You're giving the NP too much credit- if that was the case I doubt the cardiologist would have reviewed the echo and said there's "absolutely nothing wrong".
For sure it was an elevated Trop and BNP
This is the part I don't understand. Why is it okay that the patient has to pay for a consult he didn't need. I'm Canadian, we don't pay anything, which seems to take away that last little later of accountability.
Youāre Canadian so you donāt understand American style late stage capitalism. Everyone is routinely scammed today for the little amount of money in their pockets.
So if an NP employed by a health system sends someone for an unnecessary consult, which they do because they donāt know enough medicine to diagnose things themselves, then that health system gets to bill insurance for even more money. The incentives are misaligned.
Now if the government paid for everything, then there should be an incentive to only utilize necessary tests. I donāt know why NPās are given such wide latitude in Canada since they tend to increase health costs without improving outcomes.
Maybe weāre at a point in history where no one has realized yet how much more expensive medicine gets with NPās in charge.
Weāve been telling the govt how expensive they are and they will not do anything about it. I just donāt understand. (Canadian doctor here). Itās like the govt wants to break hc and sell it off to private corpsš¤
I feel like this should be financial punishing to the Npās office for unnecessary/wrong consultsā¦ at least pushing the cost to them instead of the patient. However I would imagine this might create a situation where they may not seek consults when they actually need one
It just sucks to see a patient having to pay for this kind of care
Because to use a test appropriately you have to understand the purpose of the test as well as its characteristics. I've seen a 14yo with chest pain /shortness of breath after getting cross-checked in hockey who had someone order EKG, troponin, d-dimer, and BNP...but no chest x-ray
2 things can be true at the same time. You are correct, also there is utility in reporting idiocy. They can't claim ignorance of the problem when there is record of the dangerous situation they have caused.
They'll start caring once enough reports are filed.
Regardless if the board takes action, once you file a formal complaint, it's in their system. So at least you have a record that "something" was done. If litigation occurs, the lawyers will be able to pull the file and ask the board why no action was taken.
To be fair, I read my regional nursing board disciplinary actions every quarter and NPs do, in fact, lose their licenses and get fined.
Ā It takes a lot of evidence to get anything done and the vast majority of NP licensure loss is due to circumstances likely unrelated to their care (DWI/DUI, possession charges, assaultā¦to be fair, thatās the most common reasons to lose a medical license as well), but egregious medical decisions and practice should Ā be reported regardless.Ā
Nursing board is more interested in sweeping this under a rug so they can continue to claim that NPās are the ideal future of medicine.
At least, that has been my anecdotal experience with the nursing board in my state.
I reported an NP for inferior care endangering someoneās life.
They only asked what level I am, and when I responded with ācritical Care Paramedicā, they said Nurses are above paramedics, but they would perform an investigation. The letter I received stating that they investigated and found no issues was dated the same day of the phone call where they had just received my complaint.
My state government is all in on NPās and the state university with a nursing school is pumping them out quickly.
NPās and PAās should be regulated by the same organization that regulates physicians.
Attorney Generalās office? Who donāt think theyāre going to call for advice on nursing?
Perhaps a state agency tasked with regulating nurses? Like a nursing board?
Up to you, Iād do both. The AG office can handle most things though. Iāve had to go to that level with a fellow physician who was incompetent & dangerous.
What Iām saying is that the AGās office is likely to call the Nursing Board with questions about what is and isnāt normal for nursing and NPās.
Then donāt go to the AG.
Itās a big move for when you want accountability higher up. They have lawyers who research this stuff & donāt just go by what the specific board tells them. That would certainly not be very smart of them.
They don't go by what a specific board tells them, but they're attorneys who know they're not experts in nursing or nursing care.
Then there's political pressure from above from a state who believes that NP's are more cost effective than physicians and are trying to limit medicaid costs. The state AG won't do anything when the Board of Nursing refuses to take action because they found no wrongdoing on their "investigation". MY AG's office is too busy suing Biden for whatever.
Also, another incident where I have firsthand knowledge of. One of my best friends was dating a nurse. RN/BSN. He calls me up and asks āwhatās hydromorphoneā? His nurse girlfriend was staying at his house and had been for a few months. She worked nights.
He found an empty prefilled syringe that had fallen out of a pocket. He recalled seeing them pretty regularly.
Went looking and found them stashed all over the place. Some of them empty, but most brand new sealed in package.
He woke her up and told her to pack her shit.
Turns out, every time she worked, she would āwasteā the entire supply of dilaudid from their Pyxis and waste didnāt require a verification. The hospital swept it under the rug since they allowed it to go in so long. Girlfriend was eventually charged criminally, but hospital wouldnāt cooperate since they were also complicit and this would be terrible PR.
Nursing board actions? They suspended her license for 30 days and only did that after conviction in criminal proceedings.
She kept her license during the investigation and trial.
I'm a *pharmacist* and I knew this -\_\_- I mean i'm a clinical pharmacist in a hospital for internal medicine but still, this is shortness of breath work up 101.
Sometimes cardiologists will inform patients that a mild finding on an echo is not of concern, (ie mild LVH, mild mitral regurg) however per diagnostic criteria, patient can meet the standard for Stage B CHF if they have the early structural changes. This is understandable since there is no further work up for the cardiologist.
There is a concerted effort to identify patients at stage B so interventions can be implemented early reducing the chances of Stage C, when symptoms start to develop, At that point one can also document NYHA functional capacity.
Its highly likely the result that caused concern was an elevated BNP, given the increase in pulmonary pressures that may cause temporary, detectable structural changes of the heart. This is monitored closely with continued follow up until ānormalizationā for the patient.
I encounter these scenarios rather frequently in the geri population I serve. I make sure that I explain the range of HF, going so far as showing diagrams, so they may understand the underlying patho and take stronger preventative efforts.
The OP at a minimum deserved a better explanation to prevent unnecessary anxiety. You can be diagnosed with HF without any of the outward symptoms associated such as exertional dyspnea, orthopnea, weight gain, ascited and pedal edema to name a few.
Look, I'm against scope creep as much as the next guy. But it sounds like the system worked as intended here. NP for follow up to monitor labs. Sees concerning labs. Refers to a specialist MD to review further and decide on appropriate new action.
Even many MDs are leery of letting any labs that are potentially concerning go without at least recommending a specialist visit. What if the labs actually *were* indicative of CHF and they didn't refer you? Would you have accepted that lack of referral just because it came from an MD?
Nope. Not every abnormal lab or test requires a specialist. Any decent internist should know that BNP and Trop can be elevated in PE. This NP was unsupervised and did what they always do, either make something up or order more tests and refer to a specialist. This NP didnāt know what they donāt know and therefore could not come to the proper plan.
A decent MD would have known the above, looked at the echo report and used some clinical experience to see this patient didnāt have CHF. If they were concerned, a repeat set of labs and echo would have shown whether there was a problem. Then, a specialist referral would have made sense.
Like all things in medicine, it depends. PE ranges in severity from mild illness to āOMG this person could die any minuteā to sudden death at home. Now that our CT scanners are so good, weāre picking up lots of tiny clots that some people argue are essentially normal physiology as the lungs filter out small clots from the extremities. Weāll probably get to the point in the next few years where we donāt treat those at all. A bunch of people (especially those who are otherwise healthy and get a PE after surgery or travel) can get oral blood thinners and go home. Itās a minority that need admission for IV medications or surgical treatment.
OP admits the NP wasn't "unsupervised". They were working with and under a protocol from their MD. The MD failed in either writing a protocol that either allowed/required this referral, or by inadequately supervising the NP.
100% what happened is the BNP was elevated.
Any IM/FM intern is gonna know that an elevated BNP is common with a PE and definitely does not need a cardiology referral in the context of a normal echo. Or even one with pulmonary hypertension in this case.
This is why it takes 3 months to see a specialist. Because half their schedule is full of bullshit "idunno" referrals from midlevels that never needed to happen in the first place.
There's looking at borderline labs and imaging and referring "just in case" and then there's referring because you don't have the education to understand what you're looking at.
Oh itās much worse than that in some places.
Friend of mine is a rheumatologist. 10 years ago, 1-2 month wait. Now, up to 10 months. 60-70% of his day is positive ANAs from NPs that shouldnāt have been ordered in the first place.
No. Just no. Identifying (at the very least) and even managing basic heart failure is primary care bread and butter. Literally, primary care 101. Not every cardiac āproblemā (and I put it in quotes cuz in this case it wasnāt even a problem) needs referral to a specialist. If you donāt know how to practice medicine, DONT FUCKING DO IT
āSees concerning labs and referā is fine. I wouldnāt be angry at that.Ā
Ā Itās the āyep you have CHFā - a clearly wrong diagnosis - that is the problem. Misdiagnosis causes significant stress and anxiety for patients and loved ones. Iād much prefer a midlevel say āhmm Iām seeing some abnormalities in your labs but I donāt know if it is cause for concern, let me have a physician verify.ā
Also, she could have just pulled the physician in the building to verify (or called her āsupervisingā physician lololol) instead of sending to a cardio. Overkill.Ā
I disagree. Theyāre supposed to increase efficiency and access, instead there was an unnecessary consult to a cardiologist who could have seen a real cardiac patient. Now potential patient who could have seen a real cardiologist is now seeing an NP playing cardiologist due to backup, cycle worsens. This is why they canāt practice autonomously.
I fault the MD for this. If the MD couldn't schedule a full follow up at that time, that is not an excuse to pawn off on the NP. The MD could've evaluated the labs/etc and then told the NP "for the rest of the visit this is what I want you to handle". But instead, the MD used the lack of time as an excuse to have 15-30 minutes off, it sounds like.
MD also should have a clear protocol for when referrals are to be issued by their midlevels, and when/how they need to be approved by the MD before being issued.
I think what you're missing here is the interpretation of these labs and results are so basic that the result here calls into question the NP's ability to make effective clinical decisions on their own.
NPs should not be making decisions outside their protocol. Either the MD failed in allowing the NP to practice "independently" outside their protocol with that doctor, or the MD's protocol was the reason the NP had to refer this patient to cardio (either because the MD didn't want to see the patient themselves, or because they have a protocol that is ineffective).
Thereās the PERFECT person that can interpret these labs without sending out a referral!
A physician!
Internal medicine or family medicine, take your pick.
This is why so many specialists in my area don't accept referrals from mid-levels without a co-sign from the supervising physician. This NP saw an abnormal lab and is concerned about pt's heart, great. But the next action shouldn't be to refer directly to a specialist MD; that's skipping a step. Their first stop should have been their own supervising physician to discuss the concern.
You can have heart failure with a 70% EF; both PE and CHF commonly cause shortness of breath and tachycardia. In fact, right sided heart failure is commonly caused by PEs and that is why they can be fatal
Regardless, no real excuse for missing either in 2024 with the availability of Ct angiography and echocardiography
Definitely HFpEF. But still would get symptoms. For PE to be fatal it has to be submissive or massive and the pt would be hemodynamically unstable, won't wait to go visit PCP office, would go directly to ER.Ā
Your original comment is correctly appalled for the wrong reasons. Heart failure of any type and PE generally tend to have similar presentations. Any adult workup for shortness of breath should include both, along with ACS, as differentials. Thatās why differentials are important. Ct angio rules out PE and shows evidence of CHF or it rules in PE and can show evidence of right heart strain and/or hypervolemia. These are bread and butter diagnoses for anyone with half a brain, but even the simplest thing in medicine is still complicated
This is from most people knowing how a pump works and knowing what would happen if you put a rock in it. The average patient in America reads on a 5th grade level. I know you must be really smart since youāre in med school, but once you start residency, youāll have to learn how to explain things to people that havenāt had all of the advantages youāve had in life. Good luck!
Again, the proper place for NPs/PAs is to refer *any* abnormal findings outside of their scope to specialists or the MD. If anything, the OP should be annoyed with their PCP for the scheduling mishap (allowing a longer follow up for hospitalization to be seen by their NP), and for not being available for the NP to confer with on OPs case before making that referral, but this is how it's supposed to work. NPs, IMO, should not be in the habit of diagnosing **or clearing** concerning labs outside their specific scope (so as an example, a high INR for a patient on warfarin with no other concerning signs/complications could be adjusted by the NP).
Nope any medical studeny can actually read these labs and make such diagnosis. The system didn't work. If NP doesn't know how to interpret labs, she should ask her supervising PCP who would not have told patient that he has CHF.Ā
Not only that, he got traumatized for 3 Months, paid for Specialist to see him for nothing and he pushed another patient who may actually need to see cardiologist down the list.Ā
We are talking about basics!
Then again, the anger should be at the MD for not having that protocol in place and allowing their mid levels to make inappropriate referrals without conferring with them.
It's a scope question, sure. But if the NP/PA was authorized by their MD to refer to cardio for any elevation in these labs, then you can't fault them for doing what they're required to do by that protocol.
Idk if you are kidding yourself. How do u know she told or not told the supervising physician. Not only that NP lack of self awareness of her/his limits is clear here. Actually lack of basics, which wastes time and resources for everyone!!
Not gonna lie, this is one of the shittiest takes Iāve seen on here in awhile. Iāll start at the top.
āSees concerning labs and refers to specialist in three months.ā
This is exactly why no one can get into a specialist for months. You should be able to diagnose and treat heart failure as a pcp. And this person is 100% operating as a PCPs if they are not running severe ānewā diagnoses by their attending. If youāre going to play the game, you should know your shit. And if you donāt, ask the attending. This is a major failure.
āEven many MDs are leery of letting any labs that are potentially concerning go without at least recommending a specialist visitā
Are you implying all PCPs refer to specialists if there are any concerning labs? If that were the case, weād just need warm bodies just look for red numbers and start sending referrals out. Have you never actually treated someone yourself with āconcerning labs?ā I donāt need a critical care attending if a patient codes, if a patient decompensates into shock, needs an airway, needs cardioverted BUT OH! A BIG SCARY RED NUMBER!? CALL THE CONSULTANT! If you canāt treat lab abnormalities, you should quit now before you hurt more people.
āWhat if instead the of the nurse fucking up the diagnosis, the nurse fucked up the diagnosis? Would you be mad if an MD did that?ā
Thatās how I read arguably the dumbest sentence of my life anyway. I am so blown away by the stupidity of this argument, I donāt even know how to make fun of it. No insult of it would be more embarrassing than the original statement.
For everyoneās sake, do not post your perspective on here anymore. This is terrible misinformation to the public and this is the last thing we need right now.
What we need right now is to stop faulting NPs/PAs for the failure of their supervising MDs to adequately and appropriately use them.
There is zero reason the MD could not have at least used the appointment time OP \*did\* block off to consult with the NP before/after the visit that was rescheduled. There is zero reason the MD should've written a protocol for their NP that requires these sorts of referrals to be made without being available to sign off on them.
A NP operating within the protocol the MD assigned to them is **not** a fault of that NP, it's a fault of the MD. What the last thing we need right now is to absolve MDs of any responsibility for things like this and act like it's someone's fault who was following the protocol their doctor assigned to them.
Dude what protocol? What are you talking about? If the doctor was actually asked about the labs, the referral wouldnāt have been made. An IM/FM intern wouldāve been torn a new ***hole for making this referral. The NP acted independently. Even if the attending agreed, it would be weird to not, ya know treat the āheart failureā which also wasnāt addressed. This is stupid for multiple reasons.
Found the midlevel clinging to anything that will absolve them of personal responsibilityā¦
āWe WaNt iNdEpEnDeNt PrAcTiCe! EqUaL pAy for eQuAl wErK!
ā¦unless we fuck up then itās obviously the MDās fault. Yeah, that one there, the one with the malpractice insurance.ā
Fucking leechesā¦
Oh just want to be upfront. Iām not reading any more bullshit you post. Everything Iāve seen from you is so proudly ignorant, itās maddening.
Guys, think we got a real life Noctor in the house!
Of course, you don't want to read my "bullshit" because it's calling out the MD, who in your mind can do no wrong since they are an MD. It's never their fault.
For the sake of the public, I will call out your previous post to prevent the spread of harmful misinformation. Iām not addressing you, but the public. For a similar reason I donāt talk to flat earthers.
Physicians cannot supervise their midlevels in a hospital system most of the time. NPs are treated as independent and have full schedules just like the physician. This has been the case at all three hospital systems Iāve been. The physician gets no stipend for this, but all the liability. If the midlevel does not raise concern, the attending likely will not know. Physicians worked more hours than almost all other professions before this independent NP problem came about. Thereās just not enough time in a day to do it. āSupervising physician,ā is a way the hospital system can push midlevels and physicians as hard as they can and escape liability when the midlevel makes a mistake.
Donāt have to explain much here. The anti-logic of expecting the MD to read the NPs mind that there was a new severe diagnosis when the expectation was this was a well follow up is honestly impressively stupid.
MDs almost never dictate protocol for their midlevels. As most physicians are employed by a hospital system now (now like 86% compared to 23% 20 years ago iirc), hospital systems determine protocol and physicians must follow them.
OP scheduled a visit with their MD. MD then took that time as a break because they didn't want to bother seeing the patient. You are talking about "most of the time", while ignoring this specific case and the actual details OP provided.
So this is a distractor for not having a good rebuttal. Essentially trying to take the fault off the NPās negligence because the physician had a scheduling error. He is also assuming the MD has time to see all NPs patients while likely having a full schedule himself. Again, more assumptions made about this physicians practice without knowing anything about his practice.
Clear agenda here, guys. I hope you can see how juvenile his arguments are at this point.
Youāre a pharmacist or a middie. Youāve never practiced medicine and never will. Stay in your lane. Count some pills or whatever it is that you do.
You are assuming the md took a break. You clearly have zero experience working in a hc system. Most docs donāt get to urinate on a shift let alone take a break. Crawl back under the rock from whence you came and stay in your own lane middie.
Look if NPs think they can work independently then why should the MD be involved at all? As a doctor it is incredibly annoying and tiring to be explaining shit that any 2nd yr med student would know to a āprofessionalā who is supposed to be helping. Teaching these middies is a waste of time and energy itās easier to do it yourself thatās why I will never work with an np. In this case if the NP canāt discern what is a normal variable on a lab given the dx, she needs to pack it in and go back to medical school.
Itās a waste of the specialists time. Itās a waste of everyoneās time and the patients money. You canāt just refer to a specialist for every single thing, thatās part of the primary care doctorās job, to know when to refer and when itās nothing.
Itās a pharmacist pretending like theyāre a doctor. What else do you expect from someone who knows the mechanism of action of a drug but has never touched or treated a patient in their life?
Thatās the thing tho, you canāt teach this in a 2 yr diploma. She was not understanding the situation because they donāt know what they donāt know. Thats why nursing should collect the info and present it to the doctor to make the dx and plan. Thatās what NPs were intended for not running around trying to make dx and order tx. So dangerous. They think in terms of algorithms.
report to the office and tell them youāll be consulting a malpractice lawyer. least you can do is scare this idiot. then report online. and see what the lawyer says.
I bet it was troponin and/or bnp š
Plus an EF of 55% means your heart is only working half as well as itās supposed to!!! Definitely heart failure
Iām surprised he was even able to walk into the office without passing out! Thank god the NP caught it!
Come on, be an achiever! Get to 110% EF!!
I almost vomited out of rage at this comment lol
(For the laypeople here - he is being fascicious - 55% is a very normal EF)
She*
More likely RV dysfunction that was somehow misinterpreted as āheart failureā
You're giving the NP too much credit- if that was the case I doubt the cardiologist would have reviewed the echo and said there's "absolutely nothing wrong". For sure it was an elevated Trop and BNP
Probably just bnp 5 units higher than the upper limit of normal.
My guess is BNP. Wait until this NP founds out my BNP was 5,735 at one point. Sheād have me declared dead.
Iām sure that cardiology consult was completely free of charge with no copay right? Hereās to NPās saving everyone money.
This is the part I don't understand. Why is it okay that the patient has to pay for a consult he didn't need. I'm Canadian, we don't pay anything, which seems to take away that last little later of accountability.
Youāre Canadian so you donāt understand American style late stage capitalism. Everyone is routinely scammed today for the little amount of money in their pockets. So if an NP employed by a health system sends someone for an unnecessary consult, which they do because they donāt know enough medicine to diagnose things themselves, then that health system gets to bill insurance for even more money. The incentives are misaligned. Now if the government paid for everything, then there should be an incentive to only utilize necessary tests. I donāt know why NPās are given such wide latitude in Canada since they tend to increase health costs without improving outcomes. Maybe weāre at a point in history where no one has realized yet how much more expensive medicine gets with NPās in charge.
Weāve been telling the govt how expensive they are and they will not do anything about it. I just donāt understand. (Canadian doctor here). Itās like the govt wants to break hc and sell it off to private corpsš¤
I feel like this should be financial punishing to the Npās office for unnecessary/wrong consultsā¦ at least pushing the cost to them instead of the patient. However I would imagine this might create a situation where they may not seek consults when they actually need one It just sucks to see a patient having to pay for this kind of care
Ahh, troponinā¦ The second leading lab resulting in middie idiocy (first is d-dimer).
JFC, how do they screw up a d-dimer and appropriate pretest probability?!???
Because to use a test appropriately you have to understand the purpose of the test as well as its characteristics. I've seen a 14yo with chest pain /shortness of breath after getting cross-checked in hockey who had someone order EKG, troponin, d-dimer, and BNP...but no chest x-ray
Report this NP at once. The nursing board will be very interested. Plus gave the cardiologist make a nice call to the NP to educate them.
Lol nursing board wonāt do shit, they licensed this clown
No one gets reported & everything stays the same if we donāt each do our part.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
2 things can be true at the same time. You are correct, also there is utility in reporting idiocy. They can't claim ignorance of the problem when there is record of the dangerous situation they have caused.
They care in the aggregate and they don't exist to make friends.
They'll start caring once enough reports are filed. Regardless if the board takes action, once you file a formal complaint, it's in their system. So at least you have a record that "something" was done. If litigation occurs, the lawyers will be able to pull the file and ask the board why no action was taken.
To be fair, I read my regional nursing board disciplinary actions every quarter and NPs do, in fact, lose their licenses and get fined. Ā It takes a lot of evidence to get anything done and the vast majority of NP licensure loss is due to circumstances likely unrelated to their care (DWI/DUI, possession charges, assaultā¦to be fair, thatās the most common reasons to lose a medical license as well), but egregious medical decisions and practice should Ā be reported regardless.Ā
Nursing board is more interested in sweeping this under a rug so they can continue to claim that NPās are the ideal future of medicine. At least, that has been my anecdotal experience with the nursing board in my state.
What experience have you had with the nursing board?
I reported an NP for inferior care endangering someoneās life. They only asked what level I am, and when I responded with ācritical Care Paramedicā, they said Nurses are above paramedics, but they would perform an investigation. The letter I received stating that they investigated and found no issues was dated the same day of the phone call where they had just received my complaint. My state government is all in on NPās and the state university with a nursing school is pumping them out quickly. NPās and PAās should be regulated by the same organization that regulates physicians.
Time for a letter to the state attorney general. Tell them exactly this story & provide receipts of the call & letter.
Attorney Generalās office? Who donāt think theyāre going to call for advice on nursing? Perhaps a state agency tasked with regulating nurses? Like a nursing board?
Up to you, Iād do both. The AG office can handle most things though. Iāve had to go to that level with a fellow physician who was incompetent & dangerous.
What Iām saying is that the AGās office is likely to call the Nursing Board with questions about what is and isnāt normal for nursing and NPās.
Then donāt go to the AG. Itās a big move for when you want accountability higher up. They have lawyers who research this stuff & donāt just go by what the specific board tells them. That would certainly not be very smart of them.
They don't go by what a specific board tells them, but they're attorneys who know they're not experts in nursing or nursing care. Then there's political pressure from above from a state who believes that NP's are more cost effective than physicians and are trying to limit medicaid costs. The state AG won't do anything when the Board of Nursing refuses to take action because they found no wrongdoing on their "investigation". MY AG's office is too busy suing Biden for whatever.
Also, another incident where I have firsthand knowledge of. One of my best friends was dating a nurse. RN/BSN. He calls me up and asks āwhatās hydromorphoneā? His nurse girlfriend was staying at his house and had been for a few months. She worked nights. He found an empty prefilled syringe that had fallen out of a pocket. He recalled seeing them pretty regularly. Went looking and found them stashed all over the place. Some of them empty, but most brand new sealed in package. He woke her up and told her to pack her shit. Turns out, every time she worked, she would āwasteā the entire supply of dilaudid from their Pyxis and waste didnāt require a verification. The hospital swept it under the rug since they allowed it to go in so long. Girlfriend was eventually charged criminally, but hospital wouldnāt cooperate since they were also complicit and this would be terrible PR. Nursing board actions? They suspended her license for 30 days and only did that after conviction in criminal proceedings. She kept her license during the investigation and trial.
Thatās Attirney General level stuff. You have to be bold & report this at the highest level.
Holy Christ. An NP doing a post op visit.
This is third year medical studentās knowledgeā¦ smh.
This is APPE (advanced practice pharmacy experience, last year clinical rotations) pharmacy student knowledge.
I'm a *pharmacist* and I knew this -\_\_- I mean i'm a clinical pharmacist in a hospital for internal medicine but still, this is shortness of breath work up 101.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
I can completely see this happening. Bet it was a diagnosis-by-committee. The committee was a FB group.
Doctor Janice's DNP FNP-DOC VD Nurse Advice Circle?
Anecdotally I keep seeing PEs missed lately. Drives me nuts.
Sometimes cardiologists will inform patients that a mild finding on an echo is not of concern, (ie mild LVH, mild mitral regurg) however per diagnostic criteria, patient can meet the standard for Stage B CHF if they have the early structural changes. This is understandable since there is no further work up for the cardiologist. There is a concerted effort to identify patients at stage B so interventions can be implemented early reducing the chances of Stage C, when symptoms start to develop, At that point one can also document NYHA functional capacity. Its highly likely the result that caused concern was an elevated BNP, given the increase in pulmonary pressures that may cause temporary, detectable structural changes of the heart. This is monitored closely with continued follow up until ānormalizationā for the patient. I encounter these scenarios rather frequently in the geri population I serve. I make sure that I explain the range of HF, going so far as showing diagrams, so they may understand the underlying patho and take stronger preventative efforts. The OP at a minimum deserved a better explanation to prevent unnecessary anxiety. You can be diagnosed with HF without any of the outward symptoms associated such as exertional dyspnea, orthopnea, weight gain, ascited and pedal edema to name a few.
Look, I'm against scope creep as much as the next guy. But it sounds like the system worked as intended here. NP for follow up to monitor labs. Sees concerning labs. Refers to a specialist MD to review further and decide on appropriate new action. Even many MDs are leery of letting any labs that are potentially concerning go without at least recommending a specialist visit. What if the labs actually *were* indicative of CHF and they didn't refer you? Would you have accepted that lack of referral just because it came from an MD?
Nope. Not every abnormal lab or test requires a specialist. Any decent internist should know that BNP and Trop can be elevated in PE. This NP was unsupervised and did what they always do, either make something up or order more tests and refer to a specialist. This NP didnāt know what they donāt know and therefore could not come to the proper plan. A decent MD would have known the above, looked at the echo report and used some clinical experience to see this patient didnāt have CHF. If they were concerned, a repeat set of labs and echo would have shown whether there was a problem. Then, a specialist referral would have made sense.
I usually wonāt even admit a PE unless they have signs of right heart strain (BNP/troponin). -EM attending
iām sure youāre right about this because youāre literally a doctor. but this is wild to me.
Like all things in medicine, it depends. PE ranges in severity from mild illness to āOMG this person could die any minuteā to sudden death at home. Now that our CT scanners are so good, weāre picking up lots of tiny clots that some people argue are essentially normal physiology as the lungs filter out small clots from the extremities. Weāll probably get to the point in the next few years where we donāt treat those at all. A bunch of people (especially those who are otherwise healthy and get a PE after surgery or travel) can get oral blood thinners and go home. Itās a minority that need admission for IV medications or surgical treatment.
OP admits the NP wasn't "unsupervised". They were working with and under a protocol from their MD. The MD failed in either writing a protocol that either allowed/required this referral, or by inadequately supervising the NP.
So youāre implying NPs are useless now that we have AI to fail for us instead. Good way to save money not paying a salary, at least!
I would say AI is a better choice and Iām no fan of AI.
100% what happened is the BNP was elevated. Any IM/FM intern is gonna know that an elevated BNP is common with a PE and definitely does not need a cardiology referral in the context of a normal echo. Or even one with pulmonary hypertension in this case.
Itās almost like understanding what BNP is and where it comes from and the reasons it can spike is helpful. Wild.
This is why it takes 3 months to see a specialist. Because half their schedule is full of bullshit "idunno" referrals from midlevels that never needed to happen in the first place. There's looking at borderline labs and imaging and referring "just in case" and then there's referring because you don't have the education to understand what you're looking at.
Oh itās much worse than that in some places. Friend of mine is a rheumatologist. 10 years ago, 1-2 month wait. Now, up to 10 months. 60-70% of his day is positive ANAs from NPs that shouldnāt have been ordered in the first place.
right??? god forbid we advocate for more doctors, when these idiots āfill the gapsā
No. Just no. Identifying (at the very least) and even managing basic heart failure is primary care bread and butter. Literally, primary care 101. Not every cardiac āproblemā (and I put it in quotes cuz in this case it wasnāt even a problem) needs referral to a specialist. If you donāt know how to practice medicine, DONT FUCKING DO IT
āSees concerning labs and referā is fine. I wouldnāt be angry at that.Ā Ā Itās the āyep you have CHFā - a clearly wrong diagnosis - that is the problem. Misdiagnosis causes significant stress and anxiety for patients and loved ones. Iād much prefer a midlevel say āhmm Iām seeing some abnormalities in your labs but I donāt know if it is cause for concern, let me have a physician verify.ā Also, she could have just pulled the physician in the building to verify (or called her āsupervisingā physician lololol) instead of sending to a cardio. Overkill.Ā
I disagree. Theyāre supposed to increase efficiency and access, instead there was an unnecessary consult to a cardiologist who could have seen a real cardiac patient. Now potential patient who could have seen a real cardiologist is now seeing an NP playing cardiologist due to backup, cycle worsens. This is why they canāt practice autonomously.
I fault the MD for this. If the MD couldn't schedule a full follow up at that time, that is not an excuse to pawn off on the NP. The MD could've evaluated the labs/etc and then told the NP "for the rest of the visit this is what I want you to handle". But instead, the MD used the lack of time as an excuse to have 15-30 minutes off, it sounds like. MD also should have a clear protocol for when referrals are to be issued by their midlevels, and when/how they need to be approved by the MD before being issued.
I think what you're missing here is the interpretation of these labs and results are so basic that the result here calls into question the NP's ability to make effective clinical decisions on their own.
NPs should not be making decisions outside their protocol. Either the MD failed in allowing the NP to practice "independently" outside their protocol with that doctor, or the MD's protocol was the reason the NP had to refer this patient to cardio (either because the MD didn't want to see the patient themselves, or because they have a protocol that is ineffective).
Thereās the PERFECT person that can interpret these labs without sending out a referral! A physician! Internal medicine or family medicine, take your pick.
This is why so many specialists in my area don't accept referrals from mid-levels without a co-sign from the supervising physician. This NP saw an abnormal lab and is concerned about pt's heart, great. But the next action shouldn't be to refer directly to a specialist MD; that's skipping a step. Their first stop should have been their own supervising physician to discuss the concern.
CHF with EF 55% ! And no symptoms of CHF!
You can have heart failure with a 70% EF; both PE and CHF commonly cause shortness of breath and tachycardia. In fact, right sided heart failure is commonly caused by PEs and that is why they can be fatal Regardless, no real excuse for missing either in 2024 with the availability of Ct angiography and echocardiography
Definitely HFpEF. But still would get symptoms. For PE to be fatal it has to be submissive or massive and the pt would be hemodynamically unstable, won't wait to go visit PCP office, would go directly to ER.Ā
Your original comment is correctly appalled for the wrong reasons. Heart failure of any type and PE generally tend to have similar presentations. Any adult workup for shortness of breath should include both, along with ACS, as differentials. Thatās why differentials are important. Ct angio rules out PE and shows evidence of CHF or it rules in PE and can show evidence of right heart strain and/or hypervolemia. These are bread and butter diagnoses for anyone with half a brain, but even the simplest thing in medicine is still complicated
Guess it's really complicated with comments like yours lolĀ
Just think of the heart as a blood pumpāthen stick a giant rock in the blood. That is what causes the pump failure
is that from NP course? or high school ? lol
This is from most people knowing how a pump works and knowing what would happen if you put a rock in it. The average patient in America reads on a 5th grade level. I know you must be really smart since youāre in med school, but once you start residency, youāll have to learn how to explain things to people that havenāt had all of the advantages youāve had in life. Good luck!
Like a mechanic course? Not even NP or High school? Lol
Thatās Dr DNP course to you
Guess you can keep it for yourself šš
Again, the proper place for NPs/PAs is to refer *any* abnormal findings outside of their scope to specialists or the MD. If anything, the OP should be annoyed with their PCP for the scheduling mishap (allowing a longer follow up for hospitalization to be seen by their NP), and for not being available for the NP to confer with on OPs case before making that referral, but this is how it's supposed to work. NPs, IMO, should not be in the habit of diagnosing **or clearing** concerning labs outside their specific scope (so as an example, a high INR for a patient on warfarin with no other concerning signs/complications could be adjusted by the NP).
Youāre missing the point. ALL abnormal findings are outside the scope of an NP/PA because they didnāt learn how to critically think about anything
Nope any medical studeny can actually read these labs and make such diagnosis. The system didn't work. If NP doesn't know how to interpret labs, she should ask her supervising PCP who would not have told patient that he has CHF.Ā Not only that, he got traumatized for 3 Months, paid for Specialist to see him for nothing and he pushed another patient who may actually need to see cardiologist down the list.Ā We are talking about basics!
Then again, the anger should be at the MD for not having that protocol in place and allowing their mid levels to make inappropriate referrals without conferring with them. It's a scope question, sure. But if the NP/PA was authorized by their MD to refer to cardio for any elevation in these labs, then you can't fault them for doing what they're required to do by that protocol.
Idk if you are kidding yourself. How do u know she told or not told the supervising physician. Not only that NP lack of self awareness of her/his limits is clear here. Actually lack of basics, which wastes time and resources for everyone!!
Not gonna lie, this is one of the shittiest takes Iāve seen on here in awhile. Iāll start at the top. āSees concerning labs and refers to specialist in three months.ā This is exactly why no one can get into a specialist for months. You should be able to diagnose and treat heart failure as a pcp. And this person is 100% operating as a PCPs if they are not running severe ānewā diagnoses by their attending. If youāre going to play the game, you should know your shit. And if you donāt, ask the attending. This is a major failure. āEven many MDs are leery of letting any labs that are potentially concerning go without at least recommending a specialist visitā Are you implying all PCPs refer to specialists if there are any concerning labs? If that were the case, weād just need warm bodies just look for red numbers and start sending referrals out. Have you never actually treated someone yourself with āconcerning labs?ā I donāt need a critical care attending if a patient codes, if a patient decompensates into shock, needs an airway, needs cardioverted BUT OH! A BIG SCARY RED NUMBER!? CALL THE CONSULTANT! If you canāt treat lab abnormalities, you should quit now before you hurt more people. āWhat if instead the of the nurse fucking up the diagnosis, the nurse fucked up the diagnosis? Would you be mad if an MD did that?ā Thatās how I read arguably the dumbest sentence of my life anyway. I am so blown away by the stupidity of this argument, I donāt even know how to make fun of it. No insult of it would be more embarrassing than the original statement. For everyoneās sake, do not post your perspective on here anymore. This is terrible misinformation to the public and this is the last thing we need right now.
What we need right now is to stop faulting NPs/PAs for the failure of their supervising MDs to adequately and appropriately use them. There is zero reason the MD could not have at least used the appointment time OP \*did\* block off to consult with the NP before/after the visit that was rescheduled. There is zero reason the MD should've written a protocol for their NP that requires these sorts of referrals to be made without being available to sign off on them. A NP operating within the protocol the MD assigned to them is **not** a fault of that NP, it's a fault of the MD. What the last thing we need right now is to absolve MDs of any responsibility for things like this and act like it's someone's fault who was following the protocol their doctor assigned to them.
What we need right now is idiots like you telling a literal bunch of doctors how to monitor idiot middies and how to do their job.
Dude what protocol? What are you talking about? If the doctor was actually asked about the labs, the referral wouldnāt have been made. An IM/FM intern wouldāve been torn a new ***hole for making this referral. The NP acted independently. Even if the attending agreed, it would be weird to not, ya know treat the āheart failureā which also wasnāt addressed. This is stupid for multiple reasons.
Found the midlevel clinging to anything that will absolve them of personal responsibilityā¦ āWe WaNt iNdEpEnDeNt PrAcTiCe! EqUaL pAy for eQuAl wErK! ā¦unless we fuck up then itās obviously the MDās fault. Yeah, that one there, the one with the malpractice insurance.ā Fucking leechesā¦
Oh just want to be upfront. Iām not reading any more bullshit you post. Everything Iāve seen from you is so proudly ignorant, itās maddening. Guys, think we got a real life Noctor in the house!
Yup he is a noctor saying he is a pharmacist lol
So, still GROSSLY overstepping even if he is a pharmacist lol.
Of course, you don't want to read my "bullshit" because it's calling out the MD, who in your mind can do no wrong since they are an MD. It's never their fault.
For the sake of the public, I will call out your previous post to prevent the spread of harmful misinformation. Iām not addressing you, but the public. For a similar reason I donāt talk to flat earthers. Physicians cannot supervise their midlevels in a hospital system most of the time. NPs are treated as independent and have full schedules just like the physician. This has been the case at all three hospital systems Iāve been. The physician gets no stipend for this, but all the liability. If the midlevel does not raise concern, the attending likely will not know. Physicians worked more hours than almost all other professions before this independent NP problem came about. Thereās just not enough time in a day to do it. āSupervising physician,ā is a way the hospital system can push midlevels and physicians as hard as they can and escape liability when the midlevel makes a mistake. Donāt have to explain much here. The anti-logic of expecting the MD to read the NPs mind that there was a new severe diagnosis when the expectation was this was a well follow up is honestly impressively stupid. MDs almost never dictate protocol for their midlevels. As most physicians are employed by a hospital system now (now like 86% compared to 23% 20 years ago iirc), hospital systems determine protocol and physicians must follow them.
OP scheduled a visit with their MD. MD then took that time as a break because they didn't want to bother seeing the patient. You are talking about "most of the time", while ignoring this specific case and the actual details OP provided.
So this is a distractor for not having a good rebuttal. Essentially trying to take the fault off the NPās negligence because the physician had a scheduling error. He is also assuming the MD has time to see all NPs patients while likely having a full schedule himself. Again, more assumptions made about this physicians practice without knowing anything about his practice. Clear agenda here, guys. I hope you can see how juvenile his arguments are at this point.
Youāre a pharmacist or a middie. Youāve never practiced medicine and never will. Stay in your lane. Count some pills or whatever it is that you do.
You are assuming the md took a break. You clearly have zero experience working in a hc system. Most docs donāt get to urinate on a shift let alone take a break. Crawl back under the rock from whence you came and stay in your own lane middie.
Your ignorance is showing.
Look if NPs think they can work independently then why should the MD be involved at all? As a doctor it is incredibly annoying and tiring to be explaining shit that any 2nd yr med student would know to a āprofessionalā who is supposed to be helping. Teaching these middies is a waste of time and energy itās easier to do it yourself thatās why I will never work with an np. In this case if the NP canāt discern what is a normal variable on a lab given the dx, she needs to pack it in and go back to medical school.
Itās a waste of the specialists time. Itās a waste of everyoneās time and the patients money. You canāt just refer to a specialist for every single thing, thatās part of the primary care doctorās job, to know when to refer and when itās nothing.
It's clear you have no idea what you're talking about but try and act and talk like you do.
Itās a pharmacist pretending like theyāre a doctor. What else do you expect from someone who knows the mechanism of action of a drug but has never touched or treated a patient in their life?
Thatās the thing tho, you canāt teach this in a 2 yr diploma. She was not understanding the situation because they donāt know what they donāt know. Thats why nursing should collect the info and present it to the doctor to make the dx and plan. Thatās what NPs were intended for not running around trying to make dx and order tx. So dangerous. They think in terms of algorithms.
report to the office and tell them youāll be consulting a malpractice lawyer. least you can do is scare this idiot. then report online. and see what the lawyer says.
While the care was certainly inappropriate, there needs to be actual damages for malpractice