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Integrity - EM physician integrity is under attack
Hospital system -Hospital is venue to admit and provide tools and tech for doctors to work. -Need hospital based specialists (such as ER physician) -Older system - sign exclusive contract to allow doc to see patients in hospital; hospital provides space and support staff. -Contract holders: Small group, single person, corporation Potential for trouble: Contract holder wants to pay physicians as little as possible, hire the most unqualified physician, and control doctors with ability to fire troublemakers and incur penalties for leaving.
Coercion
Corporate Practice of Medicine
How to protect EM Physicians
Lip and facial swelling - Angioedema to the Max!
Our New Scope is found in Room 1 of pixis- "endoscopy storz'. Attached to cmac to black plug, 29 yo bilateral leg pain Lactic acidosis
1. Resusucitate/supportive care 2. Identify cause with appropriate lab ordering 3. Empirically give Thiamine 500mg IV 4. Consider empiric Fomepizole after tox consult 5. Sodium Bicarbonate is controversial 6. When in doubt, call nephrology and dialyze Alcoholic KetoAcidosis -- Heavy etoh use with a recent binge, sudden cessation with abd pain, N/V. GI symptoms seen in 80%. -- Present with Absent ETOH level and Anion Gap metabolic acidosis. -- Due to increased betahydroxybutyrate ketone body, UA does not pick up ketone bodies on dip. -- Rarely will see severe lactic acidosis and if present think sepsis, seizures or thiamine deficiency. Tx:
Thiamine deficiency Pyruvate cannot enter TCA cycle causing high lactic acidosis resulting in Dry (neurologic) and Wet (cardiac) Beriberi. Also causes Wernicke (triad of AMS, opthalmoplegia, and ataxia seen only in 10% of patients). At risk- etoh, iatrogenic, aids, malignancy, gastric bypass, TPN 44yo fall from standing
Liver Function Tests are more indicative of liver damage... not "function."
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