Patient Case Review LIVE - Complex Diabetes after Hospital Discharge
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Show notes:
This was a case I reviewed with my new grad NP mentee recently, that was complicated on SO many levels and unfortunately happens quite a bit.
It's a patient case where it's not just about the complex medical management, but also the pieces of stepping into this role as a nurse practitioner to navigate the health care system and our patients' lives.
The premise is that it's a 40-year old cis-male patient presenting for hospital follow-up after admission for pneumonia and hyperglycemic hyperosmolar syndrome (severely elevated blood sugar in someone with type 2 diabetes), as well as a complex leg wound and possible necrotizing fasciitis.
Complex Patient Case Study
Medicine in the real world can be messy, and I discuss the case, pearls of practice to keep in mind, and what supports to seek and what to watch out for.
Note - I didn't address every single aspect of this case - including principles of mealtime insulin, the wound assessment and pneumonia, but these were improving! Hopefully, this is a helpful overview of the general approach and pearls of practice.
Managing Diabetes, Hypertension & CKD Review Course
If you'd like support caring for patients with these three chronic conditions, we cover diagnostic criteria, medication management, real case study examples, and when to refer inside this new program. Join the waitlist here and you'll be notified first when it opens up again.
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well hello there
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cool i think we're live um so if you are
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here
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please let me know um there is a minor
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delay between
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the video and the and the transmission
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to youtube
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so um so yeah hopefully my audio is
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working i've had some issues before
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going live
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um but i'm just gonna jump in um so
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welcome
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um this is uh liz rohr from
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real world np and you are watching np
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practice made simple the weekly videos
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to help save you time
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frustration and help you learn faster so
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you can take the best care of your
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patient
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so this is the one of the live videos i
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haven't done a live in a while and i see
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some people here hello christine
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please let me know if my audio is okay
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there's a little bit of a delay between
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um like my zoom and the actual youtube
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so um
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so yeah i'm actually doing a difficult
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case review so i'm glad you're here
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and um
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uh yeah so i'm just gonna jump in i'm
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sorry the delay is kind of
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throwing me off a little bit um but yeah
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so um
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i wanted to talk about this difficult
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case um that i met with one of my
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mentees that i work with one-on-one
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um talked about and i think that what
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inspired me
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is that i was i mean it was it was it
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was painful in a number of ways
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it was um
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yeah it's a if it's a it's a difficult
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case and there are many complicating
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factors and i think it
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brings up one of the additional like
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it's the medical piece but also the
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additional pieces that go along
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with um becoming a nurse practitioner
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and having to do those make
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make some difficult decisions outside of
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actually just learning the medicine
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right so i'm just going to jump right in
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but please let me know if you have
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questions and i'll stop
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at the end and see if anybody has any
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questions um
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but anyway this patient is a um
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is a 40 year old male 1 and um
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uh was admit so this is a 40 year old
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man
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here for hospital discharge follow-up
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and
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was admitted for about a week for
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bilateral pneumonia
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dka diabetic diabetic ketoacidosis but
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it's actually type 2 diabetes and it
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might be splitting hairs a little bit
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but
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i should have clarified with my mentee
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if it was truly dka or if it was
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actually that like hyperosmolar
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hyperglycemic syndrome
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um it's like slightly different but like
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the moral of the story
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is that um there's some it's severe
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hyperglycemia with metabolic
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abnormalities right so regardless
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um i think it's important for historical
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going forward there are some
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small slivers of people who have type 2
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diabetes that can have true diabetic
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ketoacidosis but
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anyway splitting hair is a little bit
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but um also
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had a left leg wound and there's a
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question of necrotizing fasciitis
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so um the ct they did a ct scan of this
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like upper
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leg wound um that showed some suspicion
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for possible necrotizing cellulitis but
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it wasn't conclusive
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and like kind of just to pause there
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like as a pearl of practice
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um you can uh like if we find something
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that is suggestive but is not conclusive
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we're typically gonna err on the side
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of um like making sure that it's not
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that and assuming that it is until it's
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not if that makes sense instead of like
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oh it's probably not that right because
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we don't want that to like turn into a
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big old thing
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you know um but anyway so i had surgery
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twice
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for debridement um and was supposed to
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be discharged home with a picc line
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um on iv antibiotic cephalosporin as
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well as go to a skilled nursing facility
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uh for two weeks but the patient had no
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insurance
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so um uh and was declining to go
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see a wound care specialist go to
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skilled nursing facility um
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and actually like this whole thing is
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really tragic but like another tragic
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point that kind of like it was just
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painful was that
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the patient was was placed on this
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provider's schedule
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like three minutes before the schedule
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was supposed to start the appointment
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and it was a telemedicine
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visit which really it should have been
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an in-person visit i mean
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you understand from the clinic's
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perspective like this person probably
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should be
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at least seen assessed by somebody even
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if it's by telephone
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um ideally that person would come in in
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person because that's a pretty pretty
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sick patient but
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anyway so did a phone appointment but
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then advise them to come in the patient
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to come in the next day
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um and then it comes to the medical
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management um
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atlantis the patient was discharged
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atlantis which
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like you know long-acting insulin 35
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units twice a day
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humalog which is the short-acting
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insulin
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seven units with every meal and a
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metformin
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500 milligrams twice a day um and the
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patient was out of the hospital for
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about two days i think before this
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appointment and blood sugars at home
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were 400
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um and the patient was just continuing
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on the medications that they were
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discharged on and then came in for like
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a wound check
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in person for the advisement of this
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clinician
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and so the patient brought their blood
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sugar log which was wonderful um there
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was actually no baseline to compare to
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and i i should have i should have dug
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further in terms of getting that history
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it's important for the long-term
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management in terms of like the
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management right now
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it's okay not to have this information
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but um
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yeah so it sounds like the patient
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wasn't on insulin before so it's brand
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new
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he's brand new to insulin and brand new
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to checking blood sugars
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um checking the blood sugar log as
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directed like four times a day actually
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um
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the blood sugars though on follow-up
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were in the 200s
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and um two to four hundreds right like i
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said four hundreds and then after meals
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um the pre-meals and after meals were
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like a little bit variable like around
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the 200s and then the lowest
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part was um the lowest numbers that he
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was getting was around like 150
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maybe 175 and that was actually in the
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evening
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so anyway hi jennifer there's a little
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bit of a delay between the video
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and um and my the live video and youtube
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so
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um feel free to jump in with any
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questions but i'm just going over this
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case
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and there are so many places to start
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with this case um and i think the reason
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i decided to go live and review this
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case is because a lot of the times on
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this
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on this website and this channel i talk
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about particular topics that are very
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well organized and they're concise and
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they're step by step
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but like the reality is is that behind
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the scenes when i'm having these
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conversations with conversations with my
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mentees
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it's messy right let real life is messy
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this is a messy situation right because
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there's an ideal situation right there's
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the ideal of like you have potential
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necrotizing fasciitis we're gonna
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continue your antibiotics you're going
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to get set up with home care but then
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they don't because they don't have
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insurance right
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and then the other kicker about is that
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this patient is asking to go back to
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work
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and it's a gaping wound it's really
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large um and i wish i could show a
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picture i don't think i have permission
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to do that though
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but it's gaping and it had surgical
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debridement and it's packed and it has
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special
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stuff you know that it got discharged on
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so
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so yeah and and this patient is sending
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is trying to get back to work working 12
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hour days doing a manual job so that
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they can
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afford their own stuff and send money
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back to their
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um family members so so yeah so i think
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that there's just like so many
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ways to go and i think one of the points
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i wanted to
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that i stress with my mentees but and
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new grads that i work with that i stress
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in this conversation is like what are
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those
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i guess like what are the like there's
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the medical management and then there's
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like
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the other stuff right um i'm gonna pause
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in the medical management for a second
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but it's like
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my first thing that i said to her was
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like yeah like this patient
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like there are a couple of red flags
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going on right now and i have to admit
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when i was a new nurse
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and a new nurse practitioner i had some
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ego right
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like i graduated from school i was eager
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to get going
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and i like wanted to show that i was
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doing a good job right and i wanted to
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prove to myself i wanted to prove to
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others so i feel like a total imposter
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right
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and so i definitely remember this as a
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nurse like i would have a patient that i
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was having a hard time
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that was um you know kind of declining
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and i wanted to handle it and then all
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the experienced nps came in and they
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handled it for me and i was frustrated
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so i was like trying to
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do the thing but i think that like this
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is like
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very um yeah i think i think it's some i
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just say that because i think it's
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important to keep that in your mind if
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you recognize that yourself as a new
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grad
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to like check that if you can and
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hopefully you can
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because it is terrifying it's like a new
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level of terrifying but
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i think one one place to potentially
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start and i encourage her to start and
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or stop slash start
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is like this this should be a red flag
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right there is a plan of care
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that is not coming through and has
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potential serious implications
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regardless of whether or not you know
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how to manage this or you feel
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comfortable managing this i would let my
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supervisor know
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right that i was proceeding with this
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complicated case medically and
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socially quite honestly because i mean
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safety patient safety is at stake here
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and i
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i yeah i think like keeping liability in
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mind i mean patient safety
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safety comes first but also liability
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speaking there is a plan of care that
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was recommended and you're not following
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it right
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it's not that you're not following it
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the patient's not following it right so
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i would i was like first thing we have
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to make sure that somebody knows about
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this
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second thing again i think because i'm
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in i've been several years of experience
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at this point i feel comfortable
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going this route right because i can see
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the full picture versus when i was a new
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grad i would be hyper focused on the
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medical management which is really
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important too but like
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what what else is happening to help this
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person's life right because it's really
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hard to think about
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what you're going to do for them
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medically in that moment if they can't
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do it right if they don't have the
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resources to accommodate right
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and especially what is the kind of like
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half plan of care you're going to give
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this person because
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they're not doing the full plan that's
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been recommended to them right
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so anyway so um so yeah because ideally
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this person is supposed to get iv
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antibiotics for two weeks and go to a
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skilled nursing facility right
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and here they are in your office you
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know so anyway so
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um so i think first thing is like
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letting the supervisor know like hey
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this is what's going on and you can even
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come up with your plan of care you don't
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have to say
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like what should i do like here's my
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plan you know and just like reviewing it
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together
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and then um and then like the next part
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again
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like i can step out of that because i've
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had several years of experience and i
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see how all the pieces fit together
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regardless of what i recommend for
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medical stuff is like what are you gonna
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do
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to feed yourself right like do you like
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so i guess like the other
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kind of like next step is about
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resources right um getting to the
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medical management in a second
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but like what can we do for this person
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he's asking to go to back to work right
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now he needs a note from you to
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write it right and is he okay to go back
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to work
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and um his family is depending on him
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and he needs to support himself and he's
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like i really can't
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not go to work there's no light duty
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option i can't do shortened days you
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know like having that conversation
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um what are those potential options and
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so i think that brings me to another
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point that i talk about a lot with
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mentees
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um new and new mps is that um it's
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assessing what the resources are
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right and like recognizing where that
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line is between what you need to do and
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what your
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your your health center needs to also be
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a part of what do they need to be
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involved in what do they need to know
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about
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so that they can support your patients
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going forward right because
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in the ideal world even in a community
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health center right i work in a
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community health center too we have
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limited resources right
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everyone is strapped for time everyone's
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doing more than is
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is part of their job description right
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but like
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what social like what social work um
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you know resources do you have do you
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have a social worker do you have a nurse
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case manager
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do you have a community health worker
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right do you have health benefits
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somebody to consult with health benefits
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even if it's like a super part-time
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person
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right what are those resources in your
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clinic that you can you know consult
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with
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to help with this person because that
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should hopefully like if you can implant
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that red flag for yourself of like oh
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when we're getting to these places
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somebody else needs to know about this
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right and supervisor as well as the
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clinical infrastructure
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and i think that's a really hard thing
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to understand at least i found really
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hard to understand as a new mp and i see
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that a lot with new grads is that like
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what should i do and it's all on me and
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it's like oh no no no like that's
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it is our job to take good care of our
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patients but it's also upon us to let
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the managers know right and
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what are the systemic systematic things
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that are happening because i
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actually know this clinic this person
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works in and
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i'm familiar with the population she
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works with and
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i know that this is not the first time
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that this has ever happened it's not the
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first time it's happened to her
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and i actually am very familiar with
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that clinic and so i know
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that those patients this is not uncommon
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right and this patient
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um english is a second language for this
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patient too
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so um so yeah so so i think um that's
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the conversation that we had
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about those things and um
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she's investigating what resources they
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have and then is going to bring that to
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the attention of the supervisor who's
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going to
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hopefully act on that right because that
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is their job the chief medical officer
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the operations director
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the health center people who run the
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health center need to know about this
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because this is a problem for these
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patients right
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this is not the first time so um and
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then the last thing i guess is the
13:25
medical management right the last thing
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so i guess a couple of things just to
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recap so this patient has diabetes
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that's like relatively new that's pretty
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serious
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i don't have any labs we don't have any
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hospital record information which is
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another
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tragedy and it's also like makes me
13:41
like laugh sadly because it happens so
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often right um where you don't have the
13:45
actual record so this clinician
13:47
this new grad requested records to get
13:49
them but you want to see like what are
13:50
their metabolic abnormalities
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you know um what do you need to check in
13:55
with you know as it relates to
13:57
that's usually what happens with
13:58
hospital discharge hospital discharge
14:00
information hopefully you get the actual
14:02
summary and they will say hey
14:04
recheck their bmp in a week the basic
14:06
metabolic panel within one week
14:08
or anemia within one week or whatever or
14:11
here is their specialist appointment
14:13
or their test that we ordered for them
14:15
to follow up with and like pearl
14:16
umbrella practice like at least in the
14:18
settings that i work um
14:20
federally qualified health center
14:21
specifically but anywhere honestly
14:23
just because somebody was was assigned
14:25
to see a specialist does not mean that
14:26
they understand that
14:28
that they have the appointment details
14:29
like just also checking on that that's
14:31
just like a general
14:32
purlin practice for hospital discharges
14:34
and actually um i'm collaborating with a
14:36
a physician friend of mine and i think
14:38
we're going to do some videos
14:39
specifically talking about he works in
14:41
the hospital and i work in primary care
14:42
and
14:43
talking about that um how do we overlap
14:46
and and
14:46
make sure that we're taking excellent
14:47
care of our patients right so
14:49
um so anyway so thinking that keeping
14:51
that in mind and then getting to the
14:52
medical management right
14:53
so just to recap brand new brand new
14:56
insulin 35 units twice a day
14:58
hemolog short acting insulin with meals
15:02
metformin 500 milligrams twice a day
15:05
and that's it so it's tough
15:08
it's really really tough and i think i i
15:10
can kind of like briefly get into that i
15:11
don't want to make this video super
15:12
super long but
15:13
um kind of like some general pearls of
15:16
what we talked about is like
15:18
my main thing for this is like patient
15:20
centered
15:21
again because i've seen this happen so
15:23
many times and i think when i was a new
15:24
grad i'd be like
15:25
okay like what is what exactly should i
15:27
do for this medical thing
15:29
right now you know versus like the
15:30
zoomed a picture of like yes
15:32
and like let's make sure that the
15:33
patient understands the directions
15:36
has the medication at home knows i use a
15:38
glucometer has in
15:39
has needles this patient probably should
15:40
have visiting nursing uh
15:42
services right again no insurance which
15:44
again should trigger hopefully financial
15:46
benefits if you have that option at a
15:48
health center and if not then the
15:50
supervisor needs to know that this is
15:51
a problem right and hopefully they
15:53
already recognize that but that's on us
15:54
to bring it to their attention
15:56
um and help you know of course like not
15:59
just complaining but bringing solutions
16:00
if we can
16:01
and suggestions of like hey i'm noticing
16:03
that this is an issue i
16:04
really think it's important that we
16:07
investigate this as an option right
16:09
because there are grants there are
16:10
there are other things again outside of
16:12
the scope of the primary care provider
16:14
but
16:14
something to important to think about um
16:17
hey maria um please correct me if i'm
16:21
saying your name wrong there's a little
16:22
bit of a delay between um
16:24
the video and actually youtube um but
16:27
yeah so
16:28
um so again like keeping that focus in
16:30
mind um
16:32
because the blood sugars are still high
16:33
like in the 250s i'm very concerned
16:35
about that
16:36
i am really concerned about that right
16:37
but like again like keeping in mind that
16:39
whole picture of like
16:40
we can adjust insulin all we want to do
16:42
but if the patient's not going to come
16:43
back
16:44
if they're going to decompensate like
16:45
what's the worst case scenario that's
16:46
going to happen because of this wound
16:48
that's not getting antibiotics that
16:49
doesn't have a picc line that is not
16:50
seeing wound care
16:51
right and the patient wants to go back
16:53
to work right so this is
16:54
actually still underway this is not
16:56
concluded um this is a current
16:58
um recent case we're gonna talk about
17:01
but um but yeah i think it's a
17:03
conversation with the patient of like
17:05
listen the diabetes
17:06
blood sugars are really high we need
17:07
that to we need to bring those down into
17:09
range so that your wound can heal
17:11
i'm also very concerned about the fact
17:13
that you don't have a prescribed wound
17:14
regimen
17:15
that you don't have a wound care
17:16
provider that you don't um
17:19
have these id antibiotics for two weeks
17:20
right um and so the other thing that i
17:22
kind of talked about and i'm sorry again
17:24
this is getting a little bit around and
17:25
around
17:26
um which is why i hesitate to share
17:28
videos like this because
17:29
anyway it's messy it's messy one of the
17:31
other things that i recommend
17:32
in addition to finding the general
17:34
hospital records is infectious disease
17:36
consult
17:36
so that's another kind of like flag
17:38
that's in my mind now having years of
17:40
experience is that
17:41
when patients are discharged home with
17:43
ib antibiotics or a picc line
17:45
typically there's been an infectious
17:47
disease consult to get to that point
17:48
especially with a kind of like zebra
17:50
diagnosis
17:51
of necrotizing fasciitis right um
17:54
so yeah so so adjusting the insulin
17:57
right and doing it in a safe way this
17:59
patient is checking their blood sugars
18:00
following the directions coming to the
18:01
follow-up appointments
18:03
doing as they've been asked um you know
18:05
and have been following
18:07
all of the directions you know which is
18:09
helpful
18:10
right because hopefully you're getting
18:11
in the right direction but um the
18:13
patient unfortunately needs to go up
18:14
it's a lot of insulin but
18:15
likely needs to continue to go up
18:17
because those blood sugars are so high
18:19
and there's a really great algorithm and
18:20
up to date that i love about
18:22
insulin management and type 2 diabetes
18:24
um and there's like a whole
18:26
whole flow i love my algorithms but it's
18:28
uh usually starts at like
18:30
0.2 units per kilogram per day
18:33
0.2 to 0.4 um this is also in the ace
18:36
guidelines too
18:37
um and then you go up based on the
18:39
fasting blood sugars
18:40
um three two to four units every three
18:43
days
18:44
which is like i can rattle that off
18:46
right so i've done it a million times
18:47
but like
18:48
for a patient or for a new provider like
18:50
that's confusing right so i think that's
18:52
one other kind of thing that we talked
18:53
about is that like we have options here
18:55
and we can follow those directions but
18:56
how are we going to do it
18:57
right because i've act like you can go
18:59
the kind of textbook route and advise
19:00
somebody to do that
19:02
but like are they going to be able to
19:03
follow those directions so typically
19:04
when this happens with patients i'm
19:05
having them come i
19:06
have a conversation with them right it's
19:08
all about conversations with them and
19:09
getting patients to buy in and getting
19:11
patients understanding right because i
19:12
can tell them things all day but if i
19:14
don't they don't understand and they
19:15
don't agree to it they're not going to
19:16
do it right
19:17
so i'm just explaining to them like
19:18
listen it's really important get your
19:20
blood sugar
19:21
into range so that your wound can heal
19:23
better and this is what i recommend is
19:26
slowly but gradually increasing these
19:28
numbers until your blood sugars are this
19:29
number
19:30
so please continue to keep your log you
19:32
have the option of doing it at home
19:34
we'll just spread it out to one week you
19:36
can come in every week with a diabetes
19:38
educator we have one well we have one of
19:40
those at my clinic
19:41
um or one of the nurses or even myself
19:43
right if you don't have those resources
19:44
but
19:45
touching base with somebody and then
19:47
advising of hypoglycemia stuff like that
19:49
and then
19:50
um gradually like endocrinologists will
19:52
do that too usually if somebody's on
19:53
this kind of regimen i'm having them
19:54
touch base with endocrinology but again
19:56
this patient doesn't have insurance
19:57
so i'm doing the best that i can
19:59
informing them getting
20:01
them to kind of verbalize understanding
20:03
and have buy-in right because a patient
20:04
also lives like an hour almost an hour
20:06
away
20:07
right this case is just it's so common
20:09
and it's so complicated and it's also
20:11
like so heartbreaking but
20:12
um but yeah that's the general like
20:14
algorithm of the insulin management is
20:16
to go up that gradual gradual gradual
20:18
amount
20:19
every three days or so but again
20:22
shifting it in a way that is
20:23
patient-centered right and this is like
20:24
moral of the story like i've said so
20:26
much already
20:27
hey anna um like there's a lot to think
20:30
about in this case and there's a lot of
20:32
people to involve and
20:34
there's a lot of risk right and i think
20:37
that
20:37
because this is again this is an ongoing
20:39
case um
20:41
as best as possible getting the hospital
20:43
discharge records and any consults in
20:45
the hospital especially like infectious
20:46
disease
20:47
to get their recommendations their final
20:49
recommendations of like are you doing
20:50
the cephalosporin
20:51
iv for two weeks just in case because
20:53
you were suspicious about necrotizing
20:55
fasciitis versus did they give an
20:57
alternative knowing that he wasn't going
20:58
to go to a skilled nursing facility
21:00
right hopefully hopefully someone
21:02
acknowledged that before he left
21:03
hopefully there was a social worker in
21:05
the hospital or a case manager
21:06
right and then the doctors were informed
21:08
or the or the care providers were
21:09
informed
21:10
so that they gave alternative
21:11
suggestions right and then again
21:13
just like full disclosure i don't have
21:14
all the answers to everything all the
21:16
time
21:16
but i know where to find things so
21:18
necrotizing fasciitis i've like read
21:20
about
21:20
right i don't like see that every day so
21:23
i would go
21:24
and this is what i told the mentee i was
21:26
working with i was like my up-to-date
21:27
subscriptions actually lapsed
21:29
so this is what i would do and i would
21:30
encourage you to do so i don't have that
21:31
answer right now
21:32
but like looking at necrotizing
21:34
fasciitis what are the alarm signs and
21:35
symptoms to watch out for
21:37
what are the general treatments are
21:39
there any potential things that i can
21:40
find that talk about
21:42
peo treatment of necrotizing fasciitis
21:44
suspected
21:45
and involving my supervisor because that
21:47
seems very like i don't know what that
21:49
line is but hopefully i'm imparting to
21:50
you that there's this line here that
21:52
this is like okay i need to start
21:53
thinking about other people
21:55
being involved here right and i think
21:57
that unfortunately some of that comes
21:58
with time
21:59
of seeing what is normal and what's not
22:01
normal
22:03
in quotations right and what's expected
22:04
and what's not expected in terms of the
22:06
realm of primary care and what's
22:07
appropriate and what's not
22:09
if that makes sense so um so yeah so i
22:11
was concerned about
22:12
checking labs getting those notes from
22:14
infectious disease likely
22:16
probably again that cue in your mind if
22:18
they're discharging iv antibiotics they
22:19
probably had an id consult
22:21
in the hospital um safety about diabetes
22:25
they know how to check their blood sugar
22:26
they know the signs of hypoglycemia
22:27
here's how we adjust the um
22:29
you know insulin and then from there um
22:32
doing regular check-in so this patient
22:34
didn't want to come back
22:35
for about a week and still again is
22:38
insistent upon that note to go back to
22:39
work but i whatever the conversation
22:40
that i have with the mentee and again
22:41
there's no conclusion here
22:43
she bought herself a week which is what
22:45
i would do
22:47
of like hey listen there's no way we're
22:48
going back in the next week
22:50
right so like let's just see how it is
22:53
in a week
22:54
see what social services we can have
22:56
involved see how your supervisor can get
22:58
involved how your clinic
22:59
on a systematic way can be involved in
23:01
this travesty of a case
23:03
right and then um
23:06
yeah and then just articulating with the
23:08
patient it's a it's like a rock and a
23:09
hard place here and so that's why i'm
23:10
really like i
23:11
in massachusetts where i practice and i
23:13
live there's a
23:14
you know department of transitional
23:15
assistance there are social service
23:17
programs that people can
23:19
get support in the interim so that
23:21
they're not starving so that they don't
23:22
lose their
23:23
home you know like that kind of stuff so
23:24
like what can we do to take care of them
23:26
and buy stuff by some time because the
23:28
real like
23:30
there's a lot of pressure to sign that
23:31
note for that patient to go back to work
23:32
for 12 hours a day doing manual labor
23:34
huge gaping wound on his thigh right but
23:37
like
23:37
what is the implication if he goes back
23:39
it gets a lot worse it gets infected
23:42
you know and he's hospitalized for weeks
23:44
you know what i mean so
23:45
i think it's i think that's that's how
23:47
we kind of left things and we're gonna
23:48
check in
23:49
um but that's basically that's basically
23:51
that that whole
23:53
sad case um hi liz oh i'm so glad i'm so
23:57
glad
23:58
i'm i don't know if you how how long you
24:00
were here for but this is like
24:02
this is i i'm i'm i like sharing
24:05
i just i got i just was so inspired by
24:07
our conversation of this like
24:08
it's really important to see behind the
24:10
scenes of how messy this is right and
24:12
how ugly
24:13
and not elegant this medical management
24:15
is
24:16
and like i guess the i guess those other
24:18
things to i love to just in part is like
24:20
how all the systems work together
24:21
depending on where you are in your
24:22
practice if you're still in school or if
24:24
you're currently practicing of like
24:25
who the specialists are what they do
24:28
what your clinic
24:29
is responsible for what you're
24:30
responsible for and like
24:32
your role that is so important because i
24:34
think that sometimes too
24:35
people don't want to make waves i've
24:36
seen a lot of new grads talking about
24:38
that
24:38
they don't want to make waves and
24:39
complain and all the stuff and they want
24:41
to do it all themselves or they think
24:42
that they have to do it all themselves
24:44
and i just want to encourage you that
24:45
like that is not the case i mean
24:47
we do have to go above and beyond for
24:48
people right and
24:50
that's takes so much heart and it takes
24:52
um so much caring and it's hard to
24:54
separate because we care so much
24:55
but like ultimately i can tell you from
24:57
being burned out that that is
24:59
10 to 10 do not recommend you know on a
25:02
consistent basis like
25:04
yeah i'm just a very systems but focused
25:06
person at this point and
25:08
um i don't know i don't know it's just
25:11
not right it's not right our healthcare
25:13
system and i know liz i know
25:14
you are having a hard time with your
25:17
health care troubles and
25:18
where you practice but um
25:22
yeah yeah it's it's not pretty um
25:25
but yeah um it's a little bit delayed so
25:27
it looks like i'm still talking on the
25:29
screen
25:30
but if you have questions um please let
25:33
me know
25:34
and i'm happy to answer whatever i can
25:36
again i can't really speak to
25:37
necrotizing fasciitis
25:38
because i need to read about it on up to
25:41
date
25:42
myself and that's literally what i would
25:43
do if somebody came to me and i would
25:45
just like refresh my memory of
25:46
any shreds of what i've learned before
25:49
um
25:50
to like see what things to watch out for
25:52
um but hopefully again your supervisor
25:55
can help with that
26:00
[Music]
26:04
cool well um i think i'm going to sign
26:06
off but um
26:08
thank you so much for hanging out i
26:09
really appreciate it
26:11
um and i'd love to i guess like hear
26:14
your
26:14
um yeah like any any um either topic
26:18
suggestions or
26:20
um difficult case things we can we can
26:23
definitely chat about that
26:27
but yeah anyway thanks for hanging out
26:31
talk to you soon
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