#tried to ask for auth through A DIFFERENT EMAIL

[hangrypa]

s/p first year as a PA

I was hired as a hospitalist primarily for the transplant service. However, in the setting of the pandemic and staffing shortages, I am all over the place now and work in almost everything non-pediatric and non-surgical. 

In my first few months as a PA, I was incredibly overwhelmed. I went from being a learner who switches specialties every month to a fully-fledged provider making life-or-death decisions on an hourly basis. Oftentimes I’d find myself in the room of a patient actively crumping, surrounded by the patient’s family and multiple nurses awaiting instructions on what to do to save the patient. I thought that I faced a lot of pressure in school, but it was nothing compared to this. 

And just when I started to get a hang of it all, the pandemic hit. What a nightmare. As mentioned above, I was hired to work with with transplant patients. Prior to the pandemic, my transplant colleagues and I were masking and gowning for almost every patient: 1 surgical mask and 1 gown per patient and per patient encounter. But once COVID hit, we were rationing PPE. 1 N95, 1 pair of goggles, and 1 face shield for the pandemic. 1 surgical mask per week, and 1 gown only if a patient had Cdiff or a history of MDRO bacteremia.

What did the pandemic mean for our transplant patients? 

Our patients are on immunosuppressant medications to prevent transplant rejection. Unfortunately, this makes it difficult for them to fight infections. 

Our department did what it could to prevent COVID. We'd test patients on admission for COVID, regardless of symptoms or exposure history. If they were positive, they went to the COVID team and quarantined on their unit for a period of time and had to test negative before returning to our unit and being transplanted. We took many other measures to reduce COVID risk to the best of our ability. 

People still died. To see someone get transplanted successfully and then die of a virus is horrifying. Unfortunately, despite our admission tests, sometimes patients contracted COVID within the hospital. Patients would be happily FaceTiming their family one moment, telling them all of their plans for once they were discharged- then the next day they'd be intubated. We tried Remdesivir, Dexamethasone, prone positioning, etc. But the virus moved through them quickly, and these efforts often were too late. No amount of hoping and praying brought them back. 

As a first year PA, I learned to go to an empty conference room, close the door, and remove my mask before calling to the family of the deceased. This way, as they gathered around the phone in their homes, the family could hear me unmuffled as I delivered the news. Also, this way my tears didn't ruin my mask for the rest of the week. 

I learned a lot this year. It's been a mixture of crying and laughing. There are times that I question why I ever became a PA, and then there are times when this career feels like home. In addition to transplant, I’ve also been working in the  ED, IMC, ICU, inpatient hospice, clinic, and infusion center these past 6 months. I’ve learned quite a lot along the way.

Lessons learned as a first year PA:

1. Check your pager hourly: This is in addition to checking it whenever you get paged. Sometimes I’ll get paged while I’m rounding, read it, and then forget about it. Now I go through my pager at every hour to ensure that I already responded to all my pages and then answer ones that I missed/forgot.  On a semi-related note, a while back I wrote about good paging etiquette.

2. Let people know when you're out: I work a rotating schedule. As a result, it’s hard to predict when I’m in or out of the hospital. Sometimes I’ll come back on service and find urgent emails or texts that are a few days old. Now I leave an away message with my return date and my supervisor’s contact information on both email and hospital text. If someone really needs to get a hold of me, my supervisor has my personal cell phone number.

3. Be conscientious of what time you consult: I generally try to get all of my nonurgent consults done before 3pm. Many services have only 1 resident covering after 3pm, so I try not to page/call unless I have an emergency. 

4. Call the nurse if something needs to be done urgently: Being a nurse means being the ultimate multitasker. Room 5 is due for his IV Amphotericin, Room 2's Foley is supposed to come out prior to void trial with Urology, Room 1's infusion completed and is beeping, and Room 4 is a bit altered and yanked out her PICC. Now I’m placing an order for Room 3 to get IV Lasix due to concern for pulmonary edema. However, the nurse may be preoccupied with Room 4 and not see the order in the computer for some time. If I really need to the patient to get the Lasix right way, I’ll place the order through EMR and then call the nurse and see what their situation is. If they’re crazy busy with Room 4 and likely to be unable to get to the Lasix within the next 15min, I ask whether they’re okay with me asking another nurse to give the Lasix now. Usually the answer is yes.

5. Value your nurses: Nurses know the patient best. They’re the ones answering call bells, giving meds, doing dressing changes, etc. Unfortunately they oftentimes bear the brunt of everyone’s frustrations, from patients to patients’ families to attendings to managers. Not to mention, they’re the ones doing the dirty work. Bedside nurses are the heartbeat of healthcare, but they also are high risk for burnout. Always support your nurses, whether that’s volunteering to answer a patient’s family member’s 17th phone call of the day or responding to a patient’s call bell yourself. 

6. Know how to get a hold of someone quickly: It’s less than ideal to page someone repeatedly. At my hospital, if I need to talk to an attending urgently, I call the operator and ask them to connect me directly to the attending’s cell phone. If a patient is crashing and we’re not in the ICU, I dial the emergency number and call a rapid response, which sends people running into my patient’s room. 

7. Plan your discharge meds from Day 1: The goal of every admission is to treat the patient and then discharge them safely. Send medications early for prior auth and call the pharmacy to make sure that they have medications in stock. (One time a patient’s insurance didn’t cover Levofloxacin, of all things.) 

8. Keep social work and care coordination aware of all needs from the start: Does your patient looks unsteady? Place a PT/OT consult and let social work and care coordination know that the patient might require home therapy services and/or DME so that they can start looking at services and companies that may be covered by insurance. Does your patient have a central line? They’ll likely need a home health service to teach them how to care for it daily at home. Do they seem to require frequent transfusions? They’ll probably need labs on discharge. Is the patient’s living situation safe (no heat/AC, possible abuse at home, financial difficulties, etc)? They may need alternative housing.

9. The attending is not always right: Generally speaking, the attending has the last say on how the team manages a patient. However, I’ve come across situations in which an attending’s decision put a patient in more danger. Sometimes asking them about their decision can help steer the care plan toward better patient care. Other times you just have to stand your ground and be okay with being on the receiving end of an attending’s misdirected rant. Report these instances to your manager and to other higher-ups.

10. Always have gloves in your pocket: You never know when you’ll find a mess. Or which part of the body someone asks you to examine. Or how hygienic a person is (or is not).

11. Verify weird vitals: I was very new when I walked into work, opened a patient’s chart, and promptly bolted down the hallway when I saw a patient’s O2 sats recorded as 15-20s. I found the patient sitting up in bed, eating breakfast, and bewildered by me bursting into the room. Turns out that overnight someone mistakenly recorded his respirations as the O2 sats.

12. Remove whatever tubes you can: Anything entering the body is an infection risk. Does your patient still need that Foley placed by the surgery team? No? Yank it (don’t actually yank because ouch). Is your patient A&O and able to eat without aspirating? Remove the NG tube. Does your patient have good veins and require infrequent transfusions/labwork? Pull their central line.

13. Take a buddy with you to emergencies: Two heads are better than one. Even if you’re a seasoned provider and well-equipped to manage an emergency, you might need another body to help with performing CPR, making urgent calls, grabbing supplies, etc. 

14. Ask your patients about premeds for procedures: We all have different levels of pain tolerance. A procedure goes far more smoothly if your patient is comfortable. Note: if you’re going to premed with Ativan or an opiate in the outpatient setting, make sure they have a driver.

15. Be good to your charge nurse and unit secretary: I don’t know how they do it. If I had to manage the unit’s signout, patient complaints, calls from other floor, being yelled at by providers, verifying paper orders, and finding beds for incoming patients- all at the same time - I’d lose my mind. 

16. If your patient is mad, just shut up and listen: There are many things that you can’t control: the time it takes for a patient to get a room, the temperature of hospital food, the dismissive attitude of your attending, etc. And oftentimes the patient knows this. My reflex is to want to apologize for things and overexplain why different things are happening. But sometimes the patient just needs to rant. Take a step back and just listen. That can make all the difference.

17. Fact check your notes: The framework for your progress note often is the note from the day prior. It sounds obvious, but make sure that you go through the note and make updates and changes accordingly. If today is 01/15, there’s a good chance that the Fungitell from 12/31 is not still pending. 

18. Try to learn some nursing skills: This is one of the areas in which I most envy my NP colleagues. If a patient’s IV pump is beeping or their central line need to be flushed, I oftentimes awkwardly step out of the room and look vacantly into the distance for a nurse. I’ve finally figured out how to spike a bag (albeit I do so very slowly, and it certainly makes the RNs giggle some). I talked to our unit’s nurse manager, and she’s willing for me to learn some nursing skills from the staff during a slow day- we’ll see when thing slow down!

19. Be kind: Generally speaking, being in a hospital is stressful. Patients are feeling out of sorts, and staff are working with constant dinging in the background. I rant plenty on this website, but I’m kind to everyone at work (with few exceptions) because it makes things more comfortable for everyone. Additionally, if you are always kind to your patients and colleagues, your reputation will speak for itself. One time I was walking down a hall with poor reception while on my ASCOM with a notoriously standoffish nurse from another unit. My phone cut out. She called my unit’s nurse manager to complain, and the nurse manager told her that I would never hang up on purpose. My interactions with the nurse going forward were always more pleasant in nature.

20. Support your team: The best colleagues are not the smartest colleagues; the best coworkers are the ones who have your back. Whether it’s a medical emergency or just a strange situation, it’s important to be supported and to give support.

I know that I’ve learned a lot more than this, so I’ll likely be adding to this throughout the year. Happy Snow Day, all!

[ntrending]

How to do two-factor authentication like a pro

New Post has been published on https://nexcraft.co/how-to-do-two-factor-authentication-like-a-pro/

How to do two-factor authentication like a pro

“Where did I leave the spare key to my email account?” is a phrase you can actually say. (Brina Blum via Unsplash/)

If your level of anxiety over online security and privacy is on the healthy side, you probably already have two-factor authentication (2FA) set up for your main accounts. If you don’t, you should seriously consider activating it to protect yourself from phishing, hacks, and anybody who may want to steal your data.

Don’t know what I’m talking about? Here’s the 101: 2FA adds an extra layer of security to your online accounts. When activated, this protocol will ask you for something other than your username and password whenever you log in from a new device. That may be a code, a key, or to accept a prompt on your smartphone. This way, if somebody gets your password, 2FA will prevent them from getting into your account.

“It’s definitely a lot better than not having any second factor. You’ve given any attacker more work than they need to do,” says Shuman Ghosemajumder, chief technology officer of Shape Security.

But deciding to activate 2FA is like deciding you want to start running—do you just want to jog a bit, train for a 5k, or get yourself in shape for an entire marathon? There are a number of options, including apps and security keys, that provide different levels of protection for all your security and privacy needs. You can use a single method that works best for you, or employ several for one account, depending on the platform. The choice is yours.

Level 1: SMS

Don’t get too excited—it’s not the cute guy from the weekend. It’s just Google. (Sandra Gutierrez G./)

People often choose to employ 2FA via text messaging (specifically, short message service, or SMS) because it’s so practical. The process is simple: you log into your account with your username and password, receive a text with a code, then type that code into the login screen to gain access to your account.

The problem with text messaging is that because it’s data that travels through a phone line, it can be compromised and your six-digit code intercepted. You know how you can switch cell phone providers and still keep your number? That’s called a SIM swap and you can request one by providing nothing more than your phone number and the last four digits of your Social Security number. Thanks, in part, to major hacks, the internet currently has a well-nurtured database of SSNs, which could make it rather easy for an account thief to steal your cell phone number and redirect your authentication texts to another device.

That’s exactly what happened in 2018 when hackers accessed Reddit employees’ accounts via text message-based 2FA, compromising data from thousands of the platforms’ users.

If you think nobody would ever go through so much trouble to steal your data, think again.

“It’s certainly something that happens, but what’s even easier than that is to just use that phone number to send a phishing message,” Ghosemajumder says.

That’s called smishing—a portmanteau of “SMS” and “phishing”—and it’s the text message version of those sketchy emails that claim to come from your bank and urge you to click a link.

Still, text message-based 2FA is practical and, regardless of its vulnerabilities, better than nothing at all. But if you store sensitive data in your accounts or if we’ve simply scared you away from text messages, there are other more secure methods you can try.

Level 2: Apps and prompts and codes, oh my!

Could you imagine someone snapping pictures with totally basic filters from your Snapchat? Better protect that account. (Google Play Store/)

Google users can ask to receive prompts to verify a sign-in to their account from a new device. Then, when you log in with your username and password, you’ll see a pop-up window on your phone asking if it was actually you who tried to log in, and if you authorize it. These prompts are encrypted and travel through Google’s network, so they’re less likely to be compromised than texts, which makes them safer.

But not all platforms offer prompts. That’s why another popular strategy for 2FA is to use code generator apps. They’re pretty self-explanatory—the apps generate six-digit codes that you can use to log into your accounts. These codes are created randomly using time-based one-time password (TOTP) protocol, meaning they can only be used once, and for a limited amount of time—generally 30 seconds—before they’re automatically replaced with another. Code generator apps can be practical because they let you link as many accounts as you want, but you only need to go to one place for all your codes.

One of the simplest code generator apps is Google Authenticator (available for Android and iOS). It not only works with Google accounts, but also with any other platform that supports code generator-based 2FA.

If you want a more customizable experience, you can go for apps such as AndOTP (available only for Android) or Authy (also available for iOS), which let you add labels and icons featuring the logos of several platforms, so you can identify codes at a glance.

For extra safety, you can protect these apps with a PIN number or—in Authy’s case—your fingerprint, so even if someone steals your phone and gains access to it, they still couldn’t use your code generator app. Another cool feature of both AndOTP and Authy is “tap to reveal,” which hides all your codes and only reveals one at a time as you tap the one you need. This can be useful if you’re accessing one of your accounts in a public place where someone can easily look at your phone.

To use a code generator app on Facebook, for example, go to Settings > Security and Login > Use two-factor authentication > Authentication App. Facebook will then display a QR code you’ll have to scan with your phone’s camera via the code generator app when you add your Facebook account. Finally, enter the code provided by the app. This will make sure your app is in sync with Facebook.

Level 3: If you don’t trust digital, go analog

To charge or to use your security key? Ah, there’s the rub. (Yubico/)

In an era when it sometimes seems nothing you put on your phone can be trusted to be safe, going back to basics may be a good idea. If your level of security anxiety is this high, there are a couple more-analog methods you can use with 2FA that will allow you to sleep better at night.

The easiest option is to get a security key—a tiny USB device you use the same way you would the keys to your apartment. Once you enter your username and password on a new device, the 2FA protocol will ask you to plug your security key into the device’s USB port and tap it once to complete your login. These little gadgets are super useful and exceptionally easy to carry around—just hook yours to your keychain and you’ll always have it with you.

The most traditional security keys on the market are compatible with USB-A ports or, as you may know them, regular duck-mouthed USB ports. This immediately leaves behind mobile devices such as smartphones and tablets, as well as tiny laptops such as the MacBook Air that don’t have their own USB-A ports. There are USB-C security keys on the market, too, and they’re compatible with most newer mobile devices, but they tend to be a little pricier, going for $40 to $60 on Amazon.

It’s common for people to register multiple security keys for a single account, Ghosemajumder says. That way, they can stash a spare in a secure place in case they lose one they use regularly.

If you keep misplacing your security keys or just don’t want to invest in one, your Android phone can act as a key for your Google account. The company announced this new feature in April, and it lets people use their smartphones to confirm logins through Bluetooth. Doing so will connect your phone to the device you’re logging into and make sure you’re accessing a secure website.

If this still isn’t analog enough for you, you can always opt for backup or recovery codes. Supported by all major platforms, including Google, Apple, Facebook, Instagram, and Twitter, this method involves one or more codes you can either save in a document or copy onto a piece of paper and carry around with you. For your Google account, for example, you can find them in Account > Security > 2-Step Verification > Backup Codes. In general, they’re listed within the recovery or backup codes section in the 2FA settings of most accounts.

Nothing is more analog than pen and paper. Although you can also carve your backup codes in a cave somewhere. That’ll work. (Kelly Sikkema via Unsplash/)

These are limited and you can only use each of them once, so if you run out, you have to log in again and get more. Backup codes are not designed to be used instead of prompts or security keys, but they can be quite useful in extreme cases, such as when you’re traveling and don’t have your phone or security key with you.

As you can see, there are a lot of ways to use 2FA and you can choose which one works best for you. Different platforms support different methods, so check out Two Factor Auth to see which ones are available for your accounts.

Keep in mind that you can—and should—enable more than one method of 2FA. It’s always a good idea to have a backup in case you lose your phone or security key, or something is wrong with your connection. Just remember your security strategy will be as weak as the least-secure 2FA method you choose. So choose wisely.

Written By Sandra Gutierrez G.