Friday, November 18, 2011

17 November 2011

Looking at all these EKGs today reminds me of a bozo PA that I was rotated through in South Florida. Contrary to everything else I had been told about PAs operating in the State of Florida this guy was effectively operating a one-man show. Disturbing, eh? He claimed his father-in-law was the physician he practiced with, but his FIL was retired…so in other words he just signed everything willy nilly. Doesn’t that make you feel warm and fuzzy? Notsomuch. According to what I’ve been told, Physicians Assistants by law aren’t permitted to sign orders or write scripts. The Physician must sign all scripts and co-sign anything the PA signs. Annnnyway, for two days I just sat there astonished at the sheer amount of incorrect information this guy was trying to tell us. This is just a sample:

1.     Attempting to tell us that when reading an EKG you go 300, 150, 100, 90, 75, 60, 50…Um, where’d you get NINETY pendejo? The best way to count an EKG heart rate (and that’s how it’s usually taught…) is to start with 300 at the big line and divide 300/1, 300/2, 300/3…etc etc etc. No integer will yield 90. I verified it with four texts when I got home that night. Yes I have that many useless medical texts lying around my house.

2.     THEN we got into heart blocks. I don’t even know where to begin, or how any of it makes sense. He began with stating that because this woman’s EKG showed a dropped QRS complex (the prominent pointy thing on an EKG) he had diagnosed her with a first degree AV block. Ummm, the entire definition of a first-degree block is predicated by the (albeit prolonged) PRESENCE of a QRS complex. He proceeded to discuss Wenkebach diagnoses and identified them as a Type II Mobitz, incorrectly describing them as a constant length QRS, with random QRS drop. Ugh, where do I start? First of all, he got the Mobitz Type II part right, but it’s not a Wenkebach. Wenkebach is a TYPE ONE Mobitz. There's even a song about it. Watch it and try to get the “AV Type I Mobitz” out of your head before tomorrow. Secondly, how can a First and Second degree both have dropped QRS complexes?  None of this would bother me as much if the guy hadn’t claimed to be a cardiac specialist.

3.     Acetazolamide. A classic carbonic anhydrase inhibitor. It prevents bicarb, HCO3 from being reabsorbed by the kidneys. For those not in the know this is a diuretic, and it results in the basic compound of bicarbonate being eliminated via the urine. Bicarbonate is one of the most rudimentary (I would say “basic” but basic has two definitions in this case) buffers in the body. A loss of a basic substance means that the blood is going to become more acidic, and as such the pH will DECREASE. PA Bozo made the assertions that metabolic alkalosis (ie basic blood) will ensue and the pH will INCREASE. Ugh. Strike three pal, you’re out. I realize my degree in chemistry gives me a slight advantage when it comes to dealing with subjects such as acids and bases, but c’mon, anybody who has a master’s degree (which is what PAs have) much less BE a PA should be able to grasp that concept. Even if that’s too much, they should at least know what the hell the drug they’re giving a patient does!!!!!!!! ***

4.     As if all that wasn’t enough, we get to metformin. I’ll make it short and sweet. He stated that metformin works by getting the pancreas to secrete insulin. Head. Wall. Now! One of the advantages of metformin is that it works independently of a functioning pancreas (quite common in diabetes obviously). There are indeed drugs that function by stimulating the pancreas to release insulin, and they do so by closing K+ channels. Metformin mostly works by inhibiting gluconeogenesis, which is a liver function. To make sure I hadn’t confused a drug (let’s face it that can happen), I asked him “what about gluconeogenesis?” He said he didn’t know anything about that and had never seen a drug that worked that way. Ok, I’m out. Either this guy’s a complete moron and DANGEROUS for patients, or everything I thought I learned in medical school is incorrect. I’ll form a committee to decide... I tuned out for the rest of the day and alternated my concentration between stifling laughter to quelling fits of rage.

My main problem with this guy who doesn't know squat is he is effectively seeing patients with NO accountability. And on top of that most of his patients were poor immigrants who spoke little to no English. A Spanish-speaking PCP is not hard to find in South Florida, but people in this group tend to believe the first Spanish-speaking voice they hear. My main goal out of all of this is to not develop a prejudice toward Physicians Assistants. I’m working on it.

**Foot note: I’ve noticed that we chemists tend to be more persnickety about balanced statements and making one and one add up to two than our biology colleagues. That isn’t a slam, it’s just an observation. We are taught that if it goes into the system, then it’s gotta come out, and must be accounted for. In biology, a process, reaction, or an equation if you will, is rarely taught to be balanced or quantified. ATP comes flying in from I-don’t-know where. True, we are taught that each molecule of glucose ultimately yields ~32 ATP, but frankly that’s just oh gee wiz fare for the student when one considers that there are 3.012 x 10^23 molecules of glucose in a mole of sucrose (table sugar). A mole of table sugar off the top of my head is about 340g, or roughly a six pack of soda. Yeah, you do the math. I’ll pass unless I can fish out my TI-83 Plus, but I haven’t seen that thing in over three years. Some amino acid just randomly appears. That enzyme just happens to already be there chilling. All of this stuff has been quantified (usually by chemists or physicists with a biological focus by the way), but it doesn’t seem to be stressed. I totally get it, and do not begrudge the field at all. Were all that to be quantified and taught to students as such, four years wouldn’t be enough to finish what is taught in the first year of biology. It is so much more complex and intertwined. It’s so much more integrated than chemistry or physics. Chemists, on the other hand, have the benefit of observing a great deal of our processes as an isolated system, controlled and mostly free from exogenous influence. Balance is taught to be paramount, and the end product is frequently known, and often irrelevant to the study.

I have often thought that chemists would make excellent accountants, and vice versa, simply because we are taught from Day One to take into account things such as molar equivalents, quantifiable energy, etc etc from start to finish. Were we asked to take into account all that other STUFF and then quantify it, we’d never get done either. So, to me, the two fields have done a beautiful job of simplifying their subject, but in different ways. Biology has done away with accounting and in many cases mechanism on a large scale in favor of studying process and integration. For instance, biology on the “molecular” level usually stops with DNA, which drives me nuts because as a chemist I know that a septiquadrilion little molecules make up that big molecule of DNA. Little mention is neither made about what actually makes Enzyme A convert Product A to Product B and why Inhibitor Q prevents said miracle, BUT, you can see the whole process at once. Chemistry has done away with integration of the process as a whole in favor of accounting and individual mechanisms, and in many cases the outcome is already known and incidental. It’s the how much and how that matters most. For instance, in the spoon-bending-minds-required abstract field of Physical Chemistry we spent hours modeling the structures of molecules we had known for years, such as ethanol. The biologist would in many cases be happy with the outcome simply being ethanol. The chemist in many cases already knew it was going to be ethanol, and wants to know why it’s shaped that way and precisely why it was allowed to be made in the first place. Biochemistry manages to integrate the two, but on a limited scale, and to study biochemistry you have to already know your fundamentals of chemistry and many of the fundamentals of biology. And we all wonder why these two ideologically juxtaposed fields get into interdepartmental fights??

Now back to your regularly scheduled programming…

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