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0:00
Speaker 2 (00:00.142) I'm excited today because I'm going to be talking to a critical care PA who's going to tell us more about the specialty. Now, it's not an easy specialty. You are taking care of the sickest of the sick and she's going to talk about what that is like as well. Hi, it's Michele with the Medicine Couch. Don't forget to hit the like button, share this video with friends and colleagues and subscribe to the
0:20
channel if you like what I do. All right, let's hear from this critical care PA. I'm Katie Beaudoin. I've been a PA for almost 20 years. I started my career actually doing a fellowship in emergency medicine and critical care, right off the bat. Many of you know it's a difficult field to get into sometimes for PAs. So I took that opportunity as a springboard to get into critical care of medicine. I've practiced ever since, still moonlighted in the ER. So I also
0:47
help to guide students through a fellowship for urgent care. I still practice part-time. I'm curious, you had mentioned that critical care is a little difficult for PAs to get into. So do you mean that as opposed to NPs and what is that difference? Why is it more difficult for PAs? PAs are very traditionally trained in primary care. So if we do a critical care rotation, it has to be one of our electives. And we only have so many electives
1:16
in a year. And so the bulk of us don't have the exposure to critical care. And I didn't actually until my fellowship. The nurse practitioners, a lot of times they are working as nurses in the ICU. It's a very huge field for nurses. And oftentimes, those ICU nurses who go on to be an NP and many times get hired in their area of employment. They have a lot of familiarity with the physicians and I've asked this question to some docs, you hey,
1:40
are you opposed to hiring PAs? And the responses I've gotten as well, I'm familiar with the people that I'm hiring. And so there's familiarity there, but there's also an ICU background. So they feel sometimes that PAs can take a little, they say longer to train. It's a different environment. so Speaker 1 (01:59.948) really diving into understanding ventilation management procedures. We're ready to the ground running,
2:05
but some of the other more complex critical care medicine, it's a training process. Yeah, it's different in a hospital. I did a short stint as a hospitalist, but I did not really have any rotations on hospital other than some surgery. And so I saw that the nurse practitioners who had been floor nurses and they just spent years getting that gestalt about when a patient is truly kind of circling the drain
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or truly getting critical versus ones that, you you got a little bit of time. But I also think a lot of times that the PA training, which is deeper in the medical thinking and decision making, comes into play as well. So I always say, I think that the perfect, for lack of a better term, APP or mid-level provider is a nurse who's worked for years that goes to PA school. I think that's like the best of both worlds. We probably should define what
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critical care means. I mean, obviously we can look at the title and see, but what are the... criteria and is that different or the same as ICU? How is it different than like the cardiac services and the pulmonary services? So ICU medicine, it's intensive care medicine, critical care, I flip those terms frequently. But as medicine has changed over the years and gotten more sub-specialized, bigger hospital systems have also specialized their ICUs, their internal systems. And it can
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be different in the community versus an academic institution. Some of them are just surgical ICUs. So anything that might be post-cardiac or anything that goes from the operating room. Speaker 1 (03:41.848) directly to the ICU, might reserve that only for trauma or general surgery or those type of patients. And then there might be a separate cardiac ICU, intensive care unit. So ICU is the unit, critical care medicine is the specialty,
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but there's surgical, neurosurgical, there's oncology. So there's different subspecialties within that. And then some ICUs are just open and it encompasses all of those. in the determination of what patients go there is just the complexity of their acuity, all the different problems and issues they have going on. Absolutely. And when the patient's coming into the ER, there are standards of care in every hospital.
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They'll say this meets criteria for ICU. They must go to ICU, whether that's a DKA patient, PH, if they're on different airway management systems, if they're on continuous BiPAP or inner. So all of that comes into play on where they live. And they might not meet any of them, but I frequently will get a consult from an ER doc going, the numbers look okay. the patient does not, think they should go to the ICU. And so at the end of the day,
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it's really our call. It's a medical decision. And so do you see patients of all ages, like do you guys even see pediatrics or do those pretty much always go to the pediatrics, especially hospital? Speaker 1 (04:57.966) So I am not in rural medicine, so I'm sure there's exceptions out there, but for the most part, there's pediatric ICUs, pediatric critical care, and then adults. We don't mix them, and oftentimes from the ER, they will try to triage them to pediatric hospital.
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think that most people like in their head when you say you work I see your critical care I mostly think of elderly people I'm sure you see a good share of those but would people be surprised at the age range that you see? Absolutely. I think that elderly are sometimes the exception these days. Sometimes we'll even take 16 because there might be an exception if they're a 16 year old that's a full size adult, of course,
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and up. Even if they're a DNR, DNI, you can still have 105 year old in the ICU. So we see a broad range. Currently I'm in community pulmonary critical care, but we will see neuro patients. We will see some your DKA patients new onset. So that's where a lot of younger people, trauma, PEs. all sorts of pathology there that don't discriminate by age. Exactly. This may seem like a silly question, but you know, I always like to ask people like the setting they work in. Obviously,
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you're in a hospital. Is that the only setting that critical care PAs work in? Speaker 1 (06:10.38) Yes, for the most part, critical care PAs will always work in an inpatient environment. There are some critical access hospitals or I have, you know, in my moonlighting days been in an ER, but we're putting in a critical care hallway. So my job for the day is not doing triage or fast track. My job for that day is critical care. So I will get all the ambulance critical care
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patients in, in the critical care hallway. So you can do that in some institutions. Like what kind of autonomy do you have? sounds like you have quite a bit, but how is the relationship set up, at least where you work with the physicians? Where I am, I kind of grew up in my institution. We are fairly autonomous, especially at night. are the only, I'm the only critical care provider in the hospital. So aside from the ER,
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I'm the only one that's doing intubations. Putting in central line styles as lines, I'm calling in various specialists if they need to go to emergent IR. I'm diagnosing them. I'm right there hands on and looking at my own imaging. I'm not waiting for. the radiologist to call. I'm very independent. Different providers have their different approaches to working with an APP. During the day, whether it's rounding, some people divide
7:24
and conquer. So I'll take half the patients, I round, I see my patients, I talk to families, and then I'll touch base with the physician. Other physicians prefer to just round together and we again, divide and conquer. We're in there, we both know the patient, we're making our plan for the day, making an assessment. I probably have pre-rounded and dug in a little bit deeper. have my recommendations, and then we execute our plan. So then I'm either putting in a dialysis
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line or changing lines or following up and doing X, Y, or Z. So the day's busy and then we might get interrupted. So we might get a new admit. So I'll go downstairs and I'll see the new patient, figure out what's going on, make my recommendations, get them upstairs, et cetera. So it's both team dependent, but it's also very independent, especially when we work at night. Speaker 2 (08:10.584) And I assume that you work very closely with nurses.
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Absolutely. They're my lifeline. We are a team. There's one of me. are, you know, at my current hospital, it's a smaller ICU, which is nice, but it's 12 ICU and then 10 IMU patients, which could go one way or the other at any time, as can the floor patients. So we're constantly learning from each other. I do a lot of education, especially with newer nurses, teaching them some nuances. And then the charges are always
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talking and we're always giving each other heads up and constantly problem solving, honestly. That nurses, that patients, not only they're advocate, but they're specialists, right? They're at bedside for 12 hours. And if they're on their third shift with that patient and it's my first time there, I'm very dependent on them and what their assessment is. You talk about the number of beds in the ICU. So when you're on a shift, are you
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responsible for all of those patients or is there a certain number of patients you get per shift? That's a great question because this could, it can get out of hand really fast in an internal medicine world. But in the ICU, I like to say we're a little protected, you know, we're full. We can't accept any more patients. If I'm working at night, I'm in charge of all of them. Some hospitals, you know, they might say you're capped at this
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many patients. So ICU patients, average number is eight to 10 patients. I will say the physicians, most of them will split them with me or will, if there's Speaker 1 (09:38.71) enough that we can just round together so we both know the patient that way we can get our other duties done. That's pretty efficient too, but I would say it would be on average about eight to 10 patients is a really doable load. I have
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had some people have as many as 15 patients that they're in charge of. Well, it's a lot. Yeah, especially if several of them are having new issues or something increases in their acuity. And so what kind of schedule do you work? I know in the hospitalist we did seven on, seven off. They were 12-hour shifts. Is that pretty standard in the ICU as well? Again, varies by hospital and the number of staff. The seven on seven off model
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is becoming increasingly popular because you just get that a good brain break. But, you know, there's seven days of 12 hours. Can get pretty long, pretty fast, right? That's an 80, 90 hour work week, 50 % of your weekends. There is also the model of a set number of shifts per month. And on average, it's usually 13 to 15 would be the expectation. Seven on seven off, thing I liked about is it's basically the continuity of care.
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You're seeing patients day after day, except for on your last day, you get like a new patient or whatever. But it does help instead of just randomly plugging in. I understand that. yeah, seven, 12 hour shifts in a row, it just it's a beat down. It's just you are dragging that last day and it takes you a good day or so to recover afterwards, which bites into your time off. Absolutely. Some of the night shift models are changing and I think for the better, they're doing
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like a seven on 14 off model, which is a beautiful thing because even though seven nights in a is a lot, once you're in a night shift mode, you might as well just do a couple shifts and be done with it instead of bouncing around. And then you have full two weeks to recover. It's a good model, but they have to have enough finance in the institution to hire three FTEs for that to work. Speaker 2 (11:39.732) in this specialty,
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do people normally get paid by the hour or is it a salary type situation? Generally speaking, it's a salaried position. There are locums and PRN people that get hired or sometimes even part-time where they are hourly and that's usually set by these set salaries at the hospital and then they break it down into an hourly rate. And so is this specialty, I would assume, one like emergency medicine that would lend itself
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once you have years of experience to be able to work PRN at different places? Absolutely. I get recruited by people all the time to go to different states. There are actual locums. That's all they do is just staff ICU capable PAs and MPs. Generally speaking, they want them to be pretty well-rounded. So all the different backgrounds, but there are some that are just pulmonary critical care and it's really easy to pick
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up. And if it's a staffing agency, they will pay more per hour than hospitals in general. Yeah. So speaking about, hey, like how does critical care medicine either compare to other specialties or if you do you have any kind of idea for a range like what people could expect if they were in this specialty? Speaker 1 (12:53.294) I'm in Texas, so we do have a little bit higher of a pay. Every state's different, know, California higher taxes,
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higher pay. it depends on the area. In general, the average salary for ICU work is about $130,000, give or take a few thousand between NPs and PAs. I will say that there are different hospitals that pay based on years of experience. At my institution, this is public knowledge, so it's not proprietary because University of Texas has to report. salary ranges. So there are ICU ranges by experience and it goes from the lower hundreds,
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thousands and to a max of $174,000 for somebody with 16 plus years experience. Some hospitals you'll see that NPs starting up making more money because they take in to account years of nursing experience. So that's why you'll see some of the NP salaries a little bit higher than maybe somebody with less years experience as a PA. Okay, so you had mentioned earlier some procedures that you do. I wonder if you could kind of run through the basic procedures that you guys do most often
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and then kind of what is the most complicated procedure that you do. On a regular basis, if you're in ICU medicine, you're going to be doing central lines. So that's the central venous lines that go either in the IJ, subclavian. If it's an emergency, maybe groin. We really try to avoid that very dirty areas you can imagine. Sometimes we'll be doing, still doing lumbar punctures, bedside procedures would be paracentesis, chest tubes,
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sometimes just thoracentesis. And of course it's a central line, but dialysis catheters. it would be a pretty routine procedure and of course intubation. Speaker 2 (14:38.21) And what do you think is the most complicated of all the procedures he did? I don't do these anymore, but when I first started in neuro critical care, did, we inserted the brain drains. They're called, EVDs or extra ventricular devices. So, you know, you're drilling a hole and
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putting a catheter into the middle of the brain. So that's a pretty invasive procedure and the cardiothoracic PAs are oftentimes dealing with the VADs. So those are the kind of a column, like the external heart rate. That's pretty complicated stuff and, troubleshooting those, if you're a CV. PA you will, or NP or nurse you will cringe when you, cause you know what I'm talking about when that alarm goes off and you have that panic moment and like what's going on. It's a very distinct
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visual sound. know, chest tubes are always fun. Sometimes we do bedside debridement of wounds and we'll take patients to the OR and do a wound wash or clean out. So there's a variety of procedures. It depends on your location and your provider relationship and also your credentialing and the number. So it's important to always keep track of how many procedures you're doing. think a good procedure training in PA school,
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but we certainly didn't learn how to do all those. When you first started, you learned that in your fellowship? Is that where you learned to do these things? That's where I get the bulk of my, you know, lumbar punctures, things in the ER that we're doing, intubations and through my neuro ICU. When I first started, we dropped swans in almost every patient with a subarachnoid. So that was another, I love doing those. So it's, it's really,
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it's a great procedure, not without risk, but I learned on the job with the physicians. Speaker 2 (16:10.51) I just recently went to a course that is for difficult airway intubations and it was, you you practice on mannequins so it's not like the real deal, but it's good training. So people are interested in that and that course, I'll put a link to that down below. I will probably never use it in my career,
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but it's still fascinating to learn and it's just different things you pick up along the way, right? In medicine, anything you learn adds to. your skills and your abilities. So what are some things in this specialty that have either been a surprise to you or things that you really love, maybe things that people wouldn't expect to like about this specialty? You know, this specialty has a unique niche in that you have
16:53
to really like people. And I do really love people and I've never been burned out from taking care of people ever. Maybe production pressures and hospital systems, but really taking care of people. And so some people will look at me and go, it's such a neuro ICR. Isn't that a sad environment? Isn't that really depressing? No, people do get better, but it's a challenge in that you might go from excitement to absolute devastation within.
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20 minutes. And so you have to adapt on having that, like giving good news and being happy about that, and then really having to bad news. But with that said, I think one of the surprising things is that it's not always sad when you're allowing natural death or you're having that talk that you can actually really find great satisfaction when you tap into that empathy factor and you're really providing good care because you're allowing that patient and their family a lot of dignity.
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and care and so it's never easy but I would say that it was surprising that I could actually find some gratitude in being able to provide that type of care which maybe earlier in my career I would have been like, heck no. Speaker 2 (18:02.798) Yeah, I did an interview with Tracey Piparo, a PA who works in palliative care, and she's just fantastic, has a huge heart. And she talked about some of those same aspects of palliative care and just about how great it is to have that
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honor and that privilege to be able to help people transition to pass away peacefully and gracefully. So yeah, if people are interested in watching that, I'll put a card up here. And so what are some of the other things that you love about this specialty? I get my procedure fix. I'm not in long surgeries necessarily. The diversity of disease states that come in always keep me on my toes and the ability to leverage my years of experience,
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levels of gestalt, my levels of suspicion and even new diagnoses. I'll have somebody come up. It's not making sense. And I'm able to freely put on that inspector hat, ask questions and be heard and go, we should scan. You're right, we are missing something, you so it's really, really kind of fun part of my job when I just get to play house. Well, every specialty has both sides, good and bad. What are some of the downsides or the challenges of the
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specialty that you think people should really think about before they decide to go into it? It's not easy work. know, you're getting up usually if you're in a day position, you're getting up at 4:30, 5 to get there by 6 and you're not getting home till 7. 7:30, you know, if there's a something at the end of the day, inevitably, occasionally we're staying late. You can't have that hourly mentality, right? We're just,
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you've got to take good care of these patients and you will lose patients. There are some that are, they're harder than others. You did everything possible and they pass away. Speaker 1 (19:46.008) So finding some work-life balance and figuring out how to get through those tough days, because we all have really tough days. And luckily, you're usually in a team environment, and so there's ways to navigate that. And I think one of the
20:02
other difficulties can be environment-dependent, right? If you're working for a system that's not supporting their nurses and providers, or a physician that's not supporting you. You have to be very cautious when you're accepting a position and asking about, you capping me? How are you protecting me? Right? Who's your backup? If I'm hired to be the on-call PA at night for the hospital where even the internal medicine doctors are asking me for help in the ER, who's
20:31
my backup? Are they going to actually come in? If I say, this is going to be a difficult airway, I need backup. This is dangerous. Anybody going into the field should use caution that they're not just being thrown into an environment that's not safe for you. the patients. you literally have people's lives in your hands. We say that sometimes, you know, in outpatient family medicine. And yes, it's true to an extent,
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but not not as immediate as it is like in the ICU. That's a big responsibility. It's a huge responsibility and I will say to this day and I've had tens of thousands of procedures, thousands of intubations. Every time I get ready to do a procedure, I feel like it's a healthy blip in my stomach. This person's trusting me with their life and it's up to me. And so I think it's still a healthy, kind of cautious amount of take a deep breath because their life is literally in my hands.
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Speaker 2 (21:21.634) just had a thought. Is it kind of isolating your job? I know you work in a team with nurses and with physicians, but it sounds like, especially like at night, there's not any other PAs or NPs on your team, right? Like you're kind of in a silo by yourself. Does that feel isolating? So in a bigger setting, you're going to have other APPs around. in a bigger downtown university setting, that's, think that's still a minority of physicians. So yes,
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it can be really isolating when you're the team leader. There's, you know, physicians on backup call and I find my joy in my, nursing leadership teams. So it's, it's not lonely from that aspect, but I do miss working side by side with my colleagues. used to cover evenings and we. look at each other and we tag team admissions instead of being overwhelmed and be like, procedures or no, okay, we just divide and tackle every single admin that comes
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in. that's really a lot of satisfaction that comes from having colleagues to work. I wonder what you think about people transitioning from other specialties. Are there specialties that are better than others to transition to this specialty? I would say the surgical specialties in emergency medicine tend to have an easier entry into the critical care world. Going from, you know, family practice or German, it might be an easier
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transition to, especially from family practice, to do an inpatient internal medicine and then kind of move over into the ICU world once you've gotten some of that experience of knowing what critical. Speaker 1 (22:56.75) patient looks like, right? You know, when if you're on the floor rounding and you walk in in the morning and that patient's sucking mud, you're like, gosh, okay, they we need to get them to the ICU, right? You know, because that's why
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they're in the hospital, they could go one way the other. So kind of give some experience there. You mean like being a hospitalist that does admissions and then also takes care of the patients that are already in the hospital. Yeah, and because one thing I learned doing that, and trust me, it was a huge learning experience. I also have a video on what that was like because I was family practice and went to hospital, so I'll put that up
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there. But it was a huge eye opener for many things once you're dealing with definitely. different acuity levels and different stages of disease processes, whereas when you're an outpatient, usually people are stable, you've got time to work things, people in the hospital, it changes, and you have to do things in a different order or more immediate than you would. But there's all those little things that if you've never worked in the hospital for, and I say little things,
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but it's stuff that just you're not prepared for and you're not going to like read it or or learn it necessarily when you're studying hospital medicine. And this thing's like ordering their diet, because there's like a ton of different options to order. How does respiratory therapy work? Like, when do you actually bring them in and not? There's a ton of things like that that if you've not trained in a hospital, not worked in a hospital, those little things
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can be overwhelming on top of the medicine. So, yeah. Great point. Definitely don't try to jump straight to ICU. You probably wouldn't be hired anyway, right? Trying to go straight into ICU. No, and as the number of residencies and fellowships are increasing for APPs, that is a great way to transition if you really want to make a career change. that year, it's usually a year, taking a step back if you have the ability to. And it's not a step back. Sometimes we take a
24:49
step back to make leaps forward. But many times it's a step back in terms of salary. Speaker 1 (24:56.51) It's a year goes by fast and it will set you up for success if that's really truly the path that you want to take. Yes, I wholeheartedly agree that people should do fellowships even if they're not just coming straight out of school, especially when it's a specialty like this that you have to have such
25:13
a depth of knowledge and some of that gestalt to be able to do your job well. So if somebody is looking at doing this, do have any references, any books or different societies, anything you can point people to to help them learn more about the specialty or prepare themselves? So if you're looking at just books, kind of like the ICU Bible is Marino's, it's literally called the ICU book. The Society of Critical Care Medicine, SCCM is a wonderful
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resource. And I love EMCRIT, E-M-C-R-I-T, EMCRIT. They have a website, they've got videos, podcasts, so many resources for various ICU topics if you need to brush up or to dive in a little deeper. And lastly, one of my favorite ICU resources, because I still reference it, is called the ICU One Pager. And it's a physician who's literally made one page summaries of all these disease states. One of them is just on vasopressors, your inotropes versus chrono, and it has a little dial
26:13
that shows you, know, do I need more squeeze? Which ones cause more vasoconstriction- peripheral problems? Which ones cause X, Y, or Z? He's got one on ECMO, if you need to brush up on... you know, hey, do mind putting in some lines for a paraphrase show for ECMO? And you're like, oh, I haven't done that in a year. You could just, you could brush up on that. And so it's a fantastic resource. Speaker 2 (26:34.264) Great. Okay. Yeah. Just
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funny. If you send me those links, I'll be sure to put them down below so people can check out those resources. Your final thoughts on being a critical care PA or NP like the good, bad, and the ugly. Critical Care is an incredible field, especially if you really like the complexity, if you like an organization of rounding on every body system, right? Because you're supporting this person from head to toe. It's a fantastic field for PAs. We're built for
27:03
this. And we have that ability to come and diagnose, look at the head to toe picture, physical exams and things like that. And of course, nurses at bedside are very familiar with the complexity of these patients. It's really rewarding. It is hard work. You're on your feet 12 hours a day. Many places you'll have to work both days and night shifts. There might be some night call responsibilities. And so if that inpatient world where you're missing nights,
27:32
weekends, holidays with your families, it's not for you. It's not for you, but it comes with the territory. If you want that level of acuity, working on that level. But... I will say on the flip side, I've been in it for almost 20 years now and it's so fulfilling to really take care of these patients and not just their patients, these people and their families because it's hard on the families too. if you're good at
27:55
communicating, you like procedures, you like complexity, this is for you. If you want to learn more about other specialties, then click on this medical specialties playlist here. And of course, you can go to my main channel page and see all the different playlists that I have. Thank you for joining me and as always, take care, stay sane, and I'll see you next time on the Medicine Couch. Bye.
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