Tuesday, September 10, 2013

Rough Day at Work

I had a rough day at work recently.  I was in the ER doing my usual thing, seeing the routine things we see in the ER, plus a chest pain, asthma, altered mental status, etc.  Afternoon rolled around and we got a call about an EMS unit that had responded to an MVA (motor vehicle accident).  We were informed that they were on the way with a pediatric trauma code.

EMS called with a history of a child that had been hit by a truck after getting off of her school bus.  The bus was stopped, signs out, door open. The little girl bounced out of the bus and started across the street when she was struck by a large truck speeding past the stopped school bus. 

The little girl had no vital signs on the arrival of the first unit, but they instituted resuscitation attempts anyway and rushed her in to the ED.  Resuscitation and transport were futile, and the attending physician that day pronounced her dead almost as fast at she was moved to the treatment room stretcher.  The sheer force of an 18-wheeled tractor-trailer vs. the frail body of a 6-year old child obliterated any hope that she would have survived.

I saw the bus driver later.  She was, naturally, very badly shaken by the incident. I listened as she recounted, in excruciating detail, the split-second event that took the life of the little girl, and forever impacted the life of this driver, the child's grandmother who watched this tragedy occur from their yard, the child's other family members and likely some of the horrified students that watching from the bus.  I knew that she, and many others, would likely suffer from some level of PTSD.  The driver herself, returned to the ER within 48 hours with an MI.  I myself pondered how I would feel if such a thing were to happen with own little girl stepping off her bus and couldn't even imagine it.

I love you Victoria.

Saturday, January 7, 2012

Specialty CAQs

I received notification last month that I have been awarded my CAQ in Emergency Medicine from the NCCPA. The "certificate of added qualification (CAQ)" program was established by the NCCPA as a means of recognizing those certified PAs who have met certain minimum standards of achievement is a a number of specialty areas.

The CAQ program was started, and originally billed as, a specialty certification program. This eventually morphed into the CAQ as an addition to the basic PA-C credential, rather than as a stand-alone certification. I suppose the thought being that stand-alone certifications would erode the relevance of the basic PA-C credential. It was also postulated that, if specialty certifications were issued, that these credentials might be required by employers. Thus this leads to the CAQ as it exists today. I always felt, and had written to the NCCPA in the past advocating, that the NCCPA establish a series of "extended-core" examinations that could be taken with the PANCE or PANRE to provide "special recognition in" various specialties. This would have been similar to the PANCE exams taken up until 1997, when candidates were required to write both a general exam and at least one "extended core" exam for initial certification. The "extended core" exams at that time, were limited to only primary care and surgery, but the model was established and proven.

In the current CAQ process, the first step is documentation of a minimum of 150 hours of Category I CME specific to emergency medicine within the preceding six years. Fifty of these hours must be earned in the preceding two years and must include an ACLS course. The next step is certifying your work experience. For the emergency medicine CAQ, the minimum experience is 3000 hours or 18 months of full-time experience working in emergency medicine or about half the length of an emergency medicine physician residency program. The next step is certification of your patient management and procedural skills by a specialist physician with consideration to a number of specific areas. The NCCPA also recommends that applicants complete and emergency medicine review course as well as additional courses in pediatric and trauma life support (i.e. APLS/PALS and ATLS).

The final step is taking the CAQ examination. The exam contains 120 emergency medicine-specific questions based on a content blueprint develop by the NCCPA following their 2009-2010 PA practice analysis. After completing all of these requirements and passing the examination, the NCCPA awards you the CAQ in emergency medicine, which is valid for 6 years as long as the PA-C is maintained and certain specialty-specific CME requirements are maintained. Overall, I thought the exam was fairly representative of EM practice despite it's relative brevity. The CAQ program outline for emergency medicine is outline at the NCCPA link below:


The PA-C is a generalist or primary care credential at it's core. Despite this, I have been practicing for over a decade and a half with that credential and an ever-increasing base of experience. My CME since earning my PA-C in 1996 has reflectively been geared toward topics in emergency medicine, and my post PA-graduate master's degree was granted in 2000 with a concentration in emergency medicine. So now that, after over 15 years of emergency medicine practice, I have a "certificate of added qualification" in my specialty. I ponder on what that means.

After all that specialty PAs have contributed to medicine and fought for to achieve this recognition has returned to them a well-packaged "feather in their respective caps." It's nice to be recognized and to put another qualification on your CV/resume'. After all, the recognition was long overdue, and likely prompted most by the fact that some specialty PA organizations were set to bypass both the AAPA and NCCPA to get this done on their own. This less fragmented approach seems more desirable and keeps the CAQ program under the NCCPA, which has for decades now provided the profession with it's both its de-facto licensing examination and "Board certification." In short, the credential has credibility.

Will the decision to have a CAQ, as opposed to a stand-alone certification deter employers from increasingly favoring or even requiring such a credential for employment candidates? Probably not. Now that the cat is out of the bag, so to speak, the more PA's that achieve this credential will hold a definite advantage in the specialty job applicant pool. Both employers and employees will want to showcase credentials to prospective customers/patients. I anticipate that it will not be too long before there will be groups advertising the fact that their staff is comprised of all "board-certified" physicians and physician assistants. Is this a valid representation?

Since the NCCPA is the "Board certifying" body for the PA profession, the certificate of added qualification does indeed provide a specialty certification to PAs. Whether the certification is "added" or stand-alone seems irrelevant. A PA-C holding a CAQ is essentially held out to be "certified," by holding a certificate from an nationally recognized professional certification body, as holding qualifications in both general/primary care medicine and his/her respective specialty.

Friday, May 20, 2011

Emergency Ultrasound Course

If you are a serious about pursuing a career in emergency medicine, I highly recommend taking a quality course in emergency ultrasound techniques. The potential for ultrasound in the ED is vast. All EM residency programs must now provide ultrasound training for their graduates to be board-eligible.

This year, I attended both the Introductory and Advanced emergency ultrasound courses by 3rd Rock Ultrasound. The experience was excellent and by far one of the best emergency medicine CME experiences I have attended to date. My next working day, I was able to put these new skills to work as an extension of my physical examination.

The view available courses, visit: http://www.emergencyultrasound.com/

Thursday, May 19, 2011

Gastritis gone sideways.

A woman in her early 60's came to the ER with complaints of "stomach pain" for the last six months. She localizes her discomfort to the epigastric and left upper abdomen, and a very discreet association with food. "It hurts mainly when I eat greasy foods." She reports some relief in the early weeks with Tums antacid and occasional use of OTC Omeprazole, but admits that she has taken these only sporadically. "I have a lot of burping," she tells me, "and when I do burp a lot, the pain gets a lot better." She also told me that her symptoms were worse when she was lying down at night. Though the patient had her symptoms for six month, she did not have health insurance and did not report them to her doctor "because I can't afford to have any tests done."

She denies and complaints of chest pain, weakness, diaphoresis, shortness of breath or other symptoms of concern. She also has noted no association of this illness with any physical exertion. "It's just really when I eat."

Her medical history is remarkable only for hypertension and high cholesterol. She takes medication for both, but tells me she can't take statins because they cause a lot of muscle weakness. Unfortunately, she does smoke cigarettes. She has had no surgery in the past.

On exam she is an alert, refreshingly non-obese and generally healthy-appearing lady. She is in no acute distress, but does have some complaint of her upper abdominal discomfort on exam. Her area of focal pain is mildly tender, but without peritoneal findings. Bowel sounds are normal and the aorta is not appreciated on exam. Her vitals signs are within normal limits.

I performed a bedside abdominal ultrasound and noted a normal aorta and IVC. Her liver was unremarkable, but she did have gallbladder wall thickening (5mm) with no stones, sludge, or significant edema. The common bile duct was 3-4mm. There was no sonographic Murphy's sign. I felt it likely that she had some chronic cholecystitis.

I ordered IV Zantac and Protonix and during treatment her pain subsided and she tolerated clear fluids well. Laboratory analysis showed a normal CBC and differential, essentially normal Chem 7 except for a mildly elevated glucose of 121. Liver functions showed normal bilirubin, but the AST, ALT, and Alkaline Phos. where modestly elevated. UA was normal. A cardiac profile and EKG were also ordered, the CK was normal, with a pending Troponin. I reviewed the EKG and noted inferior and lateral ST/T-wave abnormalities, Unfortunately, this was the patient's first visit to the ER, and no old EKG was available for review. Eventually, the Troponin resulted at 0.893 (MI threshold is 0.125). Chest Xray was normal.

I consulted with the hospitalist service and arranged to admit the patient for further workup. The first repeat Troponin was 0.769. I suspect that since the patient had a normal CK, this had peaked and return to normal before that patient came to the ED, and her MI was subacute. Still the extent of her coronary disease needed to be investigated and managed before a more serious event occurred.

We are taught that many MI patients will present with atypical symptoms. The higher risk groups are women and diabetics. The biggest point of liability in emergency medicine remains the missed MI. Even in a patient with clear-cut signs, symptoms, laboratory, and ultrasound findings of a compelling GI condition, you have to consider coronary disease in those with risk factors (age, HTN, hyperlipidemia, smoking). This case cannot punctuate that lesson enough.

Always consider and investigate the potential of a cardiac origin in any patient with upper abdominal complaints with coronary risk factors.

Saturday, April 2, 2011

Never trust a normal EKG

It's said that up to 20% of patients experiencing an acute MI will have a normal EKG. With over 25 years of emergency medical experience under my belt, I would dispute this statistic. I think it would be more accurate to say that a high percentage of these patients will have a "non-diagnostic" EKG. However, the totally normal EKG does occasionally happen, as in the case I am about to relate.

I recently treated a very pleasant and healthy older lady. I would say...a young eightly-year old. She came into the ER with complaints of chest pain that had been bothering her for the past 3 days. The pain was a mid-sternal pressure than radiated to her back and both axilla. She said it "cut off her wind," but didn't notice any specific provacative factors. It had been intermittant, but on the day she decided to come visit with me in the ER, she had been experiencing pain for a little over 6 hours. EMS placed her on a cardiac minitor and had started an IV.
There were no interventions because the patient had a normal EKG and told the paramedics that she had a normal stress test only 3 months ago.

When I saw this nice lady, she was still having pain and still had a normal EKG. Not a "non-disgnostic" EKG, but normal like it had been copied out of a textbook of normal EKGs. Despite this, her description of symptoms was pretty alarming, and her blood pressure was significantly elevated, she was started on typical cardiac chest pain treatment. She had already taken an aspirin at home and remained on oxygen. She was started on SL nitroglycerin and IV lopressor, which resulted in a modest reduction of her pain. Subsequently, she was started on IV nitroglycerin and titrated doses of morphine with more improvement. The EKG remained "normal," but the lab returned CK-MB and Troponin-I values well into the positive for MI ranges. Her BP and pain continued to improve with the nitrates, now in concert with Lovenox and Integrilin. Finally, now on maximal therapy, her pain was reduced to zero.

I consulted with her primary physician and cardiology and wrote orders to admit her to the ICU. The expectation was that she would undergo cardiac catheterization within 12 hours if she remained pain-free.

A few take-to-work messages:

1) The history is the most important diagnostic tool in your box
2) AMI can certainly happen, even with a stone-normal EKG
3) A negative stress test (treadmill, nuclear, or stress-echo) means nothing. These studies are only significant if they are abnormal (positive).
4) Don't delay treatment waiting on enzymatic testing

One more thing regarding cardiac catheterization reports. A normal cath may rule out CAD, but I have still seen patients die from arrhythmias and suffer MI caused by coronary vasospasm (printzmetals). In younger patients (<40) especially, screen for cocaine abuse. A cath with small (20-40%) lesions without critical stenosis does NOT reduce the risk of AMI. It is these younger and less stable lesions that will often rupture and cause an acute thrombus. Larger lesions (>50%) tend to be more stable (less likely to rupture), but may cause anginal pain and occlude with smaller thrombi.

Thursday, February 10, 2011

Sexual Harassment: Not just for women anymore

In the ED, as in most health care fields, men and women work closely together. The work-friendship bond in this environment, sometimes develops into a very casual familiarity between the sexes. In this setting, the line between good-natured banter and out-right harassment can be a narrow one. Most reported cases of sexual harassment involve women being harassed by males. As I recently found out myself, this is always not necessarily the case.

One day a few months ago, I was working a shift in the ED minor care area. The ED was uncharacteristically slow, and the nurses and secretary were working with an off-duty nurse on a special project. I was sitting at my desk a few feet away doing something on the computer. The visiting nurse, with who I have had a couple of friendly conversations with previously, came over to my desk and starting looking at the computer too. She asked me what I was doing and slowly sidled up very close to me. Leaning in, she very explicitly propositioned me in a sexual way.

I was more than a little caught off-guard, but managed a nervous laugh and told her that I was in a relationship. I thought that would be it, but her reply was, "So am I, but I'm not interested in a relationship...I just want a little fun." I avoided eye contact, and just said something to the effect of "thanks, but like I said I am in a relationship." She then told me to think about it, but before she left the ER a little bit later, walked by and planted a surprise kiss on my cheek.

A day or two later, we were in the main ED together, and she suggested that we have coffee after work. She was getting off at 7pm and myself at 9pm. I politely declined and told her that I wasn't interested. I actually wound up working until 10:30pm, but when I walked out to the medical staff parking lot, this nurse had pulled her car up next to mine. I stopped to talk to her for awhile and repeatedly told her that I was not interested, and declined multiple invitations to join her in her vehicle. I told her that I was only interested in maintaining a friendly, professional work relationship with her. Eventually, I got into my car and drove away.

Several days later, I received a letter from this nurse at my home. I was actually at work at the time, and since it was addressed to Roger Scott Best PA, I asked my girlfriend to open it up and see what it said. The letter was full of personal information from this nurse...about her life, her marriage issues, sexual preferences and the like. The letter was "signed" with lipstick mouth-print.

A couple of days after that, this nurses approached me with questions about PA programs. She suggested we get together outside of work. I was busy and in a very public area of the ED, so I asked for her email and told her I would get back in touch with her soon. When I got home, I composed an email about her behavior, advances, and most particularly the matter of her letter. I made it very clear that I was not interested in anything other than a professional relationship at work, and that I expected no further inappropriate offers in the future. I eventually received an email in reply, which was unapologetic, but did say that I would receive no further inappropriate advances. I left it at that.

A week later, we worked together again with a critical patient. After work, I went home, had some coffee and talked with my girlfriend on the telephone. Almost 11:30 pm and as soon as I hung up the phone, my doorbell rang. I answered the door and it was this nurse at my home. She was dressed in some type of "costume" under a jacket, and was very persistently attempting to persuade me to allow her into my house. Despite the night being very windy and near freezing outside, I refused to let her into my house. Despite this, it still took me almost 45 minutes of telling her to "get in your car and go home," for her actually to do so. I told this story to a physician colleague of mine the following day, and he said she had mentioned to him the prior evening that she might do that (go to my house). He made comments to her in an attempt to dissuade this idea, but it apparently fell on deaf ears.

Finally, I had a sit-down with the ED director and went over the entire ordeal. I told her my opinion regarding this nurse as a valuable member of the team, and my desire for her not to lose her job, but that if this continued I would be forced to make a formal complaint. She later spoke with this nurse and made clear to her that she expected to observe nothing other than a completely professional relationship between she and I in the future and reiterated this again a couple of weeks later in a follow-up conversation. Fortunately, she did not have to lose her job...the certain outcome of a formal complaint. The directer, in our conversation, alluded to the fact that this was not an unheard of situation.

I have dwelt on that for some time. In work environments where a male presence predominates, you often hear of male on female sexual harassment. However, when the female-to-male ratio is reversed, my experience and the director's comment suggests that the reverse may be true. In addition, being a man, I was somewhat embarrassed by all this and didn't want be the "guy" that whines about sexual harassment from a woman. In retrospect, I should have done that after the parking lot incident, and certainly after the letter incident. After all, does "no" not mean no when a man says it to a woman? Apparently not to everyone. In my reality, it seems that both sexes have the equal propensity to inappropriately harass the other. Only in my case, and likely that of many other men, I was less likely to report it until the situation became intolerable. I hope the outcome will cause this nurse to re-evaluate her behavior, but I suspect that with the lack of definite consequences, she will eventually redirect this behavior towards someone else.

Monday, October 4, 2010

On the doctoral degree for entry into either PA or NP practice.

A doctorate as an entry-level clinical degree is a bit much for either group. I'll admit that my knowledge of DNP programs is limited, but unless there is additional advanced training in clinical medicine...then it wouldn't enhance the care given and makes the degree pointless from a clinical standpoint. If the degree hinges on some type of research project, then it is essentially the same thing as a PhD degree in nursing and again, becomes pointless from a clinical standpoint. If the goal is simply to get the title of "Doctor," and makes you feel better about all the extra money you spent...great.

I've been acquainted with PA's and NP's for over 30 years. I've been a PA myself going on 15 years. The first NP I ever met was a diploma RN, who completed a certificate NP program. I dare say all the master's (and now doctorate) prepared NP's have nothing to offer above and beyond what she had. I believe the same is true for the varied degrees offered by PA program. In the end, we all take the same standardized national examination for licensing. "Degree creep," "credentialism," of whatever you want to call it for attaining an entry-level of practice only drives the cost without offering any tangible benefits to patients.

I do think an advanced clinical degree is appropriate if in imparts advanced clinical knowledge and skills. The Baylor EMPA program for example. But a doctorate for entry-level PA or NP isn't really reasonable or necessary.

Everyone wants to be a doctor today. Medical doctors, pharmacists, physicial and occupational therapists, audiologists, now nurses. In essence, like like the comedic "hello doctor, doctor, doctor" skit...the title actually become meaningless. Many licensed physicians I have worked with actually hold a bachelor of medicine and surgery from UK medical school. We call them "doctor" when they don't actually hold a doctoral degree. Should I be called "master" by the "doctor?" That would be a hoot. Regardless of degree... you are licensed as a 1) physician, 2) pharmacist, 3) physicial or occupational therapist, 4) audiologist, 5) registered nurse. I am licensed as a PA. That should be the focus...not getting caught up in a title.