The Q-Wave: Live from GAPA’s Summer Conference

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Everybody’s a genius, but if you judge a fish by its ability to climb a tree, it will live its whole life thinking it’s stupid. That’s my story. I didn’t graduate from high school on time because I struggled to learn. I flip around letters and I struggle with reading comprehension, so I grew up feeling like I was stupid.

I couldn’t do well in school but I love people and I love reading people. I could play chess. I’d hear a song twice and know all the lyrics. Why couldn’t I do well on standardized tests? Because standard, traditional teaching didn’t work for me.

I had to bust my ass to get Bs in PA school because I’m a non-traditional learner. You know what though? That made me a non-traditional teacher. I thought my inability to learn in high school was this huge liability. I realized it was a gift.

This story, this passion I have for teaching differently, doesn’t just equate to patient care. Who am I? What’s my credibility? I spent four years in the Marine Corps. During Desert Storm, I learned how to learn, because they gave me a stack of flashcards to differentiate tank armor. I was able to learn all the different armor like the back of my hand using flashcards. What I realized was I learned through repetitive kinesthetic methods.

Those experiences taught me that we all learn differently. Maybe you succeed when you hear lectures. But someone else may need to read about it or see a diagram. I try to incorporate that into my presentations.

After serving, I went and graduated from King’s College and I’ve been a PA for 21 years. Some of that time was spent as a hospitalist, covering telemetry, respiratory, heme-onc, nephrology and med surg. Then, I ran emergency rooms autonomously. Both of these jobs required me to be on my game all the time because there wasn’t anyone else. These experiences helped me develop “systems” for handling chest pains, shortness of breath, EKG interpretation and a lot more.

Last month, I had the pleasure of speaking at the Georgia Association of Physician Assistants’ annual Summer Conference. I want to share with you what I shared with the PAs there and encourage you to come and see for yourself how life changing a live event can be.

Understanding Key Concepts

I can’t stand in front of you and read slides. That’s not me. I want to give you information you can use in your clinical practice, so I’m going to focus on key concepts. Our urgent care conferences are usually four-day events, but for the GAPA event, I covered a review of blood clots, recent antibiotic updates, common infections and wound care, all in about 90 minutes. It was intense.

3 Catastrophic Blood Clots

No matter what field of medicine you’re in, there are three catastrophic blood clots that you need to understand:

  1. Heart Attack
  2. Stroke
  3. Pulmonary Embolism

Let’s compare and contrast for a second. Two of these clots are emboli and one is a thrombus. Typically, an MI is a growing clot and pain comes on crescendo-like. Two are arterial; one is venous. The risk factors for arterial disease are almost completely exclusive from venous disease.

In each category, there are big clots and little clots. No one misses a big PE. It’s the small PEs that get you. This is where we use the mnemonic “Who’s your PAPPA?” to cover the five causes of chest pain.

Bayes’ Theorem

Good clinicians embrace Bayes’ Theorem, which is the concept of pre-test probability. How sure am I that a patient’s sick before I even run the tests? You have to consider risk factors. For an MI, we use the mnemonic “SAD CHF” to remember the risk factors of smoking, age, diabetes, cholesterol, hypertension and family history.

Infectious Diseases and Antibiotics

Infectious disease can be almost overwhelming, but if you break it down to the fundamental basics, it’s not that hard. I believe PAs and NPs are on the front line of infectious disease and a lot of us are unprepared for that. It’s why we cover the topic so often on our emergency medicine videos.

My goal is to make sure you’re updated on the most current information about common infections in an urgent care setting. When you’re faced with infectious disease, I want you to keep these things in mind:

  1. When you’re working up someone for an infectious disease, get a valid temp.
  2. CBC is an incomplete picture. I don’t want just the white count, but also the neutrophils and bands.
  3. We have to think about five body systems: wind, water, brain, belly and skin.
  4. To identify a septic child, use the mnemonic TICKLES: tone, irritable, consolable, cry, labor, environment and suckling.
  5. Familiarize yourself with Sanford’s new recommendations on treating otitis media and conjunctivitis otitis syndrome. This was a game changer for me.
  6. Amoxicillin is a pretty safe medicine, as are cephalosporins and macrolides. Fluoroquinolones are dangerous. Proceed with caution.
  7. When you have someone with cellulitis, I want to know if they have bacteremia, stripes up their legs or lymphangitis.
  8. You need to use CENTOR criteria (cough, exudates, nodes, temp, or mono) for strep throat. Otherwise, you might miss a case of mono or end up with a complication like rheumatic fever.
  9. To diagnose rheumatic fever, you need evidence of a recent strep infection and two of the Jones criteria: chorea, myocarditis, erythema marginatum, subcutaneous nodules and polyarthritis. You can treat with penicillin, amoxicillin or Augmentin.
  10. Pyelonephritis can be life-threatening when combined with a kidney stone. Otherwise, you can treat with ceftriaxone and fluids, or as an outpatient with Cipro, Levaquin or moxifloxacin.

These ten takeaways are just the beginning. We go into much more depth at our own live conferences and on our blogs and podcast. I encourage you to educate yourself on these updates.

The Big Picture on Wounds

Wounds are very risky. Wounds and orthopedics are some of the biggest reasons we get sued. Know what you can and can’t do. If you look at a really nasty wound and say, “I’m uncomfortable with this,” that’s okay. Get a consult or send them to somebody else. Wound care is an art. There are a lot of different kinds of equipment and tools. We can let it close naturally or use paper, Steri-Strips, liquid glue, string, sutures and metal.

A huge part of trauma is wound care. In these cases, you need to slow down and understand what happened. When you have a laceration, take an extra minute and say, “Explain again how exactly this happened.” Then you can flush, brush and remove crust.

Our goal is always to avoid infection, as well as maintain skin integrity and minimize scars. Wounds account for a quarter of all medical malpractice claims, so you need to treat each wound as if it’s contaminated, with a tendon injury, nerve injury and retained foreign body.

I spoke for about an hour and a half at GAPA’s Summer Conference covering infectious disease, antibiotics and wounds, because I think they’re really important for PAs and NPs in urgent care. If you think this information is relevant to your practice, we would love to see you at one of our upcoming emergency medicine events.

Thank you for being a part of this body of information. Stay tuned for next month’s newsletter.

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The Q-Wave: Live from GAPA’s Summer Conference
John Bielinski, Jr., MS PAC is a practicing emergency medicine clinician, and has been lecturing nationally for more than ten years, teaching the tactics that have proven invaluable in his career as a medical professional.
The Q-Wave: Live from GAPA’s Summer Conference

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