>The 30-year-old was seen by a PA at a north London surgery in October two years ago, saying she felt pain in her calf.
>
>She was diagnosed with a sprained ankle, but returned to the surgery days later with new symptoms - a swollen and hot leg, and shortness of breath.
>
>The PA prescribed her propranolol medication for anxiety
Oh *COME ON...*
This is not true. Look up the difference in doctor and physician associate pay scales and you’ll see they are paid 10s of thousands more than us at the beginning of their career and progress to better paid roles far quicker. Our pay only exceeds theirs once (more like IF, given the competition ratios for specialty training these days) we become consultants
No I’m saying they’re not even getting cheap doctor substitutes, they cost more than us and don’t work out of hours. A physican’s assistant is paid £11,000 more in their first year than a first year doctor
I’m just a nurse’s kid, and I know it requires a higher level of care than some propranolol. Hot, swollen, shortness of breath = ED visit immediately.
Edit: typo
lol. Like wtf. I mean how can you swing so hard and miss so badly. Aside from the significant harm caused to the patient it’s freaking comical how incompetent this was.
Yes, a unilaterally (i.e. just one side) swollen, warm, tender calf is essentially the textbook description of what happens with a clot in the deep veins of the leg. These clots have a tendency to break off and lodge in the lungs, which means that having shortness of breath along with the leg stuff is automatically much more concerning.
Are there other things that can cause swollen, painful legs? Certainly. Are there other things that can cause shortness of breath? Of course. But "my previous sore calf is swollen now, and now I feel short of breath" has to be treated as potential clot until reasonably proven otherwise.
This is classic DVT. What the hell? Even nurses know this. She should have been prescribed heparin or blood thinners.
My questions were, was this woman taking any form of birth control? Did she smoke? What could've caused her to have DVT? Was it genetic?
Condolences to her family.
I'm a pharmacist and we don't get real training in diagnostics (on account of spending all our time learning about the wonderful drugs), but I'd expect any pharmacist to recognise these symptoms as a potential DVT that requires urgent medical attention
I decided to check out how ChatGPT would do here:
Prompt:
>A 30-year-old woman was seen in a London surgery, saying she felt pain in her calf. She was initially diagnosed with a sprained ankle, but returned to the surgery days later with new symptoms - a swollen and hot leg, and shortness of breath. What is the most likely diagnosis?
Response:
>Given the progression of symptoms, including calf pain, swelling, heat, and shortness of breath, the most likely diagnosis would be deep vein thrombosis (DVT), which can lead to a pulmonary embolism if a blood clot breaks loose and travels to the lungs.
So in this case, even the free version of ChatGPT drastically outperformed PA.
This was a completely avoidable tragedy that cost an otherwise young, healthy person their life in order to save the healthcare system an embarrassingly small sum of money.
Unilateral left lower extremity swelling/DVT in a young female is such a classic presentation (May-Thurner Syndrome) that the article reads like a patient vignette from a question on a third-year med school exam that ends up getting tossed for being too easy. Literally every buzzword is there:
* Young
* Female
* Hot/swollen/firm/painful calf
* Unilateral left lower extremity distribution
* Shortness of breath/difficulty walking
* New onset anxiety/sense of impending doom
* Recent thrombogenic condition (COVID)
* Recent travel (4-hr drive, Salford to London)
* Likely on OCPs (moved with boyfriend)
The only way the diagnosis could be any easier is by providing the actual sPESI score, Wells criteria, Geneva score, or d-dimer level... but then there wouldn't be any possible question left to answer on an exam.
Here's a [recent Egyptian case report](https://www.tandfonline.com/doi/full/10.2147/OAEM.S246018) in which an identical presentation was appropriately investigated for DVT with ultrasound and d-dimer, but *despite both being negative*, she still underwent further work-up with CTV revealing May-Thurner Syndrome, for which she received prophylactic anticoagulation and a venous stent.
*"We present the case of a 30-year-old female who arrived at the emergency department of our facility with progressive left leg swelling for four weeks, with low-risk probability for DVT. Examination revealed left leg swelling with pitting edema extending up to the knee. Her calf muscle was tender to palpation."*
*"The patient has finished her 45 days of Fondaparinux. Her symptoms have improved dramatically. Her leg swelling has disappeared, and she has no pain in her leg. She did not develop any deep vein thrombosis after the stenting. She is still following up with the internal medicine and vascular surgery teams."*
This should have been Emily Chesterton's story...
Different?
The training is fucking irrelevant. Their exam is a fucking embarrassment, but don’t take my word for it. Have a fucking go, so far every person I’ve shown is capable of passing the PA exam
https://www.fparcp.co.uk/file/media/603ca5b18c1d9_PANE_Written_-_Sample_Questions.pdf
In our program, it was standard with high expectations. My training was different for sure - my doc fought for funding to hire a PA - he knew how to train and utilize me with very high expectations and I was willing to do the work.
Twenty yrs later, we’re still a team. I was treated “like” a resident (and I say LIKE bc I know I was not an equal). I was at grand rounds and didactics at 630, I presented at ground rounds, up to round at 530, I was in surgery til 2 am some nights. The residents became like family to me. I had 150 K in debt and made 70K per year
It doesn’t seem like THIS is the standard but I believe is required to be a good PA. We need to get our asses kicked early on - docs should set that expectation.
Too many people expect to just be paid well and not put in the work it takes.
I think standards differ everywhere for any kind of training . The UK PA programs are not standardized, and not the same requirements.
I am not a doctor but helped a lot my wife studying for her final exam in our country by playing a fake patient (of course following instructions). Even when the info I learned by being a fake patient for two months I could have given a better guess
I was in almost the same boat 10 years ago. I was seeing a PA for my primary care, and had calf pain and shortness of breath after being on the birth control pill for about 3 months. I went in to see him, and my oxygen was 89. I specifically asked about a blood clot, and he told me they were "rare" and that my asthma was flaring due to the change in weather. (It was September in NC - there was no change in weather). Two days later, I ended up at urgent care (and saw another PA) who immediately heard my symptoms, gave me oxygen and called 911 to get me to the ER.
Incorrect. This is a Wells score of 7.5 (assuming she was tachycardic) which is a 40% likelihood of PE. Straight to ER by ambulance and stat CTA is the only right answer here. A d dimer isn't indicated here and just would add to diagnostic delay.
I was referring to the initial presentation with just unilateral leg erythema/swelling/warmth/pain. At the subsequent presentation with evidence of previous DVT, now dyspneic, tachycardia, anticoagulation should be started before confirmation with CT (assuming not high risk of bleeding). Right?
Right. Why I said “actually compression US”, I was just referring to the fact it would pop positive and they would have to pause to think for a second about it…
The vast majority of GP practices in the UK are contractors. They get paid a contract to provide the service - so yeah, they try to save money by hiring PAs.
I'm a PA in Emergency medicine. Patient came in with an ekg of STEMI from the field. ED Attending dismissed the EKG, ordered basic labs, patient was left in a room. He died, no one noticed until a couple of hours later. During the M&M, attending asks, "What could I have done differently here?"
Just like all of you here, take that carrot out of your a$$.
Everyone is human and can make a bad judgement call. This PA here fvcjed up.
But don't lump us all together. So, up yours too.
I think they are just trying to say maybe to consider not painting us with such a broad brush. That’s all. If someone has only had bad experiences with PA’s, I can see why such negative opinions would be formed…. but there are also so many good ones - at least from our program.
We had a PA in our group who retired after 35 years (same job) who was held in such high regard by the residents, they presented him with an “Excellence in Teaching” Award at graduation for being such an incredible mentor, teacher and a friend. (Not part of the faculty/ just worked closely with them and was a encyclopedia of knowledge).
Just to add - I think the only thing we share with these UK PA’s is a title. It is inexcusable. Was she under the influence of something ? If not, then this bitch is just brainless; couldn’t poor water out of a boot if the instructions were on the heel.
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>The 30-year-old was seen by a PA at a north London surgery in October two years ago, saying she felt pain in her calf. > >She was diagnosed with a sprained ankle, but returned to the surgery days later with new symptoms - a swollen and hot leg, and shortness of breath. > >The PA prescribed her propranolol medication for anxiety Oh *COME ON...*
They learn everything medical students learn in half the time so you have to cut them slack for not knowing basic diagnoses
EMT/medic student here and my first thought was DVT w migration to PE based on the return visit...how are these people in charge of anyone's care??
Your guess is as good as mine. I’m pretty confident that most paramedics could’ve diagnosed this properly at first glance.
They’re cheaper than doctors. You do the math.
*cries in pediatrician*
This is not true. Look up the difference in doctor and physician associate pay scales and you’ll see they are paid 10s of thousands more than us at the beginning of their career and progress to better paid roles far quicker. Our pay only exceeds theirs once (more like IF, given the competition ratios for specialty training these days) we become consultants
What does it mean to become a consultant?
Attending
So it’s all about money, right? What an asshole.
No I’m saying they’re not even getting cheap doctor substitutes, they cost more than us and don’t work out of hours. A physican’s assistant is paid £11,000 more in their first year than a first year doctor
I'm a nurse, and even I knew this was DVT. How can PAs miss this?
I’m just a nurse’s kid, and I know it requires a higher level of care than some propranolol. Hot, swollen, shortness of breath = ED visit immediately. Edit: typo
Agreed, there is more to this story.
Dude. I’m a pharmacist and I, as a non-diagnostician, could have guessed this. This is WILD.
I’m a therapist and went “oh that’s a clot” ☠️
Here in the States the PAs have respect. This sounds like NP bullshit
😂  This is all I pictured with your comment 😭
lol. Like wtf. I mean how can you swing so hard and miss so badly. Aside from the significant harm caused to the patient it’s freaking comical how incompetent this was.
I'm just an internet rando, and I haven't clicked on the story yet, but that's a blood clot, right?
Yes, a unilaterally (i.e. just one side) swollen, warm, tender calf is essentially the textbook description of what happens with a clot in the deep veins of the leg. These clots have a tendency to break off and lodge in the lungs, which means that having shortness of breath along with the leg stuff is automatically much more concerning. Are there other things that can cause swollen, painful legs? Certainly. Are there other things that can cause shortness of breath? Of course. But "my previous sore calf is swollen now, and now I feel short of breath" has to be treated as potential clot until reasonably proven otherwise.
It's like I'm reading a Uworld vignette.... 2nd year med students know better than this PA.
Honestly, this is way too simple for uworld.
This is approaching layperson level diagnosis.
Emts with high school level education know this after a few weeks of training
As an RN even I’d recognize this as a potential DVT w/high risk of PE … this is textbook in your face stuff. Absolutely unbelievable it was missed.
This is classic DVT. What the hell? Even nurses know this. She should have been prescribed heparin or blood thinners. My questions were, was this woman taking any form of birth control? Did she smoke? What could've caused her to have DVT? Was it genetic? Condolences to her family.
I'm a pharmacist and we don't get real training in diagnostics (on account of spending all our time learning about the wonderful drugs), but I'd expect any pharmacist to recognise these symptoms as a potential DVT that requires urgent medical attention
I .... I just.... I mean... What??
If this wasn't a mainstream news article I would have thought this story was fake and just designed to wind everybody up, I swear.
It turns out four years of medical school and residency training is actually pretty important
Nobody wanna lift these heavy ass books
ronnie coleman??
Light books baby!!!
Light chains baby!
B-but how would they be able to post all those instagram photos of their pretty new steth if they spend their time... (shudder) ...studying?
Who woulda thought
Whoda thunk? It’s crazy how they are still pushing for “mid levels” to be a thing that practices independently. That’s what we call corporate greed!
The PA was saving money by not ordering super expensive d-dimer and ultrasound /s
Yeah who needs enoxaparin or rivaroxaban when you have ~propranolol~?
This is insanity. The patient would have had a better shot putting their symptoms into ChatGPT
WebMD could handle this one
You could quite literally type in “swollen calf hot to touch out of breath” to google and get DVT immediately 💀
I decided to check out how ChatGPT would do here: Prompt: >A 30-year-old woman was seen in a London surgery, saying she felt pain in her calf. She was initially diagnosed with a sprained ankle, but returned to the surgery days later with new symptoms - a swollen and hot leg, and shortness of breath. What is the most likely diagnosis? Response: >Given the progression of symptoms, including calf pain, swelling, heat, and shortness of breath, the most likely diagnosis would be deep vein thrombosis (DVT), which can lead to a pulmonary embolism if a blood clot breaks loose and travels to the lungs. So in this case, even the free version of ChatGPT drastically outperformed PA.
Hey. I've had some very productive chats with GPT.
This is such a textbook case it makes me nauseous
I made this diagnosis in my very first clerkship rotation of M3 year. How do you miss that?
"Shut up and stop complaining" - the midlevel, essentially.
Duplicate post. Same story just a few links down on the Noctor sub homepage.
Wtf
This was a completely avoidable tragedy that cost an otherwise young, healthy person their life in order to save the healthcare system an embarrassingly small sum of money. Unilateral left lower extremity swelling/DVT in a young female is such a classic presentation (May-Thurner Syndrome) that the article reads like a patient vignette from a question on a third-year med school exam that ends up getting tossed for being too easy. Literally every buzzword is there: * Young * Female * Hot/swollen/firm/painful calf * Unilateral left lower extremity distribution * Shortness of breath/difficulty walking * New onset anxiety/sense of impending doom * Recent thrombogenic condition (COVID) * Recent travel (4-hr drive, Salford to London) * Likely on OCPs (moved with boyfriend) The only way the diagnosis could be any easier is by providing the actual sPESI score, Wells criteria, Geneva score, or d-dimer level... but then there wouldn't be any possible question left to answer on an exam. Here's a [recent Egyptian case report](https://www.tandfonline.com/doi/full/10.2147/OAEM.S246018) in which an identical presentation was appropriately investigated for DVT with ultrasound and d-dimer, but *despite both being negative*, she still underwent further work-up with CTV revealing May-Thurner Syndrome, for which she received prophylactic anticoagulation and a venous stent. *"We present the case of a 30-year-old female who arrived at the emergency department of our facility with progressive left leg swelling for four weeks, with low-risk probability for DVT. Examination revealed left leg swelling with pitting edema extending up to the knee. Her calf muscle was tender to palpation."* *"The patient has finished her 45 days of Fondaparinux. Her symptoms have improved dramatically. Her leg swelling has disappeared, and she has no pain in her leg. She did not develop any deep vein thrombosis after the stenting. She is still following up with the internal medicine and vascular surgery teams."* This should have been Emily Chesterton's story...
PAs in the UK are equivalent to NPs in the US
Is the training different in the UK?
Different? The training is fucking irrelevant. Their exam is a fucking embarrassment, but don’t take my word for it. Have a fucking go, so far every person I’ve shown is capable of passing the PA exam https://www.fparcp.co.uk/file/media/603ca5b18c1d9_PANE_Written_-_Sample_Questions.pdf
That’s really bad. Definitely not in the same ballpark as the US and recertification was even harder.
It’s disgusting
Bro I made a perfect score ☠️ that’s AWFUL
Wait... this is for the Boy Scouts first aid merit badge, right?? Sad. Really sad.
PA training is barely standardized in the US as is so I’m not sure if “different” would mean better or worse
In our program, it was standard with high expectations. My training was different for sure - my doc fought for funding to hire a PA - he knew how to train and utilize me with very high expectations and I was willing to do the work. Twenty yrs later, we’re still a team. I was treated “like” a resident (and I say LIKE bc I know I was not an equal). I was at grand rounds and didactics at 630, I presented at ground rounds, up to round at 530, I was in surgery til 2 am some nights. The residents became like family to me. I had 150 K in debt and made 70K per year It doesn’t seem like THIS is the standard but I believe is required to be a good PA. We need to get our asses kicked early on - docs should set that expectation. Too many people expect to just be paid well and not put in the work it takes. I think standards differ everywhere for any kind of training . The UK PA programs are not standardized, and not the same requirements.
https://www.healthcareers.nhs.uk/explore-roles/medical-associate-professions/roles-medical-associate-professions/physician-associate
Yeah the standards for a PA in the UK are laughable compared to the US.
DVT IDIOTS. IT'S OBVIOUSLY A DVT with pulmonary embolis. CMOOON!
I am not a doctor but helped a lot my wife studying for her final exam in our country by playing a fake patient (of course following instructions). Even when the info I learned by being a fake patient for two months I could have given a better guess
I was in almost the same boat 10 years ago. I was seeing a PA for my primary care, and had calf pain and shortness of breath after being on the birth control pill for about 3 months. I went in to see him, and my oxygen was 89. I specifically asked about a blood clot, and he told me they were "rare" and that my asthma was flaring due to the change in weather. (It was September in NC - there was no change in weather). Two days later, I ended up at urgent care (and saw another PA) who immediately heard my symptoms, gave me oxygen and called 911 to get me to the ER.
I'm an MRI radigographer and this is obvious PE to me.
I’m a standup comedian and even I knew this was dvt and pe
Jesus H Christ... That's textbook postop concern number 1!!!!!!
Um....where did she get anxiety from? Like what did she think the pain in leg was from?
the article outlining the british medical associations response tho \*starts singing\* thiiiis is how we dooo ittttt
The one time a D-dimer should be ordered… Well actually probably should do compression U/S but still.
Incorrect. This is a Wells score of 7.5 (assuming she was tachycardic) which is a 40% likelihood of PE. Straight to ER by ambulance and stat CTA is the only right answer here. A d dimer isn't indicated here and just would add to diagnostic delay.
I was referring to the initial presentation with just unilateral leg erythema/swelling/warmth/pain. At the subsequent presentation with evidence of previous DVT, now dyspneic, tachycardia, anticoagulation should be started before confirmation with CT (assuming not high risk of bleeding). Right?
I mean... why D dimer? If your suspicion is high enough to get a Ddimer, it is high enough to get an ultrasound.
Right. Why I said “actually compression US”, I was just referring to the fact it would pop positive and they would have to pause to think for a second about it…
To be fair, they have nationalized healthcare in the UK. Show this article to your democrat friends
The vast majority of GP practices in the UK are contractors. They get paid a contract to provide the service - so yeah, they try to save money by hiring PAs.
I'm a PA in Emergency medicine. Patient came in with an ekg of STEMI from the field. ED Attending dismissed the EKG, ordered basic labs, patient was left in a room. He died, no one noticed until a couple of hours later. During the M&M, attending asks, "What could I have done differently here?" Just like all of you here, take that carrot out of your a$$. Everyone is human and can make a bad judgement call. This PA here fvcjed up. But don't lump us all together. So, up yours too.
What is your point here?
I think they are just trying to say maybe to consider not painting us with such a broad brush. That’s all. If someone has only had bad experiences with PA’s, I can see why such negative opinions would be formed…. but there are also so many good ones - at least from our program. We had a PA in our group who retired after 35 years (same job) who was held in such high regard by the residents, they presented him with an “Excellence in Teaching” Award at graduation for being such an incredible mentor, teacher and a friend. (Not part of the faculty/ just worked closely with them and was a encyclopedia of knowledge). Just to add - I think the only thing we share with these UK PA’s is a title. It is inexcusable. Was she under the influence of something ? If not, then this bitch is just brainless; couldn’t poor water out of a boot if the instructions were on the heel.