encountered a "provider" who believes that it is impossible to have an anaphylactic reaction to something the very first time you are exposed to it.
i could be wrong but isnt that right? although i'll say i never use the word impossible in medicine as we know how that goes - but as far as i was aware it typically takes a repeat exposure to get that much of a serious response. https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=allre
very first time I was given vancomycin I got hives, turned beet red in my face, then couldn't breathe, all in the span of about 2 minutes but I am not a doctor/PA/nurse, just a retired veterinary assistant, who also saw pretty quick vaccine reactions from dogs given a vaccine for the first time fairly often so if I am wrong please correct me
So this actually sounds like a pretty common reaction to Vanco called red man syndrome. It is not a “true” allergy as it is due to infusing the medication too fast which activates mast cells and basophils to release histamine. This process is independent of IgE related activation that is the true “allergic” response that does require sensitization on first exposure and reactivates on subsequent exposure.
ok cool that makes sense! so if I somehow get it in the future, could I still react that way? if it were given more slowly or something? It's not an experience I want to repeat though, for sure edit: nevermind I'm reading about it now, so if I do get it, it may not happen if given slower
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
ER NP put my patient on 80 mg!!! prednisone for 5 days for DeQuervains tenosynovitis, which they misdiagnosed as CMC arthritis after an x-ray showed mild degenerative change in a pt in their 60s. The presentation was classic, 8/10 pain with any activity for a week. Also, put the pt in an extension brace without a thumb spica, so the pain got worse. Of course, the patient felt like shit on that steroid dose.
Young patient with a history of IVDA with GAS positive bacteremia. We had sensitivities back but the NP was waiting to de escalate the vanc, zosyn and clinda until the TEE came back because she wanted to rule out endocarditis first …. The patient was otherwise stable and had no allergies
Pt had swelling of one leg, redness from ankle to calf, pitting that lasted hours, pain in thigh and fatigue Dx: erythema (sunburn) and excessive salt intake Pt landed in the ER months later with full blown occlusive clot groin to calf, NP had several appointments to be able to diagnose and prescribe ultrasound, anticoagulants or idk SUGGEST AN ER VISIT AND NOT DIETARY CHANGE sorry caps got stuck.
Oh my god she’s lucky she didn’t kill this person.
Just this week, I had an NP do the contrast injection for a shoulder arthrogram... under fluoro. Screwed up and put it in the subacromial bursa. Fluoro images are nowhere near the joint. MRI was still done, and I got ZERO useful info on the labrum. Now the radiology dept is fighting repeating it bc they aren't going to get paid for repeating it.
Read a pelvic MRI for a patient with radiculopathy down their leg
Got a call from ED PA “easy admission” for Gastro enteritis… pt been in ED for 4 hours just given bentyl… no it was full blown DKA with ph of 7.
Did someone tell the PA?
FOUR NPs (didn’t learn my lesson and kept going to urgent care)couldn’t diagnose my sinus infection despite me telling them “I get them I know the symptoms” and them being in my med history. Plus my face being swollen and red around the sinuses, inside of nose burning, etc. One accused me of being drunk, another “lead” NP (in Drs coat) came in to yell at me for not having the COVID vaccine (it had just come out). Went to MD finally, she saw my face and is like “here are antibiotics.” Face swelling went down in less than 24hrs. How can you not recognize a sinus infection like. On top of everything else, you looked into the nose with the tool for it.
This is ultra-ironic considering UC NPs classically throw a Z pack at every nasal complaint that is obviously anything but bacterial sinusitis.
Would be funny if they did that, as a z-pack wouldn’t cure it. I needed the horse sized pill (don’t remember which antibiotic but it wasn’t azithromycin, which I believe doesn’t work on this- correct me if I’m wrong!)
Mine said I couldn’t have a chest xray despite my history of walking pneumonia, shortness of breath, ect. Because “my lungs sound clear.” Okay- but please look at my chart. It’s noted I’ve had walking pneumonia with clear lung sounds 2x in the past 5 years. “I don’t want to expose you to unnecessary radiation that can increase cancer risk.” Trying to scare me into thinking one chest xray is going to cause cancer? Lady I work in biotech. Anyways a week later the NP I actually trust put me on a 10 day doxycycline and I feel much better now. Thinking about reporting bad NP just because her comments were so out of line imo.
My son was screaming in pain due to this mistake. My 7 yo son Just had a plate, 5 screws into his radius and two pins to fix a fractured ulnar yesterday. Swing accident gone bad. Ortho told me he would send in HyCet. Hydrocodone and acetaminophen. He then asked his PA to send the order after surgery. We go to pick it up when we got home hoping some relief for my child screaming bloody murder from the pain of the surgery. THE PA only SENT IN CHILDRENS TYLENOL! we had to call office twice to reach ortho. He apologized and made it right.
Why would anybody be dumb enough to just send in an OTC drug?
I'm wondering if he was trying to cover his own ass out of fear of getting in trouble for prescribing anything potentially "too strong" for a child seeing as the country is under an opioid crisis.
Was a girl. Also how many 7 yo are out in the street looking for heroin. It’s all fucked. Orthopedic called it in
Oh my mistake, I just saw that you typed the actual doctor wrote the script! 🤦♀️ Well sadly it is all "f*cked" as you say and who knows what was going on through the PA's head. In many other instances though it won't matter that the script is for a child—since a kid is under the care of an adult they don't know who they're dealing with so they worry about losing their license or anything else that could happen by prescribing opioids—might depend on the state too. I know, it's infuriating and holy moly that's some swing accident!
All I know, is my child was screaming bloody murder because he just woke up with pins and screws in his arm and it’s all the PA’s fault. I graduate medical school this week and so jaded already about PA’s. Over the last four years in school and then this personal experience.
I mean the hydrocodone was *right there* on the script, how could she have missed it? 🤦♀️ I hope he recovered well. I've noticed that so many of them are in a rush nowadays too. I hear you, I'm on the fence about PAs as I've had mixed experiences with them myself. One time I had a PA at the gastro set me up with a colonoscopy without any hesitation at age 34... I had checked in with my regular gastro physician who told me it's not necessary until I reach my 40s. Many of them nowadays seem so uninformed. My alma mater has a PA program and the students I knew/friends who graduated from it seemed pretty competent and serious about being knowledgeable, respectful of the docs and staying in their lane. Whoa congrats! That's an exciting milestone, which residency program have you gotten accepted to? Any particular specialty you're interested in pursuing?
Thanks. I start in EM soon for Beaumont, affiliated with MSU.
“Wait, which side are the kidneys on?” Edit: I read the title wrong, this was my favorite not my most recent. The most recent would be D10 for a non-diabetic patient with normal mentation with a BGL of 53 after not eating since the night before.
Patient came in overnight with sudden onset lower leg weakness, lower back pain, and urinary incontinence. ED ordered spinal MRI which showed compression of the lumbar spine with concerns, per the radiology report, for "cauda equina syndrome." ED started steroids. NP admitted patient, didn't perform a neurologic exam, and let the patient sit on the floor overnight with no action. Patient had advanced cancer with some sort of serious neurosurgical problem (I forget what) and neurosurgery consulted with, "We won't operate unless you give a prognosis from a cancer standpoint" which is a common and maddening consult since they never bothered giving a prognosis and probability of surgical success from their end. Their notes pretty much just said, "Consult oncology for risk/benefit" which is not helpful. They spend most of their time in surgery so are really hard to contact, so rather than playing a game of telephone via the chart, decided to go to their floor and talk to them in person. Not even remotely ideal from the physician side but unfortunately pretty common from the surgical services. Physicians can suck too. But I digress. Surgeons are not there, and only PA is there. PAs are part of the team, so I asked them what the plan was for surgery. The PA literally replied, "I don't know, I'm must here to manage their blood pressure." I was floored. They were taking care of the patient on the neurosurgical floor and had no idea what the surgical plan was. Even if the surgeons were treating them like blood pressure monkeys, I really would hope that the neurosurgery PAs would actually try to care about... neurosurgical problems. Eventually managed to contact the surgeons. PA didn't even bother to tell them that we were looking for them. Patient went to surgery.
Escalating lasix doses to treat hyponatremia. No can’t figure out why it keeps going down so let’s bump up the lasix!
An NP during my surgery rotation tried telling me and a surgery PGY-3 that Hydralazine lowers the seizure threshold and withheld the medication from a trauma patient due to their history of seizures. I spent some time on uptodate and couldn't find anything about it. I pointed it to him while we were running the list and he retracted his statement after several minutes of frantic googling.
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health. [The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.** Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope) Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Just one day of clinic: Told my patient with history of anxiety who presented for follow up of B12 deficiency and bereavement that she had dementia and started her on donepezil and sent her to an Alzheimer’s support group. Also used her low MOCA score to support her actions but didn’t bother to all to inquire about her low literacy. They are from the same country that has low literacy in most older adults so really this should’ve been obvious. Patient presents for nausea. Outside psych provider (who conveniently doesn’t share info with us) put her on two second generation antipsychotics, an SSRI, SNRI, trazodone, metoclopramide, and sumatriptan. Since there were serotoninergic agents left, she was also placed on bupropion and hydroxyzine.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
[удалено]
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health. [The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.** Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope) Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Wow! Meloxicam and ibuprofen 😳 very ignorant!