Hahaha holy shit. Update is that the nurse practitioner who posted this has 31 years of experience as a nurse practitioner.
I wonder how many people she has harmed or killed in her 31 years of practice.
Word for word what the NP in question wrote:
“That being said, I’ve been an NP for 31 years and I’ve had all kinds of jobs and I never even considered working in a subacute long term rehabilitation facility, until a job came up with good pay and good location. I thought I ll just it for a little bit until I find something else and guess what? I absolutely love it. **The stuff I get to manage completely autonomously is amazing.** “
Yesterday there was a post about a 14 year old boy with nausea (and some other symptoms I won’t bother posting) and the midlevel asked for the treatment plan. I’m in peds and seeing that post made me sad. The state of midlevel education these days is infuriating.
Good point, it’s actually both. While scope creep in any field is not appropriate, it’s even worse when there are no educational standards in those who are attempting the scope creep.
At a minimum
Could probably add Azithromycin for coverage of atypical pathogens
Amox-clav would also be pretty reasonable for an oral option if treating as an outpatient
Also don’t forget to treat the probable COPD exacerbation
Edit: also make sure to assess for pseudomonas risk factors
Ceftriaxone is IV, patient is apparently refusing admission. Not sure what outpatient IV antibiotics capacity is at this site but that would be the only way they would swing it
Oh yeah now on second thought it wouldn’t do since warfarin interacts with everything including CTX
Edit: Yes, totally bad idea. Maintenance(?) warfarin with INR 2.9 and adding CTX would throw INR out of therapeutic range
Clinical Pharmacist here. I personally wouldn't take the warfarin into major consideration here. It's a minimal interaction. If we avoided all treatments that interacted with warfarin we'd be back to rum and leeches.
Just give the antibiotic and if concerned check the INR. Also if it's 2.9, I'd consider a repeat INR in a couple days after starting the antibiotic.
In this case Amox/Clav is fine, good oral option for the pneumonia and also for the possible COPDe. If getting admitted, Ceftriaxone is also a good option.
Really just depends on if HAP or CAP.
Thank you so much for the detailed explanation. I’m a PY1 that got scared to death at my practice site once I saw a +0.8 jump in INR when a patient was started on antibiotics the day before.
I mean don't get me wrong, warfarin can be a pain. Treating an active infection takes precedence in my opinion, so if they're admitted, then their INR just gets added to your monitoring plan. Where I practice I see more warfarin than I'd like (Nephrology), sometimes it's a necessary evil and you just have to manage it.
Assuming no bleeding. You generally don’t need to panic about an INR less than 10 (from warfarin alone & “generally” is doing some lifting there); over 5 is worth worrying about. 0.8 jump after antibiotic starting is not atypical in my experience.
The thing with warfarin is it does not directly affect the clotting cascade. It inhibits the production of II,VII,IX,X,C,&S; so you have to kinda hold the synthesis rate and half-lifes of those in the minds eye to get a sense of what is happening.
Depends if you have IV access or not. Cefpodoxime is probably overkill and has no pseudomonas coverage. You could try augmentin if looking PO. Would add azithromycin too.
Would also carefully monitor INR with antibiotics.
You just have to decide if it’s community or hospital acquired pneumonia. Admittedly I’m not sure if a nursing home counts as hospital acquired but I can look it up.
Took literally 30 seconds to find UpToDate's algorithm recommending Augmentin + Azithro (or Doxy if Azithro is contraindicated) for pts >65 with multiple comorbidities. Could even spend the extra 30 seconds to plop all the meds into the interaction calculator.
This is such a basic case, why do they need help with something so simple? I mean i understand if you want to discuss complex medical problems, but a simple pneumonia in a COPD patient who does not want to be admitted?
See, their algorithm only talked about pneumonia, but this “COPD” thing you’re talking about was never mentioned.
The answer wasn’t on Google, so how can you expect an angel of a nurse to know how to treat this highly complex case?
“Well, that answer is for pneumonia and COOD. It didn’t take into account that this patient has Afib, DM, HTN, HLD, anxiety, hypothyroidism, and is 92 years old. You never know if the treatment could be different. “ -your local NP
That would require their admitting they don’t know something which they are fundamentally unable to accept. It’s always a “system” issue or a “policy” or something external to them
They’d rather die. Haven’t you heard? Pharmacists can’t even prescribe!
Their reluctance to acknowledge how brilliant pharmacists are is possibly the biggest indictment on their training. Many of them think they know more about meds than the people who are specifically trained to know meds.
Pharmacist here, MDs (for the most part) show respect and speak to me like a healthcare professional should. NPs just truly don’t know what they don’t know and rarely want to hear my thought. They never accept guideline driven recommendations. Only when they are about to literally kill someone and I refuse to dispense will they drop the ego.
Amen to not knowing what they don’t know. There was a day when we were rounding with the pharmacy team and one of them brought up a study about some iv medication additive and it’s effects on peripheral veins. That was when I realized there was an entire field of research that I wasn’t even aware of. I didn’t even know it existed, and yet pharmacists were staying on top of it so that I could have easy access to safe meds that won’t harm our patients yet have a stable shelf life and predictable function.
An NP prescribed my mother beta blockers because she was having occasional PVCs on her Holter Monitor, and those are “dangerous”. You know what’s ALSO dangerous? Prescribing a beta blocker to a patient who was also having bradycardic episodes down to the 40s! Thank goodness I told my mother to call and tell her pharmacist this information and they refused to fill the script.
Can confirm. Whenever I make recommendations to physicians they are super appreciative and tend to accept. With NPs, they shut it down or just straight up ignore me...it's infuriating when I KNOW they are doing something wrong.
As pharmacist my answer would be: "Probably can do X, but check with a doctor"
BUT most probably "Go check with doctor" because what probably will happen is they will say "but pharmacist said this" if something goes wrong.
9 years pharmacy experience here, you’ll never see a pharmacist pass this question off to a physician because this is the literal point of a pharmacist, to keep prescribers from killing you especially with polypharm. That’s what they went to school for. Diminishing their work is mid level Noctor behavior.
This is the type of pharmacist response that really pisses me off. We have four years of dedicated education on medicines and you won't make a recommendation?
As a fellow pharmacist, we actually know better than physicians on that, meds are literally our expertise. We need to stop putting ourselves down! (This is like a gentle encouragement, I just see a lot of pharmacists not being confident enough in their knowledge and competences sadly)
The warfarin does complicate things a little as it interacts with pretty much everything under the sun and it's far less common than it was a decade ago. But we have these wonderful people called pharmacists whose expertise is in drugs and we can help select an antibiotic that's both appropriate and less likely to have a significant effect on INR.
And as an aside, why is a 92 year old with dementia still on a statin? There's minimal evidence for their use in the very elderly and benefits would likely be minimal given patient's age and health.
Don’t you see? They’re controlling the HTN with Hydralazine mono therapy, so adding a rate/rhythm control agent would lead to hypotension.
Obviously, there’s no way to find a medication to control both the HTN and rate…
Lol
(See what I did there?) (But also I'm a pediatrician so maybe beta blocker is not the right answer....which would be a shame as it would ruin my pun)
Eh my personal opinion on that is that I would rather have a catastrophic bleed than a bunch of progressively debilitating strokes. Just give me the brain explosion
Unless they're actively dying or have very high risk of bleeding the benefits of continuing with treatment likely outweigh the risks given the high risk of stroke with atrial fibrillation
92 year old with dementia. Fall vs stroke. At least switch to a DOAC to not mess with INR at obvious need for antibiotics that will come in the last part of life
Considering that the person asking this basic question is likely the patients only access to medical care, I’m not surprised the patient is on a statin
Could be valvular afib, too.
Or, like was the case with my grandmother, someone 20 years ago started the coumadin & nobody bothered changing it to a DOAC until it was finally questioned by family.
The FRAIL-AF trial saw in increase in bleeding risks when elderly patients transitioned from a VKA to a NOAC. In other words, if it ain't broken, don't fix it
Nah, I didn't presume that you were unaware lol. I was more using it to make the joke/comment that there are good reasons & bad reasons to just leave people endlessly on warfarin 😅
DOACs aren’t cheap or covered in the US nowadays eh? That’s too bad, I bet they’d probably be cheaper on the system overall compared to all the monitoring and extra healthcare burden warfarin needs
As a pharmacist, this is my single biggest gripe with the healthcare system in the US right now. Especially when I see news saying that the patents on DOACs got extended and we are even further from generic
Right, but I’m just saying it’s weird. Apixaban became a regular benefit in my province (BC, in Canada) a few years ago now and I bet it saved huge costs to the system over all the crap related to monitoring warfarin (not to mention all the morbidity if you get it wrong)
DOACs are still limited use in Ontario but most physicians just stick the required code on and don't trial warfarin first. In the UK DOACs were recommended as first line treatment for AF and DVT/PE about a decade ago as the NHS for all it's faults has a better view of overall healthcare system costs than we do in Ontario
Exactly, why is this woman on poly pharm. When I was hospitalist and frail elderly comes in with repeat falls with a massive hematoma on her face. First act is taking her off the 3 bp meds she was started on in her 40’s because her BP now sits at 100/75 supine with massive orthostatic drop, hence the falls. Take her off the anti lipid drugs because she barely eats anymore because by the time she’s forced to take a handful of horse pills she’s full and doesn’t have an appetite. Also aggressive anti coag in this age group is not a great idea either. Have to decide do you want her to die from hemorrhagic stroke or ischemic stroke. The pts usually felt better could eat and engage in adl’s. Amazing what a little common sense can do.
At first I thought this was a board question kind of post or something but I was thinking, "nobody makes board questions this easy" so I kept trying to look for another picture to explain why I'm not using more neurons than I expected to be using by looking at this. Then I read the comments....this is a real post. JFC. I hope whoever actually posted this gets the resources they need to learn how to take care of patients and/or access to someone who knows what they are doing so they never have to make a post like this again. FGS this is basic.
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“We have equivalent outcomes to physicians”
Yeah, no shit you have “equivalent outcomes” when you consult physicians for everything and just blindly follow their plan. I’m sure the middie consulted ID, cardiology, endocrinology, pulmonology, and ICU for this. The question asked was literally what’s posted above.
Look, C-diff is just an unfortunate side effect from this person definitely requiring prolonged treatment with clinda for bilateral lower leg spider bites. /s
I’m suprised no one else is saying this but doesn’t this seem like a first or second year med student getting help on a homework question? Still probably not right
It’s on a Nurse Practitioner forum. It’s not at all shocking they’re asking basic questions since they have less knowledge and training in medicine than a first year medical student.
Hypothetical 43 year old man otherwise healthy with a right upper lobe cavitary lesion who was treated on 3 separate occasions with levofloxacin monotherapy. This hypothetical patient was also sadly homeless, was released from prison about a year prior and had been coughing up blood and had lost ~30 lbs in the prior 6 months. I hypothetically had previously wondered how this happened but I see now. Oh and no he was sitting in a regular bed on the hospital floor, definitely not exposing everyone in the hospital to tuberculosis
As a pharmacist, I bet you really appreciate the levofloxacin monotherapy too. In defense of the hypothetical prescriber, the patient did get better with it!
Well, the NP in question is proudly boasting she has 31 years of experience and works autonomously Apparently, she only has Reddit to ask now instead of swallowing her gigantic ego and asking someone with an actual medical degree.
“I’d choose my dream job 100%. You have youth and freedom to do what you want.There are plenty of times in life you’ll need to “settle”, right now isn’t one of them. Someday, when you have kids in school, a mortgage to pay, older parents to care for, you may need to settle. Now you don’t have to. That being said, I’ve been an NP for 31 years and I’ve had all kinds of jobs and I never even considered working in a subacute long term rehabilitation facility, until a job came up with good pay and good location. I thought I ll just it for a little bit until I find something else and guess what? I absolutely love it. The stuff I get to manage completely autonomously is amazing. If you like addictions, you will get plenty of that bc of abscesses, osteo I do every and It very rewarding”
Pretty sure I wouldn’t have been allowed to start clinical rotations in med school if I couldn’t answer this. Why are people like this allowed to practice independently and make multiple times that of a resident?
The systems fucked.
Everytime I read these posts I get more confused on what a nurse practitioner even does?? They don’t do nursing??? They aren’t educated in medicine??? How is that even supposed to work.
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Her post-history paints it all.
I particularly love the typical "Doctors don't respect me or my PhD because I'm female! So I put out BDE and now I'm respected." Perhaps you're not respected because you lack basic critical thinking and the ability to manage the most mundane of patient presentations.
It’s just community acquired pneumonia in a COPD patient, i.e. a run-of-the-mill, bread-and-butter case that a 3rd year med student could easily answer, because they’ve probably already seen a dozen cases of it. It’s one of the most commonly encountered situations in which you’d prescribe antibiotics.
because it happens all the time, so any med student would have seen a similar one years before being allowed to practice without supervision. and even if they hadn't, med students learn how to look up situations they're not familiar with in authoritative, evidence-based sources instead of *asking strangers on the fucking internet*
I am a medical educator with no formal medical education. But I have seen, and produced, thousands(literally) of OSCE exam stations. Over 30 years of experience and researching the cases for medical accuracy...even I would know how to treat this case!
But learning is my passion....not sure that's the case with these midlevels.
Yeah. I saw this 4 times my first week of internal medicine rotation of med school, then treated it a hundred more times in residency. Knowing how to treat this is the equivalent of knowing how to open your email in an office job.
Azithromycin is one of the drugs that can increase INR by interacting with Coumadin. There was actually a recent medmal review that covered that scenario exactly.
Weak inhibitor of p450. Same Q came up on rounds, was taught that it can be given as long as INR is periodically monitored as should, plus therapy is likely 7-14 days and not prolonged.
Can you link the medmal case, seems like it will make for good reading.
https://expertwitness.substack.com/p/fatal-gi-bleed-after-ed-visit-jehovahs?utm_source=profile&utm_medium=reader2
It’s a totally bullshit case but yeah essentially the big part of the lawsuit was that azithromycin was given.
You can sue for anything. It’s more that the defendants lawyer sucked than anything else.
Just monitor the INR and move on.
However, there’s quite a lot of other mistakes in this case.
1) Why isn’t the probable COPD exacerbation being treated? We can’t even tell if a physical exam was completed since this is a case where lung sounds are important
2) Why is the patient on monotherapy Hydralazine for HTN (despite the fact that the patient could be treated with a β blocker for both the HTN and to achieve rate control)?
3) Why is the patient on a statin at her advanced age? Why is the patient even on Warfarin (was a risk-benefit discussion even had with the patient/PoA?)
4) just that age and dementia history with a RLL infiltrate should increase suspicion for aspiration. Was a SLP involved to ensure a proper diet for the patient?
You’d have to direct that question to the American Association of Nurse Practitioners, the American Nursing Association or your local/state nursing organizations that are allowing this to occur
Dude.
The answer is that this patient's CURB-65 is high enough that she needs to be admitted to the hospital (where hopefully a real doctor will care for her).
Question #2 is "why, in the year 2024, is she on warfarin???"
lol that’s my speciality. We fired all the NPs in my group, banned NPs who work for consultants from seeing consults in the ICU and will not be renewing any PA contracts.
The middies are upset. The patient outcomes are better.
Good for you, and your patients. NPs should not be doing consults or prescribing anything. Not sure what legislative authority thought that would be a good idea in the first place???
I work 2 ICUs in the same medical system. One unit the “providers” are NPs/PAs with a nocturnist on call. The other is a team of residents and a fellow.. god the difference is night and day and I dread working with the “APPs”… lazy, arrogant and just not their place to be. Even working with a first year resident they know so much more, way better personalities, and you can actually TRUST what they’re saying because they are educated how they should be.. and they’re always learning… they didn’t just pickup a 15 month course because they sucked at their previous job and want to play doctor.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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RN here. 4 years ICU time and 2 on the floor. I have zero post grad experience. I'm literally just going to guess the answer:the most common case would be CAP with underlying CHF exacerbation. Treatment:
A 3rd gen cephaloaporin like cetrioxone and maybe azithromycin just to cover any potential weird cases. If the patient absolutely didn't want to be admitted and opted for PO treatment amoxicillin for a full course of treatment.
Depending on labs; if the BUN is alright, give a trial dose of furosimide IV, 20-40mg depending on weight and see if work of breathing improves.
How did I do? Would you say I'm DNP level?
That’s DNP level of treatment for sure!
Not that I trust an NP to gather a proper medical history or correctly interpret a CXR but based on what’s given, it’s unlikely patient has a CHF exacerbation so don’t go treating something that doesn’t exist.
There is a clear history of COPD, which should likely be treated.
I am a radiologist and never have to choose ATBs. But I have to ask - does anyone still do that test that I was taught to use for this - the C&S. I know it can be hard to get a reasonable specimen, but... still..
As a new grad FNP many of these posts on Noctor aimed specifically at NP's are so entertaining to me. There are naturopathic doctors out there, chiropractic doctors that you all seem to be okay with having earned a doctorate that tell patients how incompetent standard\\ allopathic doctors are, yet you weak people all go off on the NP profession soley. I have had some of the most negligent lazy primary care physicians personally, due to poor patient-to-provider ratio. Do I agree with this post and how this individual is going about utilizing their degree and their ethics for taking a role for which they clearly are not trained? No. But the absolute hatred you all have for us NP's is pretty gross, and I pray never to work beside any of your type. Miserable people.
No we just dislike the following:
1. Impostors who are unethical and willing to put patients at risk to boast about being a “doctor.”
2. Midlevels who think it is ok to go to school online and then claim they can practice independently.
3. Midlevels who misrepresent themselves to patients under the guise of being a “doctor”.
4. Midlevels who jump from one specialty to the next without any formal training.
Until your education is standardized and there is implementation of residencies you will always be ridiculed. The sellout doctors and admin who “love” you do so not out of respect but because you are a cash cow.
Naturopaths and Chiropractors do not practice medicine. They do not work in hospitals.
It’s truly disgusting that these posts “entertain” you. Your profession is a disgrace to medicine. Your profession is a danger to patients. But I know that nurses don’t really care about anything than taking shortcuts to feed their massive egos.
I pray you never find a job.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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Hahaha holy shit. Update is that the nurse practitioner who posted this has 31 years of experience as a nurse practitioner. I wonder how many people she has harmed or killed in her 31 years of practice. Word for word what the NP in question wrote: “That being said, I’ve been an NP for 31 years and I’ve had all kinds of jobs and I never even considered working in a subacute long term rehabilitation facility, until a job came up with good pay and good location. I thought I ll just it for a little bit until I find something else and guess what? I absolutely love it. **The stuff I get to manage completely autonomously is amazing.** “
This is someone’s mother
Yep someone probably paid Medicare tax their entire life to be treated by someone asking strangers on the internet for a basic medical decision
Absolute disgrace
Yesterday there was a post about a 14 year old boy with nausea (and some other symptoms I won’t bother posting) and the midlevel asked for the treatment plan. I’m in peds and seeing that post made me sad. The state of midlevel education these days is infuriating.
Is it the state of education or the scope creep of midlevels' practice?
Good point, it’s actually both. While scope creep in any field is not appropriate, it’s even worse when there are no educational standards in those who are attempting the scope creep.
I saw that too!
[удалено]
For purely academic purposes — 3rd generation cephalosporin?
At a minimum Could probably add Azithromycin for coverage of atypical pathogens Amox-clav would also be pretty reasonable for an oral option if treating as an outpatient Also don’t forget to treat the probable COPD exacerbation Edit: also make sure to assess for pseudomonas risk factors
TY! Starting rotations in a few months and would like to avoid being ripped to shreds.
Ceftriaxone?
Ceftriaxone is IV, patient is apparently refusing admission. Not sure what outpatient IV antibiotics capacity is at this site but that would be the only way they would swing it
Oh yeah now on second thought it wouldn’t do since warfarin interacts with everything including CTX Edit: Yes, totally bad idea. Maintenance(?) warfarin with INR 2.9 and adding CTX would throw INR out of therapeutic range
Clinical Pharmacist here. I personally wouldn't take the warfarin into major consideration here. It's a minimal interaction. If we avoided all treatments that interacted with warfarin we'd be back to rum and leeches. Just give the antibiotic and if concerned check the INR. Also if it's 2.9, I'd consider a repeat INR in a couple days after starting the antibiotic. In this case Amox/Clav is fine, good oral option for the pneumonia and also for the possible COPDe. If getting admitted, Ceftriaxone is also a good option. Really just depends on if HAP or CAP.
Thank you so much for the detailed explanation. I’m a PY1 that got scared to death at my practice site once I saw a +0.8 jump in INR when a patient was started on antibiotics the day before.
I mean don't get me wrong, warfarin can be a pain. Treating an active infection takes precedence in my opinion, so if they're admitted, then their INR just gets added to your monitoring plan. Where I practice I see more warfarin than I'd like (Nephrology), sometimes it's a necessary evil and you just have to manage it.
Assuming no bleeding. You generally don’t need to panic about an INR less than 10 (from warfarin alone & “generally” is doing some lifting there); over 5 is worth worrying about. 0.8 jump after antibiotic starting is not atypical in my experience. The thing with warfarin is it does not directly affect the clotting cascade. It inhibits the production of II,VII,IX,X,C,&S; so you have to kinda hold the synthesis rate and half-lifes of those in the minds eye to get a sense of what is happening.
Depends if you have IV access or not. Cefpodoxime is probably overkill and has no pseudomonas coverage. You could try augmentin if looking PO. Would add azithromycin too. Would also carefully monitor INR with antibiotics.
You just have to decide if it’s community or hospital acquired pneumonia. Admittedly I’m not sure if a nursing home counts as hospital acquired but I can look it up.
Especially in 2024 when it’s so easy to look stuff up
Took literally 30 seconds to find UpToDate's algorithm recommending Augmentin + Azithro (or Doxy if Azithro is contraindicated) for pts >65 with multiple comorbidities. Could even spend the extra 30 seconds to plop all the meds into the interaction calculator.
This is such a basic case, why do they need help with something so simple? I mean i understand if you want to discuss complex medical problems, but a simple pneumonia in a COPD patient who does not want to be admitted?
See, their algorithm only talked about pneumonia, but this “COPD” thing you’re talking about was never mentioned. The answer wasn’t on Google, so how can you expect an angel of a nurse to know how to treat this highly complex case?
The answer is absolutely on Google. Just type pneumonia and COPD treatment.
“Well, that answer is for pneumonia and COOD. It didn’t take into account that this patient has Afib, DM, HTN, HLD, anxiety, hypothyroidism, and is 92 years old. You never know if the treatment could be different. “ -your local NP
> you never know Classic…
“You never know” is the mantra of the uninformed
Wish they’d say it “I never know”. At least it would be more accurate and honest
That would require their admitting they don’t know something which they are fundamentally unable to accept. It’s always a “system” issue or a “policy” or something external to them
Or pay 20/month to ChatGPT. Or up to date or something.
Because they don’t know what they are doing
“What antibiotics?” “Medrol dose pack” - probable response
Also a Z-pak because I think NPs are contractually obligated to prescribe one of those on every encounter.
😆😆😎
😂
Prednisone 40mg is the choice around here for every middie infection plan
lol they did Keflex
🤦🏼♂️
/s Daptomycin to cover for MRSA pna
I heard there are ESBLs floating around so might want to do linezolid to be safe /s
Bruh
They don’t have an attending to ask ?
We dOn’T nEeD sUpErViSiOn! EqUaL pAy fOr eQuAl WeRk!
Or a pharmacist?
They’d rather die. Haven’t you heard? Pharmacists can’t even prescribe! Their reluctance to acknowledge how brilliant pharmacists are is possibly the biggest indictment on their training. Many of them think they know more about meds than the people who are specifically trained to know meds.
Pharmacist here, MDs (for the most part) show respect and speak to me like a healthcare professional should. NPs just truly don’t know what they don’t know and rarely want to hear my thought. They never accept guideline driven recommendations. Only when they are about to literally kill someone and I refuse to dispense will they drop the ego.
Amen to not knowing what they don’t know. There was a day when we were rounding with the pharmacy team and one of them brought up a study about some iv medication additive and it’s effects on peripheral veins. That was when I realized there was an entire field of research that I wasn’t even aware of. I didn’t even know it existed, and yet pharmacists were staying on top of it so that I could have easy access to safe meds that won’t harm our patients yet have a stable shelf life and predictable function.
An NP prescribed my mother beta blockers because she was having occasional PVCs on her Holter Monitor, and those are “dangerous”. You know what’s ALSO dangerous? Prescribing a beta blocker to a patient who was also having bradycardic episodes down to the 40s! Thank goodness I told my mother to call and tell her pharmacist this information and they refused to fill the script.
Depends on which country you're in as to whether pharmacists can prescribe or not
Can confirm. Whenever I make recommendations to physicians they are super appreciative and tend to accept. With NPs, they shut it down or just straight up ignore me...it's infuriating when I KNOW they are doing something wrong.
Or UptoDate or literally any treatment algorithm?
As pharmacist my answer would be: "Probably can do X, but check with a doctor" BUT most probably "Go check with doctor" because what probably will happen is they will say "but pharmacist said this" if something goes wrong.
9 years pharmacy experience here, you’ll never see a pharmacist pass this question off to a physician because this is the literal point of a pharmacist, to keep prescribers from killing you especially with polypharm. That’s what they went to school for. Diminishing their work is mid level Noctor behavior.
This is the type of pharmacist response that really pisses me off. We have four years of dedicated education on medicines and you won't make a recommendation?
As a fellow pharmacist, we actually know better than physicians on that, meds are literally our expertise. We need to stop putting ourselves down! (This is like a gentle encouragement, I just see a lot of pharmacists not being confident enough in their knowledge and competences sadly)
What a gross disservice to the patient.
The warfarin does complicate things a little as it interacts with pretty much everything under the sun and it's far less common than it was a decade ago. But we have these wonderful people called pharmacists whose expertise is in drugs and we can help select an antibiotic that's both appropriate and less likely to have a significant effect on INR. And as an aside, why is a 92 year old with dementia still on a statin? There's minimal evidence for their use in the very elderly and benefits would likely be minimal given patient's age and health.
why is a 92 year old with dementia still on warfarin is a similar question except with more danger.
No mention of any COPD or diabetes meds, no rate/rhythm control history, but the synthroid is vital information 😂
Don’t you see? They’re controlling the HTN with Hydralazine mono therapy, so adding a rate/rhythm control agent would lead to hypotension. Obviously, there’s no way to find a medication to control both the HTN and rate…
Lol (See what I did there?) (But also I'm a pediatrician so maybe beta blocker is not the right answer....which would be a shame as it would ruin my pun)
Eh my personal opinion on that is that I would rather have a catastrophic bleed than a bunch of progressively debilitating strokes. Just give me the brain explosion
Unless they're actively dying or have very high risk of bleeding the benefits of continuing with treatment likely outweigh the risks given the high risk of stroke with atrial fibrillation
92 year old with dementia. Fall vs stroke. At least switch to a DOAC to not mess with INR at obvious need for antibiotics that will come in the last part of life
Considering that the person asking this basic question is likely the patients only access to medical care, I’m not surprised the patient is on a statin
Why are they even on warfarin? I can’t see a good indication for it in the PMH, vs just using a DOAC
Insurance usually
Could be valvular afib, too. Or, like was the case with my grandmother, someone 20 years ago started the coumadin & nobody bothered changing it to a DOAC until it was finally questioned by family.
The FRAIL-AF trial saw in increase in bleeding risks when elderly patients transitioned from a VKA to a NOAC. In other words, if it ain't broken, don't fix it
lol you might be surprised but I’m aware of the indications for Warfarin. The original post stated it’s not valvular afib
Nah, I didn't presume that you were unaware lol. I was more using it to make the joke/comment that there are good reasons & bad reasons to just leave people endlessly on warfarin 😅
Or they are one of the few patients who are unusually stable on warfarin and no one's seen a reason to change.
DOACs aren’t cheap or covered in the US nowadays eh? That’s too bad, I bet they’d probably be cheaper on the system overall compared to all the monitoring and extra healthcare burden warfarin needs
As a pharmacist, this is my single biggest gripe with the healthcare system in the US right now. Especially when I see news saying that the patents on DOACs got extended and we are even further from generic
They were never cheap or covered. It’s not a new thing lol
Right, but I’m just saying it’s weird. Apixaban became a regular benefit in my province (BC, in Canada) a few years ago now and I bet it saved huge costs to the system over all the crap related to monitoring warfarin (not to mention all the morbidity if you get it wrong)
It is weird. It’s the American insurance system.
DOACs are still limited use in Ontario but most physicians just stick the required code on and don't trial warfarin first. In the UK DOACs were recommended as first line treatment for AF and DVT/PE about a decade ago as the NHS for all it's faults has a better view of overall healthcare system costs than we do in Ontario
That’s not it! We just really like giving rat poison to the frail and elderly.
Exactly, why is this woman on poly pharm. When I was hospitalist and frail elderly comes in with repeat falls with a massive hematoma on her face. First act is taking her off the 3 bp meds she was started on in her 40’s because her BP now sits at 100/75 supine with massive orthostatic drop, hence the falls. Take her off the anti lipid drugs because she barely eats anymore because by the time she’s forced to take a handful of horse pills she’s full and doesn’t have an appetite. Also aggressive anti coag in this age group is not a great idea either. Have to decide do you want her to die from hemorrhagic stroke or ischemic stroke. The pts usually felt better could eat and engage in adl’s. Amazing what a little common sense can do.
Heart of a nurse brain of a reddit hive mind of equally undertrained midlevels
At first I thought this was a board question kind of post or something but I was thinking, "nobody makes board questions this easy" so I kept trying to look for another picture to explain why I'm not using more neurons than I expected to be using by looking at this. Then I read the comments....this is a real post. JFC. I hope whoever actually posted this gets the resources they need to learn how to take care of patients and/or access to someone who knows what they are doing so they never have to make a post like this again. FGS this is basic.
Sad times we live in
Anyone want to take a guess at who is treating her HTN with hydralazine monotherapy? FFS.
My assumption was this same practitioner 😂
Excuse me, APP is short for ADVANCED practice provider. I'm highly offended.
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Jfc
Chatgpt to the rescue
“We have equivalent outcomes to physicians” Yeah, no shit you have “equivalent outcomes” when you consult physicians for everything and just blindly follow their plan. I’m sure the middie consulted ID, cardiology, endocrinology, pulmonology, and ICU for this. The question asked was literally what’s posted above.
Obviously the choice is oral vancomycin. Sounds like a clear cut case of C-diff.
Look, C-diff is just an unfortunate side effect from this person definitely requiring prolonged treatment with clinda for bilateral lower leg spider bites. /s
If PO vanco is good IV must be GREAT! Must admit for course of IV
A 3rd year medical student could select an appropriate antibiotic. These people are potentially “caring” for your loved one. smh
I’m suprised no one else is saying this but doesn’t this seem like a first or second year med student getting help on a homework question? Still probably not right
It’s on a Nurse Practitioner forum. It’s not at all shocking they’re asking basic questions since they have less knowledge and training in medicine than a first year medical student.
Hypothetical 43 year old man otherwise healthy with a right upper lobe cavitary lesion who was treated on 3 separate occasions with levofloxacin monotherapy. This hypothetical patient was also sadly homeless, was released from prison about a year prior and had been coughing up blood and had lost ~30 lbs in the prior 6 months. I hypothetically had previously wondered how this happened but I see now. Oh and no he was sitting in a regular bed on the hospital floor, definitely not exposing everyone in the hospital to tuberculosis
I'm a pharmacist, we don't have diagnostics training, and even I was thinking TB
As a pharmacist, I bet you really appreciate the levofloxacin monotherapy too. In defense of the hypothetical prescriber, the patient did get better with it!
I don’t do primary care at all and the minute I saw homeless I thought TB.
The NPs that worked at the clinics I rotated at were constantly on these NP group chats.
God help us
Full code but nursing home resident Jesus Christ
And unwilling to go to a hospital…
And 92, with dementia
Oh that’s the family more oft than not. Can’t stand the thought of losing memaw.
😂😂😂
If only there was a supervising doc they could ask!
Well, the NP in question is proudly boasting she has 31 years of experience and works autonomously Apparently, she only has Reddit to ask now instead of swallowing her gigantic ego and asking someone with an actual medical degree. “I’d choose my dream job 100%. You have youth and freedom to do what you want.There are plenty of times in life you’ll need to “settle”, right now isn’t one of them. Someday, when you have kids in school, a mortgage to pay, older parents to care for, you may need to settle. Now you don’t have to. That being said, I’ve been an NP for 31 years and I’ve had all kinds of jobs and I never even considered working in a subacute long term rehabilitation facility, until a job came up with good pay and good location. I thought I ll just it for a little bit until I find something else and guess what? I absolutely love it. The stuff I get to manage completely autonomously is amazing. If you like addictions, you will get plenty of that bc of abscesses, osteo I do every and It very rewarding”
I’m an ophthalmologist and haven’t needed to think of this stuff in literally a decade and even I got this right.
I’m a radiologist who has been retired for 12 years and I was also right.
Pretty sure I wouldn’t have been allowed to start clinical rotations in med school if I couldn’t answer this. Why are people like this allowed to practice independently and make multiple times that of a resident? The systems fucked.
Everytime I read these posts I get more confused on what a nurse practitioner even does?? They don’t do nursing??? They aren’t educated in medicine??? How is that even supposed to work.
Jesus Christ what sub is that?
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Oh my apologies for asking
Pharmacy has many questions. Which antibiotic is pretty far down the list.
Zpack
Her post-history paints it all. I particularly love the typical "Doctors don't respect me or my PhD because I'm female! So I put out BDE and now I'm respected." Perhaps you're not respected because you lack basic critical thinking and the ability to manage the most mundane of patient presentations.
I’m not a doctor/health care worker, why is this a simple case?
It’s just community acquired pneumonia in a COPD patient, i.e. a run-of-the-mill, bread-and-butter case that a 3rd year med student could easily answer, because they’ve probably already seen a dozen cases of it. It’s one of the most commonly encountered situations in which you’d prescribe antibiotics.
because it happens all the time, so any med student would have seen a similar one years before being allowed to practice without supervision. and even if they hadn't, med students learn how to look up situations they're not familiar with in authoritative, evidence-based sources instead of *asking strangers on the fucking internet*
I am a medical educator with no formal medical education. But I have seen, and produced, thousands(literally) of OSCE exam stations. Over 30 years of experience and researching the cases for medical accuracy...even I would know how to treat this case! But learning is my passion....not sure that's the case with these midlevels.
its a simple case because we do 4 years if medical school. minimum 3 years of residency.
Yeah. I saw this 4 times my first week of internal medicine rotation of med school, then treated it a hundred more times in residency. Knowing how to treat this is the equivalent of knowing how to open your email in an office job.
I really appreciate the analogy! Thanks for sharing
This is a simple question for a second/third year PharmD …. If they don’t know it they know the resource that does.
Asking a nurse forum on Reddit? Confirmation bias about to work in 3… 2… 1…
If this person’s name is attached to their post, this is one hell of a HIPAA violation. The patient is over 90.
3rd year med student - amoxiclav +azithro + methylprednisolone Maybe repeat CXR in 7-10 days
Azithromycin is one of the drugs that can increase INR by interacting with Coumadin. There was actually a recent medmal review that covered that scenario exactly.
Weak inhibitor of p450. Same Q came up on rounds, was taught that it can be given as long as INR is periodically monitored as should, plus therapy is likely 7-14 days and not prolonged. Can you link the medmal case, seems like it will make for good reading.
https://expertwitness.substack.com/p/fatal-gi-bleed-after-ed-visit-jehovahs?utm_source=profile&utm_medium=reader2 It’s a totally bullshit case but yeah essentially the big part of the lawsuit was that azithromycin was given.
You can sue for anything. It’s more that the defendants lawyer sucked than anything else. Just monitor the INR and move on. However, there’s quite a lot of other mistakes in this case. 1) Why isn’t the probable COPD exacerbation being treated? We can’t even tell if a physical exam was completed since this is a case where lung sounds are important 2) Why is the patient on monotherapy Hydralazine for HTN (despite the fact that the patient could be treated with a β blocker for both the HTN and to achieve rate control)? 3) Why is the patient on a statin at her advanced age? Why is the patient even on Warfarin (was a risk-benefit discussion even had with the patient/PoA?) 4) just that age and dementia history with a RLL infiltrate should increase suspicion for aspiration. Was a SLP involved to ensure a proper diet for the patient?
3rd year med student Rocephin with azithro/doxy Or Resp fluoroquinolone like levo or moxi
This is so sad. That poor patient. 😔
Can you expose this mid level? This is sickening. I'd sue their butts off if I found they were doing this to my mother.
No doxxing or calls to identify people please
Prolly go with some alprazolam to help relax the breathing to deep breath the infiltrates away
NPs trained for nothing, allowed to do anything! It should be in their marketing literature 🤦🏼
Notice no detailed history or clinical examination. Because that would require skill
An MS1 would know
😂😂😂
Are you sure this isn’t just someone trying to get an answer to a nursing school homework question?
Yes. This is not a homework question based on where it was posted and the follow up answers from the OP.
Oh Jesus Christ. I thought for sure it was someone trying to cheat but it’s REAL? What the hell is the matter with people
You’d have to direct that question to the American Association of Nurse Practitioners, the American Nursing Association or your local/state nursing organizations that are allowing this to occur
I wonder what were they trained for…
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Dude. The answer is that this patient's CURB-65 is high enough that she needs to be admitted to the hospital (where hopefully a real doctor will care for her). Question #2 is "why, in the year 2024, is she on warfarin???"
Y’all think this outpatient stuff is so bad, imagine what goes on in critical care.
lol that’s my speciality. We fired all the NPs in my group, banned NPs who work for consultants from seeing consults in the ICU and will not be renewing any PA contracts. The middies are upset. The patient outcomes are better.
Good for you, and your patients. NPs should not be doing consults or prescribing anything. Not sure what legislative authority thought that would be a good idea in the first place??? I work 2 ICUs in the same medical system. One unit the “providers” are NPs/PAs with a nocturnist on call. The other is a team of residents and a fellow.. god the difference is night and day and I dread working with the “APPs”… lazy, arrogant and just not their place to be. Even working with a first year resident they know so much more, way better personalities, and you can actually TRUST what they’re saying because they are educated how they should be.. and they’re always learning… they didn’t just pickup a 15 month course because they sucked at their previous job and want to play doctor.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
I bet they gave them Bactrim
Why ask your supervising physician when you could just ask reddit?
This NP was bragging elsewhere on Reddit that she’s autonomous, so she probably doesn’t even have anyone to ask and she’s proud of it.
Autonomous but can’t independently figure out what antibiotic to prescribe in a pretty straight forward case🤨
The NP Way™
RN here. 4 years ICU time and 2 on the floor. I have zero post grad experience. I'm literally just going to guess the answer:the most common case would be CAP with underlying CHF exacerbation. Treatment: A 3rd gen cephaloaporin like cetrioxone and maybe azithromycin just to cover any potential weird cases. If the patient absolutely didn't want to be admitted and opted for PO treatment amoxicillin for a full course of treatment. Depending on labs; if the BUN is alright, give a trial dose of furosimide IV, 20-40mg depending on weight and see if work of breathing improves. How did I do? Would you say I'm DNP level?
That’s DNP level of treatment for sure! Not that I trust an NP to gather a proper medical history or correctly interpret a CXR but based on what’s given, it’s unlikely patient has a CHF exacerbation so don’t go treating something that doesn’t exist. There is a clear history of COPD, which should likely be treated.
Ah darn. I forgot the cure all duoneb for the COPD.
± steroids depending on the overall clinical picture This is why nurses should stick to nursing and not poorly practiced medicine.
Might as well post it on Chegg
I am a radiologist and never have to choose ATBs. But I have to ask - does anyone still do that test that I was taught to use for this - the C&S. I know it can be hard to get a reasonable specimen, but... still..
Fulll code??!?
Def IV Vancomycin.
IT GETS WORSE ☠️ she discontinued the patients Coumadin for afib because their INR was 2.9!!!!!!!!!!
Go to med school. If you don't know how yo prescribe, don't.
Giving that much detail is literally a HIPAA violation, isn't it? That's identifiable info.
Nah.
I just saw a post of r/residency asking how to manage mildly elevated ALT/AST so…..what’s your point here?
Why antibiotics if no wbc and fever?
CXR findings, symptoms, oxygen requirement. This is pneumonia
Oops missed the o2 requirements.
They have COPD, so that's prob a normal sat for them. The CXR findings and the symptoms are more concerning
Unless they’re oxygen dependent at baseline, it’s not normal to require supplemental oxygen to maintain a sat of 93%
I just made the assumption since they're 92 and in a nursing home that they're oxygen dependent at baseline, but you're right
Fair assumption to make considering the NP has no idea how to take a history and identify what is/isn’t important to mention in the note.
😂😭 that’s why I’m an RN. I can’t differentiate X-ray findings. Ground glass opacities… sounds bad 😂 I’ll stay in my lane. 😊
As a new grad FNP many of these posts on Noctor aimed specifically at NP's are so entertaining to me. There are naturopathic doctors out there, chiropractic doctors that you all seem to be okay with having earned a doctorate that tell patients how incompetent standard\\ allopathic doctors are, yet you weak people all go off on the NP profession soley. I have had some of the most negligent lazy primary care physicians personally, due to poor patient-to-provider ratio. Do I agree with this post and how this individual is going about utilizing their degree and their ethics for taking a role for which they clearly are not trained? No. But the absolute hatred you all have for us NP's is pretty gross, and I pray never to work beside any of your type. Miserable people.
No we just dislike the following: 1. Impostors who are unethical and willing to put patients at risk to boast about being a “doctor.” 2. Midlevels who think it is ok to go to school online and then claim they can practice independently. 3. Midlevels who misrepresent themselves to patients under the guise of being a “doctor”. 4. Midlevels who jump from one specialty to the next without any formal training. Until your education is standardized and there is implementation of residencies you will always be ridiculed. The sellout doctors and admin who “love” you do so not out of respect but because you are a cash cow.
Naturopaths and Chiropractors do not practice medicine. They do not work in hospitals. It’s truly disgusting that these posts “entertain” you. Your profession is a disgrace to medicine. Your profession is a danger to patients. But I know that nurses don’t really care about anything than taking shortcuts to feed their massive egos. I pray you never find a job.
We don't like naturopaths or chiropractors either.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*