Calling all NP Preceptors

I have been asked to help moderate a FB page: "Nurse Practitioners Offering to be Preceptors". As we all know, finding a preceptor for ourselves is a daunting task in itself. The majority of the NP programs are now requiring the students to "find their own preceptors".
I am working on a data base of preceptors (NPs and physicians) from across the country that will be pinned to the top of the page. If you are a preceptor, or know of someone willing to precept, please send me a  private message with your name, specialty, setting,, and city/state for the data base. As an example, mine is:
Dr Thomas Cooper DNP, ACNP-BC, FNP-C Emergency Room Memphis, TN
I will alphabetize the listings by state.
Contrary to popular belief, we don't have to "eat our young".
Thanks for everyone's help!

Sad day for Hospital Wing and Lebonheur Children's Hospital

 

 

Flight Team Update: With the families' permission, we can now announce that the Le Bonheur family members lost today are Pedi-Flite Nurse Carrie Barlow and Pedi-Flite Respiratory Therapist Denise Adams.  Pilot Charles Smith also died in the crash. Their legacy will live on through the care that they provided for so many children during their careers. Our thoughts and prayers are with these employees, their families and the Pedi-Flite and Hospital Wing crews.

 

I knew both of these Pedi-flight crew members. They loved what they did and their care has improved the lives on many Mid-south children and positively affected many families.

While I am sure heaven has gained three new angels, my prayers are for their families and co-workers.

When the light bulb turns on!

When the light bulb turns on!

 

While I was “running” today, Ralph and I had a very in depth discussion about life. Now understand, my version of running is more like an unstimulated zombie shuffle.
I do realize that I am aging (NOT getting old), overweight, stubborn, sometimes obnoxious, uber competitive, and very opinionated. Whenever I forget any of these things, Ralph sees fit to prod me back to reality.
Prior to my last 6 ...month assignment in Alaska, I worked out with a personal trainer two days a week and had “adjusted” my dietary habits some. This resulted significant improvement in my overall health as well as a 44 pound weight loss. While in Alaska I walked a couple of miles 2-3 times a week and erratically used resistance bands for upper body workouts. While I did not gain back any weight, my overall conditioning suffered fairly significantly.
A few weeks ago I went with my wife, Kat, to Augusta, GA for her to compete in her first IM 70.3 (half Ironman). I had the privilege of meeting many of her Tri friends there who were also competing. One of them slipped me some of their “koolaide” and I am now starting to train for a Sprint distance Triathlon at Memphis in May 2014, thus the reason I was out running.
I now am working with Leslie Brainard (triathlon coach extraordinaire – www.trinitytricoach.com) who has given me a personalized training schedule to prepare for the Memphis in May event. The workouts rotate between swimming, biking, and running. Now my version of running is more like an unstimulated zombie shuffle.
I live with a wife that started training and getting fit two years ago and has completed events from 5K, half marathons, and a Half Ironman 70.3. My competitive side thinks that I should be able to consistently run sub 15 minute miles, ride my bike forever, and swim like Flipper. My body tells me: WTH are you doing to me. And good old Ralph tells me that I am a fat failure, that I am too old to start this crap now, and many other “non-encouraging” remarks.
I consider myself a spiritual person. I have a God that I talk to on a very regular basis .When I run, I listen to a very eclectic array of music. Today, while Ralph was attempting to fill my head with self-doubt and excuses, “Through the Fire” by The Crabb Family began to play and light bulbs began to flash! The words say: “He never promised that the cross would not be heavy”.
That is when it hit me and Ralph was speechless. This isn’t supposed to be easy! It is work! I have watched Kat sweat and work very hard to be where she is. I have observed the price that these Triathletes pay to accomplish their goals. I needed to suck it up and get moving!
I deal with life and death situations on a regular basis and have been told I do it well. Well I have thoroughly explained to Ralph the following: 1) Water is just “wet”, I will swim better 2) The bike saddle hurts my ass, callouses are earned, I will earn some and 3) running is just putting one foot in front of the other and NO ONE cares how fast I get there as long as I don’t give up!
It is ok if Kat is faster, she will be there cheering me on when I get there. If Ralph or I need an “attitude adjustment” Kat or one of our Triathlete friends will have no problem giving us one while being there to encourage and cheer for my accomplishments, no matter how insignificant I think they might be.

Have a GREAT week!

Nursing: A Rewarding Career Choice for Both Genders

The following is provided by Sandra Mills and is definitely food for thought.

 

Nursing: A Rewarding Career Choice for Both Genders

 

Thanks to a steady pay check, an abundance of employment opportunities, and stable job growth, nursing has become one of the highest "in demand" professions in the country. One of the reasons for this field's growth in popularity, is due to a variety of opportunities within the nursing profession. From working in a traditional hospital setting, to providing in home nursing assistance or hospice care, there is no shortage of unique and exciting career opportunities for nurses.

Traditionally, there has been several degree tracks which lead towards obtaining nursing certification. However, over the course of ten years, many hospitals have eliminated positions for licensed practical nurses, instead opting to hire registered nurses who have obtained a bachelor’s of science in nursing.

While nursing has remained a popular degree choice for women in college, men are starting to excel in this historically female dominated field. One of the biggest hurdles that male nurses face, is a negative stereotype. Many people assume that male nurses are simply medical students who were unable to become physicians for various reasons. Most male nurses cite their reasoning for entering the nursing field, as being due to a desire to provide empathetic, personalized care to their patients. While the average salary of a male nurse remains slightly higher than females, there is more gender equality within the field of nursing than among most other lines of work. Read actual facts on males in the nursing field, as well as general nursing career statistics, in this male vs. female nurse infographic created by Carrington.edu.  

Will the sky really fall if someone calls me "Doctor"?

First I want everyone to know that I work with a great bunch of providers here in Alaska. There are no “egos”, it is truly collaboration among providers, and a provider is a provider regardless of the letters after their name (NP, PA, MD, DO, PT, etc). The physicians here call me Doctor Cooper, and several have expressed their opinion that I should be called “Doctor” because I earned it.

Now with that out of the way, I know many of you are fighting the battle in you home state about the use of the term “Doctor”. There is a movement among the boards of medicine that think only a “physician” should be able to use the term “Doctor. Interestingly enough, many physicians are married to “doctoral prepared spouses”, although their “Doctorate” is not in medicine. If we are to validate their request to only allow “physicians” to use the term Doctor, think of all the professionals that would have to change their business cards.  Dentists, educators, college professors, veterinarians, and a multitude of other occupations would be required to change not only their business cards, but the signs on their businesses, their stationary, their checks, and who knows what else.  So I have to wonder if this is not a ploy by the “physician community” to “stimulate the economy”.

What if there was no “battle of the title Doctor”?  Well, let me tell you what would happen in that fairy tale land:

The Board of Medicine would hold their quarterly meeting in a rural hospital in their state. The Board would meet and conduct their business during the day, then have a get together in the evening at one of the local physician’s homes. The entire medical staff from the hospital would be invited (that means MDs, DOs, NPs, Pas, and PTs).

Now of the non physician medical staff present, there would be a NP or two that had their DNP and a physical therapist that had his DPT. Throughout the evening, the physicians and the non physicians enjoyed great food, great atmosphere, and discussed medicine and healthcare amongst themselves on a “peer to peer” level.

Well that is exactly what happened in Dillingham Alaska this week. And believe it or not, the sun came up this morning, the sky did not fall, last I checked the earth was still rotating, and I have not grown a third eye. It is really amazing what can happen when egos are checked at the door.

Have a great day!

Pain management in wrist fractures

How do you control pain when reducing wrist fractures?

For those of us in rural settings, we frequently have patients present with broken bones. When we do, the problem is not usually “how to reduce a fracture”, but “how do we manage pain while reducing the fracture”. If you are working in a metropolitan area, you give the patient a little pain medication and send them to the Orthopedist. Well guess what, in the rural setting you are probably going to be as close to an Orthopedic Surgeon as the patient gets.

Now some of the techniques Ralph and I are going to mention might not be within your scope of practice in the state you are working in, so just because you read about it here, DOES NOT give you permission to go try it. You have to remember that I work in frontier rural Alaska and the closest orthopedist is over 300 air miles away.   Also, some of the “details and statistics” I mention come from a variety of places. If you are looking for specific data and the most recent and factual information, you need to research it yourself so you can include specific citations.

Today we are going to talk about “wrist fractures”. These fractures usually occur in two specific populations. The first is youth and result from high energy falls, the second is the elderly and result from low energy falls and are an indirect result of osteoporotic bones. In both groups, the fractures are most commonly the result of a fall onto an outstretched hand.

With any fracture, we want to identify the mechanism of injury and complete assessment of neurovascular status including motor function. ANY FRACTURE WITH NEURO OR CIRCULATORY COMPROMISE IS A TRUE EMERGENCY! These are not the focus of this discussion.

After we have established adequate circulation, motor function (remember there is a BIG difference between “I don’t want to because it hurts” and “I am trying and nothing is happening”), and neuro status, we need an x-ray.  Things that increase the severity of the injury include, but are not limited to: severe comminution, fracture-dislocation, etc.

 

Indications for Orthopedic consultation include: open fractures, fractures that cause circulatory compromise, compartment syndrome, acute neuropathy, palmarly displaced fractures (Smith’s fractures), fracture dislocations, distal radial fractures associated with styloid and scaphoid fractures, or fractures with significant displacement.

Now that we have determined that it is appropriate for us to reduce and stabilize the fracture, how do we manage pain during the reduction? If the usual populations are the young and the old, do we really want to use moderate sedation? I am not sure about you, but I would rather not, despite what Ralph says.

The method of choice for reduction pain management is a “hematoma block”. It sounds complicated, but it really isn’t. The hematoma block can be used with or without systemic pain medication. I am going to summarize the technique from several sources.  Before attempting this, verify it is within your scope of practice and find a mentor that is willing to show you the proper technique on an actual patient.

This fracture was reduced using a small amount of IV Fentanyl prior to performing a hematoma block. The patient tolerated the procedure well without sedation.

Have a great day!

Some things you just can’t make up!

Hello again from beautiful Dillingham, Alaska. I have been back here for a week and am all settled in my apartment. Everyone has made me feel welcome to the point that I really don’t feel like I have been gone for almost three months. As usual, there are several new faces. For a few of the “newbies” this is their first Alaska experience, the rest are like me, here because they enjoy working here. The official term in Native Facilities for what I do is (TDY). There are TDY positions in just about every licensed healthcare position in these facilities: physicians, nurse practitioners, physician assistants, dentist, dental hygienist, radiology techs, registered nurses, and some I probably haven’t even thought of.

I originally planned to blog two or three time a week, but Ralph and I have been discussing some of the things that we have noticed about the newbies. We have been trying to understand the thought processes, or lack of thought processes, for  someone traveling many miles from home to work for several months in a setting they have never been in. In some previous blogs, I have told you how I prepare to go to a new place or state. The research I do about “little things” like: scope of practice, licensing, prescribing laws, and many other “little things”.

Now I am in no way finding fault, Ralph and I are just making observations. We are going to tell you a “pretend story” about Sally (no we ain’t dumb enough to use real names, except our own). We are going to pretend that Sally is a Physician’s Assistant (PA) who is coming to a state that she has never practiced in before. There are a few things that Ralph and I think Sally should have known about BEFORE she got to Alaska.

1)      Sally is coming from a state where she can not prescribe medications (her sponsoring physician has to write prescriptions).

2)       Sally has only worked in a large emergency room and has NEVER practiced rural (much less frontier) medicine.

3)      Sally does not have a DEA number.

4)      Sally does not know that she can only get a “provisional license” in Alaska until she has worked for 160 “directly supervised” hours in Alaska.

5)      Sally does not know what schedules of drugs a PA can prescribe in Alaska.

6)      Sally is going be assigned to a remote village clinic and will be doing and seeing “everything that comes through the door”, but when she gets here, Sally says: “I don’t do OB or skin, who comes and takes care of them?” 

7)      Sally made a statement to us that really upset Ralph: “you are just a mid level, why don’t you know what schedules of drugs I can prescribe?”

8)      Sally didn’t know that Alaska is a ZERO tolerance state as far as drugs and alcohol in the work place.

Now those of you that really know Ralph and I are probably betting about know that we probably said some “un-nice things” to Sally. Well I hate to disappoint you, but for once the filter was working, at least for my “out loud” voice. And other than number seven, our mouths were gaping open too wide to utter a response.

Ralph and I can not even imagine coming here and not knowing the answers to the above questions. It has nothing to do with PA, NP, RN, MD, Rad Tech ……….

IT IS ALL ABOUT BEING A PROFESSIONAL!

You have “paid the price” to earn you license (at what ever level), you say you want to be treated like a professional, yet many evidently do not even know the definition of the word “professional”. In order to be respected, you should earn it by your actions and preparation. Too often healthcare workers want to “talk the talk” about being treated as a professional, but Ralph and I find very few that really “walk the walk” every day.

My response to number seven is:

First, I hate the term “mid level”, but I tolerate it at this point in my career because I have much more important sand boxes to stick my flag in where I can choose to “die on my sword”.  Anyone that puts the word “only” in front of their profession, well I don’t think their opinion of themselves is very high on the “notching stick”, so it is really their problem to address. But I can recommend several good therapists.

Now Ralph’s response to number seven can not be posted here, because this is only a PG site. He did reference sunny beaches, miles and miles of desolate tundra, and something about Sally’s figure cause he kept talking about bodies.

Have a great weekend, and be PROUD of your profession by ACTING like a professional!

Sitting in the Anchorage airport

Well yesterday afternoon and evening was spent getting from Memphis to Anchorage. When we boarded the plane in Memphis for the flight to Minneapolis, the pilot "informed" us that we would be delayed "a few minutes" for a maintance issue. As always seems to be the case, the “bitching” started almost instantly. A “gentleman” (Ralph says he was no gentleman) a few rows in front of me started cussing and using words I had to look up in Mr Webster’s book. He seemed to be fueling the other passenger’s frustration. Now understand that the entire delay was less than ten minutes. The pilot informed us that the “maintance” had been completed and he would do his best to make up some time in the air and have us to Minneapolis on time.

Unfortunately, this did little to quell the “bitching passengers” nor did it improve their vocabulary. Fortunately for Ralph and I there were no small children on the flight. The flight was basically uneventful after that. Our captain, true to his word, had us deplaning eight minutes before we were originally scheduled to arrive in Minneapolis.

Now I do not profess to be the “brightest bulb” on the tree, BUT, I am personally glad someone found the “maintance issue” prior to our take off. I felt sorry for the flight crew because of the verbal comments and snotty attitude that several passengers had during the flight. I wonder how they would have felt had we needed to make and emergency landing because the “maintance issue” was not addressed prior to take off? What if it had caused an in flight emergency or resulted in major equipment failure?

Every time I witness these delays and the passengers reactions, Ralph repeats the words of Ron White in my ear over and over:

“We will be the first ones at the crash site”……

Have a great day!

Getting ready to leave again!

Getting ready to leave again!

Well the time at home has been great and I have accomplished a lot around the house. The “hunny do list” is much shorter than it was when I got home in February. I have had a few dates with my wife, went on a week-long family cruise over spring break, and got to watch my son shoot trap every week. I have finished the fence in the back yard for the girls (that would be female dogs) so they won’t have to be walked. The lawn mower has sharp blades and the grass has been cut (several times).

Since this is going to be an extended trip (5 months), the family will be there visiting for several weeks, and salmon season opens in May, I am shipping some things to Dillingham. I have found out that the least expensive way to ship is via USPS parcel post. The drawback is that it will take about two weeks to get there. I have those boxes packed and will drop them off at the Post Office on my way to the airport Wednesday morning.

My “plan” was to pack my bags today, BUT yesterday afternoon I noticed the house was awful warm. When I checked the AC unit, the start capacitor (thingy that makes it run) had been destroyed by a voltage surge during a thunderstorm the night before. So I spent the morning driving to the other side of Memphis to get the part to fix the unit. So my AC repair went something like: 15 minutes to diagnose, 4 ½ hours running down the part, and 15 minutes to do the repair. Needless to say, I did not pack today.

So tomorrow I pack and plant blueberry bushes. Wednesday will be spent flying from Memphis to Anchorage then Thursday on to Dillingham. Of course it is supposed to snow 1-3 inches Thursday in Dillingham, lucky me. My next blog will be about what I find when I get back to Dillingham.

Have a great week!

What I think of Dickies EDS Scrub Tops

Just like most of you, I have worn scrubs almost every day for many years. What I look for in scrubs is comfort and durability. When I travel to an assignment, I am limited in what will fit into my suitcase. That means if I am on an extended assignment, my scrubs get washed frequently. They must hold their color after repeated washings and be made of a durable fabric.

I have been asked by Uniformed Scrubs to do a product review of their new line of Dickies scrub tops. When I got the email asking me if I would be interested in doing a review, automatically red flags went up. I responded to the email inquiring as to the companies “expectations” of my review. Ralph had already envisioned them expecting me to write a glowing rant about their product.

Usually the companies want final approval of what will be posted. I do not blog for anyone’s benefit but mine and I will not be bought or “bribed”. The response I received was definitely a pleasant surprise, and I quote: “We would be happy to get your honest opinion and have your review posted on the blog for your followers”. This led me to believe that they were confident in their product and I would be satisfied with my evaluation.

I received a navy blue Dickies EDS (Every Day Scrubs) Men’s scrub top by Priority Mail. When I opened the package I found, what appeared to be, a well-made scrub top. The size I requested is the “normal” size I wear; when I tried it on I found it roomy and comfortable. I was pleasantly surprised to find the left front pocket is actually two pockets, one over the other. The back pocket is full size and has a pen sleeve. The front pocket overlays the back pocket and its opening is about one inch below the back pocket. Then came the real test, since it is navy blue how will the color hold up. Well I am pleased to say after ten washings, it is just as blue as the day I got it.

So for this product I definitely have a positive review. The scrub top is well made and well worth the cost. Below is the “official” description of the top and a link to the Uniformed Scrubs catalog:

Dickies Men's Raglan Sleeve Scrub Top in 15 Colors

Style 816106

Men's Fit V-neck features raglan sleeves and layered chest pocket. Back length: 29".

Brand: Dickies

Collection: EDS Fit for Men

 Fabric: Poly/Cotton,Poplin
Detail: 65 % POLYESTER/POLIESTER-35% COTTON/ALGODON

 Gender: Men's

Neckline: V-neck

Sleeve: Short

 Body Type: Contrast Raglan Slv

Top Pockets: Chest

http://www.uniformedscrubs.com

Heart of America Medical Center

Heart of America Medical Center

Rugby, ND

This past weekend I have been at HAMC in Rugby, ND. When I work at this facility, I cover the ER, a 20 bed Acute unit, and an attached 80 bed skilled nursing facility. I have worked here in a locum’s status since 2012. To get here, I fly to Minot, ND from Memphis on Friday morning and “usually” fly home from Minot on Monday afternoon.

This weekend is a little different, due to the “severe winter storm” last night and this morning, my relief could not get here. Besides that, the 80 miles of road between Rugby and Minot were iced over. Needless to say I am still in Rugby. I have cancelled today’s flight and hopefully will be able to get home tomorrow (Tuesday).

Since many of you ask about the facilities I work in, I will tell you about the facility and a little about Rugby which just happened to be the geographical center of North America.

Heart of America Medical Center

History

Good Samaritan Hospital Association was founded by farsighted, pioneer Lutheran pastors dedicated to community service. This sense of loyalty has been a landmark for the organization since its inception in 1904. The association, which has sustained Rugby's hospital and medical services since 1904, is supported by 27 area churches of several denominations.

Today the Good Samaritan Hospital Association, doing business as Heart of America Medical Center, includes a 20-bed critical access hospital, surgical suite and a nursing facility facility.

Haaland Estates, the association's 80-bed basic care facility and assisted living apartments, first opened as an intermediate care nursing home in 1962.

Johnson Clinic, founded in 1933 by Dr. Olafur W. Johnson, merged with Heart of America Medical Center to form Heart of America Johnson Clinics in 2010.

The Hospital

Heart of America Medical Center is a Level V Trauma Center. Lab, X-ray, respiratory therapy, anesthesia and surgical staff are on call 24 hours a day.

In our 18-bed medical/post-surgical unit we provide acute inpatient care and observation. Our state-of-the-art intensive care unit is staffed by registered nurses and physicians certified in advanced cardiac life support.

We also provide swing bed services for people with chronic illnesses or who are recovering from recent

illnesses or injuries who need additional therapy before going home or to another care setting. We also provide chemotherapy, infusions or other treatments on an outpatient basis.

Rugby, ND

Rugby is a city in Pierce County, North Dakota, in the United States. It is the county seat of Pierce County. The population was 2,876 at the 2010 census. Rugby was founded in 1886. (Wikipedia)

Rugby was founded in 1886 at a junction on the Great Northern Railway, where a spur to Bottineau met the main line.  The railroad promoters initially named it the "Rugby Junction" for the famous railroad junction in Rugby in Warwickshire, England, in the hope of attracting English settlers.  About 80% of the population is of North Germanic and Scandinavian ancestry.  When the community became a city, the "Junction" was dropped from the name.  Wikipedia

According to the 1931 U.S. Geological Survey, the geographic center of the North American continent is located approximately 6 miles west of Balta, Pierce County, North Dakota.  The approximate coordinates are given as latitude 48* 10' North, 100* 10' West.  In 1932, a field stone cairn recognizing this was erected in Rugby at the intersections of US Highway 2 and ND State Highway 3.

Rugby has a museum, library, golf course, Movie Theater, swimming pool, parks, playgrounds, hockey arena, ball diamonds, and excellent hunting grounds for waterfowl, upland game, and big game.

I'm back!

I’m back!

I have not been prudent about my blogging for several weeks and for that I am truly sorry. It has not been for lack of “material”, but I have been enjoying spending time with my family.

Since I returned form Alaska last February I have accomplished a few “honey do list” things, spent a week cruising the Western Caribbean, got to watch my son at his Trap meets, went on a few dates with my wife, and worked a few weekends at various facilities in North Dakota.

Now as I prepare to return to Alaska for the summer, it is time to get back to blogging. I have made a list of questions that you have been asking that I will be trying to answer as I go along. I have even been asked to do a product review (to Ralph that was a challenge to “tear something up”) on a new design Cherokee scrub top that I will be posting next week.   Some of you have asked me to tell you about the facilities I work in and/or the communities where I work.  And finally, I get asked a lot of questions about critical access hospitals and “what they actually are”.

So for today, I will share a little history about critical access hospitals and what they mean to our healthcare system.

BACKGROUND

For those of you that have been around a while, you will remember the days in the 80s and early 90s when hospitals were closing across the country. These closings were rampant in large cities as well in rural areas. When a hospital closed in a large city, there were usually several other hospitals in the area to absorb the patient load. Two examples of this are West Paces Ferry Hospital in Atlanta and Baptist Hospital in Memphis. In both instances, there were multiple “other choices” for health care. When these closings happened in rural areas, it presented a different dilemma. There were not other hospitals close by and patients were forced to go long distances for hospital services.  Many of the rural hospitals were not able to stay open due to the rising cost of services and the declining reimbursement rates. This resulted in inaccessibility to healthcare for many citizens.

In 1997, the Balanced Budget Act authorized States to establish a State Medicare Rural Hospital Flexibility Program (Flex Program) by which certain facilities that participate in Medicare would become Critical Access Hospitals (CAHs). The Critical Access Hospitals (CAH) program is designed to improve rural health care access and reduce hospital closures. Critical Access Hospitals provide essential services to a community and are reimbursed by Medicare on a "reasonable cost basis" for services provided to Medicare patients.

REQUIREMENTS TO BE A CRITICAL ACCESS HOSPITAL

A Medicare participating hospital must meet the following criteria to be designated as a CAH:

.Be located in a State that has established a State rural health plan for the State Flex Program (as of September 2011, only Connecticut, Delaware, Maryland, New Jersey, and Rhode Island did not have a State Flex Program);

.Be located in a rural area or be treated as rural under a special provision that allows qualified hospital providers in urban areas to be treated as rural for purposes of becoming a CAH;

.Demonstrate compliance with the CoPs found at 42 CFR Part 485 subpart F at the time of application for CAH status;

.Furnish 24-hour emergency care services 7 days a week, using either on-site or on-call staff;

.Provide no more than 25 inpatient beds that can be used for either inpatient or swing bed services; however, it may also operate a distinct part rehabilitation or psychiatric unit, each with up to 10 beds;

.Have an average annual length of stay of 96 hours or less per patient for acute care (excluding swing bed services and beds that are within distinct part units); and

.Be located either more than a 35-mile drive from the nearest hospital or CAH or a 15-mile drive in areas with mountainous terrain or only secondary roads OR certified as a CAH prior to January 1, 2006, based on State designation as a “necessary provider” of health care services to residents in the area.

Critical Access Hospital (CAH) Payments

Medicare pays CAHs for most inpatient and outpatient services to Medicare patients at 101 percent of reasonable costs.

For purposes of payment for ambulance services, if a CAH or an entity owned and operated by the CAH is the only provider or supplier of ambulance services located within a 35-mile drive of that CAH, the CAH or the CAH-owned and operated entity is paid 101 percent of the reasonable costs of the CAH or entity in furnishing ambulance services. Additionally, if there is no other provider or supplier of ambulance services within a 35-mile drive of the CAH but the CAH owns and operates an entity furnishing ambulance services that is more than a 35-mile drive from the CAH, that CAH-owned and operated entity can be paid 101 percent of reasonable costs for its ambulance services as long as it is the closest provider or supplier of ambulance services to the CAH.

CAHs are not subject to the Inpatient Prospective Payment System (IPPS) and the Hospital Outpatient Prospective Payment System (OPPS).

CAH services are subject to Medicare Part A and Part B deductible and coinsurance amounts.

What this means for rural areas is they have a “local hospital”. Obviously, not all services are available at critical access hospitals, many tertiary hospitals offer “outreach” services for the smaller facilities. Additionalyl, with the advent of telemedicine, many additional services are becoming available in rural communities

Resources

http://www.raconline.org/topics/critical-access-hospitals/

The chart below provides CAH resource information.For More Information About…	Resource
Critical Access Hospitals	http://www.cms.gov/Center/Provider-Type/Critical-Access-Hospitals-Center.html on the CMS website “Medicare Claims Processing Manual” (Publication 100-04) located at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html on the CMS website
Health Professional Shortage Areas	http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses on the CMS website
Compilation of Social Security Laws	http://www.ssa.gov/OP_Home/ssact/title18/1800.htm on the U.S. Social Security Administration website
“Code of Federal Regulations”	http://www.gpo.gov/fdsys/browse/collection.action? collectionCode=FR on the U.S. Government Printing Office website
All Available MLN Products	“Medicare Learning Network® Catalog of Products” located at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNCatalog.pdf on the CMS website or scan the Quick Response (QR) code on the right
Provider-Specific Medicare Information	MLN publication titled “MLN Guided Pathways to Medicare Resources Provider Specific Curriculum for Health Care Professionals, Suppliers, and Providers” booklet located at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/Guided_Pathways_Provider_Specific_Booklet.pdf on the CMS website
Medicare Information for Beneficiaries	http://www.medicare.gov on the CMS website

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Fighting the battle for prescribing rights.... HELP!

Well Ralph and I made it home without any drama. But what we did find when we got here is an attempt by the Tennessee legislature to remove the ability of NPs and PAs with prescribing authority to prescribe schedule drugs. Not just the opoids either, ALL schedule drugs. So I have been beating the drum and reinforcing my soap box as we prepare for the fight.

(Yes Ralph I will go ahead and tell them this is gonna be a "rant")

If this goes into law, NPs and PAs will not be able to prescribe opoids, ADD, ADHD, narcolepsy drugs and many others that the primary care provider writes for on a daily basis. We all know about healthcare shortages, and also know that NPs and PAs ar ethe ONLY helathcare Provider many rural residents see.

If this goes into law, the chronic patient's are not going to be the only ones who loose. What about your child that sits beside the child with ADD that can not get his medications because he lives in Podunk, TN and the closest "physician" is 100 miles away (remember, a "physician" would be the only one who could write a Rx for amphetamine salts)? What about the teacher attempting to teach the class with this child in it? If you live in, or are visiting, a rural area and yo break your leg? Sorry you will have to deal with excruating pain until you get some where with a "physician" so they can give you morphine.


If this passes, what will be next? Well they couldn't prescribe schedule drugs, so let's not let them prescribe anything? How big a step backward this would be for healthcare across the country. I don't want to be the "example" state that other states use to limit NP and PA scope of practice. This bill could ultimately affect every state to some degree.

I have written letters to my state legislators Represenative Barrett Rich and Senator Dolores Gresham( a copy is at the end of this blog, er rant). I will be in Nashville, TN on March 5th for NP Hill Day. PLEASE join me if you live in Tennessee. If you live elsewhere, bring this to the attention of your fellow NPs and PAs.

THERE IS POWER IN UNITY!

SB 0976 by *McNally ( HB 1211 by *Shepard)

Controlled Substances - As introduced, places certain conditions on nurse practitioners and physician assistants who are authorized to prescribe or issue Schedules II, III and IV drugs. - Amends TCA Title 63, Chapter 19 and Title 63, Chapter 7.

The bill in the Tennessee Senate is sponsored by Senator Randy McNally, a pharmacist:

Senator Randy McNally

R-Oak Ridge
District 5 — Anderson, Loudon, and part of Knox Counties — Map

district address

94 Royal Troon Circle
Oak Ridge, TN 37830
Phone (865) 483-5544

nashville address

301 6th Avenue North
Suite 307 War Memorial Building
Nashville, TN 37243
Phone (615) 741-6806
sen.randy.mcnally@capitol.tn.gov

Personal Information

• Married with two children
• 1962 Graduate of Oak Ridge High School
• B.S., Memphis State University, 1967
• U.T., College of Pharmacy, 1969
• Hospital Pharmacist, 1978 to present, at Methodist Medical Center, Oak Ridge, TN

My letter:

RE: SB 0976 by *McNally ( HB 1211 by *Shepard)

Controlled Substances - As introduced, places certain conditions on nurse practitioners and physician assistants who are authorized to prescribe or issue Schedules II, III and IV drugs. - Amends TCA Title 63, Chapter 19 and Title 63, Chapter 7.

I am currently board certified as both a Family Nurse Practitioner and an Acute Care Nurse Practitioner working as a provider in the emergency room of Saint Francis Memphis hospital. As such, the above bill will essentially eliminate my ability to treat patients in the emergency setting suffering from painful injuries. Additionally, it will severely limit the ability of my nurse practitioner colleagues to provide healthcare in the outpatient setting.  

As you know, there exists a Health Care Provider shortage currently - especially for physicians. In many rural communities Nurse Practitioners are the only source of quality healthcare available to the residents. Nurse Practitioners are educated on the pharmacological effects, abuse potential, and proper prescribing of all schedules of controlled substances, just as physicians are.

This bill will completely handicap the abilities of Nurse Practitioners to care for many of their patients. This legislation would not only prevent us from writing opioids, it will also prevent us from writing anti-anxiety medications, as well as medications for ADHD and ADD. This is a far reaching issue with many radiant effects on the entire healthcare system in the state of Tennessee, should this bill pass.

I will be the first to admit that there is a severe drug abuse problem throughout our country. However, if you will research the clinically based evidence, there is no indication that the problem is improper Nurse Practitioner prescribing practice. If you look at the states with “strict prescribing limitations” on Nurse Practitioners, you will find that the evidence shows their drug abuse rates are the same or greater that Tennessee’s.

I would appreciate the opportunity to meet with you and discuss this matter and some realistic alternatives to this bill at your convenience. I can make myself available as your schedule at home or in Nashville allows.  I will be in Nashville on the evening of March 4^th and on the hill all day on March 5^th if you have any available time then.

Thank you for your time and consideration,

Telemedicine in the ER

This is a link to a video I did about telemedicine in the ER.

http://www.youtube.com/watch?v=rTgLhPgXjR4&feature=share

Just because the Troponin is elevated doesn't mean it is a MI!

January 9, 2013

Most of us associate an elevated Troponin with a cardiac event. What do you do when you find no cardiac cause for the elevation? "Ralph" says: "send'em home their heart is ok." I am sure that none of you will do that, but where do we look, what do we look for? I have listed a few things that will cause elevation of the troponin without specific cardiac damage.
How did I figure this out? Well if you haven't seen by now that Brother Murphy hangs out with Ralph and I on a fairly regular basis, ya need to clean your glasses. If it is weird, uncommon, or "doesn't occur in this population", trust me, the patient will seek me out.
I had a patient present with a Troponin of 3.89 with NO EKG changes, NO chest pain, NO shortness of breath, NO CAD, and NO familial cardiac risk factors. His CKMB was at the upper limit of normal, and his CK index was normal.

After doing some research I discovered that sepsis, septic shock, systemic inflammatory response syndrome (SIRS),  hypotension, and hypovolemia, renal failure, inflammatory disease, burns > 25 % BSA, exertion, and post transplant were a few of the many reasons that could cause a "non cardiac event"  elevation in one's troponin.

I will let you research the patho behind these causes if you feel the need, but the point of this lesson is:
Sometimes we, as providers, forget that every patient does not "read the book". We ALWAYS have to treat the patient, not the monitor, or the lab results. If something isn't making sense, we probably need to look at it from a different direction.

In my patient, I ultimately found he had a chronic (undiagnosed) GI bleed. If I had "knee jerked" and given aspirin for an elevated troponin (thank you Dr Bandura, who told me "if the index is normal, look for something else"), I would have potentially made the patient worse.

Have a GREAT day!

Is your patient sick enough to admit?

1/6/2013

Is your patient sick enough to admit?

     For those of us that admit our own patients, we are always in a battle between case managers, utilization review, and our desire to provide the best care possible for our patients. Do you admit to observation, or do you do a full admission? Exactly how can we tell if our patient should be an “observation” status or a “full admission”?

     I am going to give you some “magic numbers for admission” from utilization review. This is by no means an all inclusive list, but it should give you some insight into how you patient should be admitted. These criteria are basically, “How sick is your patient?”

 1) Generally speaking, the condition should have an onset in the last 24 hours

 2) VITAL SIGNS

                Temp < 91 or > 106 (105 if patient is over 65)

Pulse- generally < 60 with symptoms or ? 3 second pause or >120 with arrhythmia +/- hemodynamic instability

Resp - >35 or impending intubation

SBP < 90 (only if decreased from baseline) or postural drop of > 30 or hypertensive emergency (sx or end organ damage)

SaO2 < 89%

 3) LABS

                WBC      > 16,000 (12,000 if suspect sepsis) or

< 4,000(if you suspect sepsis) or

Bands > 10%

                                Hgb < 6.0  Hct < 18%

                                Hgb < 8.3 Hct < 25% = age > 65

                                Plts < 60,000

                                Na < 120 or > 160 (with mental status changes)

                                K < 2.5 or > 6.0 with neuromuscular or ECG changes

                                BUN > 45

                                Cr > 3.0

                                Ca < 5.0 or > 15

                                Mg < 1.0 or > 3.0

                                Phos < 1.0

                                Acetaminophen > 300 + AST > 1000

                                Carboxyhemoglobin > 40%  or > 30% with mental status changes

WHAT ARE YOU DOING FOR YOUR PATIENT THAT CAN”T BE DONE AT HOME?

                Vital signs q 4 hours ( NOT q shift / while awake)

                Neuro checks q 4 hours

                IV fluids > 75 mL/hr

 IV meds _ antibiotics, proton pump inhibitor, insulin, steroids, pain meds (3X24 hours), diuretics (2X24 hours), anti-emetics (<3/24 hours)

Nebulizer Tx q 2 hours

O2 > 40%

Blood transfusion (>3 or 4 units/24 hours)

Chest tube TO SUCTION

GI suction

Hope this helps give you an idea as to whether it is an OBS or FULL admit. Unfortunately, as you can see even the guidelines "aren't sure".

The Flu is in Alaska!

1/2/2013

The flu is on the war path!

     Sorry for the sporadic posting, but I put these together in my apartment and then upload them when I have time at the hospital where my Wi-Fi access is. Now with that out of the way…..

     The flu has made it to Alaska! Interestingly enough, there is also a similar viral illness going around. It is only lasting for about 24 hours and all the “victims” are Flu A&B negative. Those that are Flu positive are predominately type A. So far we have only had two Type B positives.

     Another interesting note is that the Flu vaccine has only been available here since the middle of December, so several of the patients with flu “had their flu shot”. Interestingly enough, those that had their flu shot and now have the flu, had their immunization less than 2 weeks before getting the flu. Their body did not have enough time to protect itself from the virus.

     I have done some non scientific investigation into the evaluation and treatment of flu patients here. I got to wondering, actually Ralph was wondering, if we were getting flu swabs on appropriate patients. In other words, are we swabbing enough, too much, or just the right amount of patients? If we are not swabbing enough, we are missing cases. If we are swabbing everyone, we are artificially inflating the cost of health care. If we are swabbing “appropriately” we may miss one here and there, but we will be catching the majority of cases. At least, that is how Ralph and I think.

     So, I went to the lab and tallied up the total number of flu swabs done, the number of A positives, and the number of B positives. Using scientifically primitive math skills, I determined that 65% of the swabs we have done were positive. It would seem to me and Ralph that this indicates we are reasonably appropriate with our swabbing.

     Now some of you are in epidemiology and have real scientific evidence based data about the appropriate percentage of positives to negatives I am sure. I would appreciate your input on this so all of us can evaluate our practices and adjust accordingly. Please let us know what the “evidence based practice” goals should be.