Wednesday Lectures, 11/19/2014

TTHM 6.1 PDR, EOLC, Contracts…

 

10a Contracts (DiRubbo)

Beware & Remove Noncompete Agreements!

Employee v Partnership (usually after 3 to 5 yrs) v Independent Contractor (IRS Audit Indemnity clasuse?)

Scheduling, Insurance, Term, Salary, Termination clause…

2080 hours ~40hrs x52wks… Holidays? Vacations?

Typical Max 1840hrs ~40hrs x46wks gives 4wks vacation, 2wks CME…

1500hrs better…

*Scheduling requirements, know liability!

Title 38 scheduling requirements require call!?

*Insurance ~ occurrence & claims made (tail, nose)

Claims made insurance cheaper initially & ramps up…

NYS Occurrence policy ~$15K

*EMR requirements

*Salary Base, Incentive?, Taxes, Benefits & relation

*Termination Cause: *Material Breach? Due Process “as accorded to other members of the medical staff” & No Cause termination (business reason, time frame)… & Time Frame? effective immediately?

*Potentially everything is negotiable, but keep in mind base salary negotiation is potential for strife! Keep large bonuses to yourself.  Know who you are negotiating with.  Be prepared to walk away from the table.  HR will do the negotiations.  Know what you’re worth.  Waiting & weighing options can work, but still risky.

Career Planning Guide for EM (EMRA)

IRS.gov Indepeendent Contractor Test…

“PracticeLinks.com”

Talk to Joslin about quality projects…

 

11a Ultrasound (Nicholas) Book by Dr. Ma & Mateer

AAA, US probe to pt’s right… Ao top to bottom intransverse plane; IVC compressible, bifurcation of Ao is around umbilicus.  90% of AAA bleeds are retroperitoneal.

Firm pressure may be needed to push bowel gas out of the way… start up by the heart & work down…

FAST cardiac view subxiphoid should show RV closest to probe, LA farthest away/deepest, lokk for pleural effusion

eFAST includes lung sliding Mmode for “sandy beach” (good, “Seashore”) v “bar code” (bad,”Stratosphere”)… Comet tails are normal artifact but increase in pulmonary edema.

 

12p RPL#4 Trepanation/Burr Holes (Deepak)

 

1230~230 Grand Rounds (Lapointe, Tox)…

Cannabinoids… & Synthetics!

Late 1800s, opium developed to morphine… Coca to cocaine… but THC not easily located…

MJ caught a bad cultural rap in the 1930s, 1940s…  1964s structure determined & Pfeizer started making derivatives CP 47,497 one of the first… none came to market…

1970 Controlled Substances Act (Nixon) c CSA schedules 1 to 5…

CB1 & CB2 receptors, tend to be inhibitory Gprotein mediated channels exist for endogenous cannabinoids…

~Anandamide… JWH018 (John W. Huffman, 1990s)

“Painful mechanism slide”…

Rimonabant… Sz & Suicidality… (inverse CB1 agonist)

New products, new delivery methods, new politics…

MJ not yet shown to be good medicine, but needs comprehension as drug.

THC concentrations increasing.

Vaporizers on the rise, better for the lungs…

Honey butter dabs oil, 98% THC… Butane labs

10mg starting dose for edibles… 4.20 bars have 180mg!… Starts working ~1 to 2hrs.

Hyperemesis only helped by hot water, only after smoked form?!

Zostrix Capsaicin creme ~ case series up to 18pts, consider other heating modalities.

TrypV1 receptor…

Analogue Act… “Not for human consumption”?…

Google Flu predicts flu outbreaks from trend data & similar trend data may be useful for Tox…

 

230p EOLC/DNR Issues (Prince)

Death Notification…

Gather (Data, Family, Social Work, Resources…) KNOW THE NAME!

Resources (SW, Spiritual Care) DO NOT GO ALONE!

Identify PT BY NAME, move to eye level; Identify what they know.

Educate, clearly, briefly, plainly, & use the word “DIED/DEAD”.

Verify, express condolences

… Space, Quiet, Questions…

INquire ~ Questions, Resources needed/requested

Grieving Process, Autopsy Details, Plan… Give condolences, support, Resources…

*DNR/DNI ~ Capacity ~ A&O? Understand options & consequences? Informed medical decision?

Form does not need pt signature, should be witnessed by 2nd provider & documented conversation in chart.  Be gentle yet honest.

Order of consent priority: 1)guardian/HCP; 2)spouse or domestic partner; 3)adult child; 4)parent; 5)sibling; 6)other family member or friend with knowledge of pt wishes…

*Palliative Care is NOT necessarily Comfort Care! (although can include comfort care discussions…)

*Minors, Emancipation, & Consent ~ vary state to state…

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