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.

Tuesday, April 27, 2010


Once again, Physician Assistants are raising the issue of changing the name of the profession. I suppose it's appropriate to consider adopting a professional title that accurately reflects the job that we do. As the PA concept is being eagerly adopted internationally, more appropriate titles for the PA role (Medical Care Practitioner, Assistant Physician, etc.) are being utilized. In the US, the term Physician Associate seems the preferred title amongst our profession. The title accomplishes two important goals; it more accurately reflects the role that PAs provide as part of the health care team and preserves the "PA" acronym.

A professional name change does present challenges, namely the revision of the practice codes in every state and the federal government that makes reference to Physician Assistants. Despite the advances and inroads the profession has made in it's 43 year history, every revision attempt opens the opportunity to lose something in return. A name change would likely raise the ire of some of the more insecure physicians organizations, who would undoubtedly take the opportunity to try and curtail PA practice in some way. Take for example the idiots in NJ right now up in arms to keep PAs from performing EMG studies. Perhaps the way to go is simply to alter state and federal licensing codes to recognize the two titles as interchangeable. Thus you might be licensed as a "physician assistant/associate." This would allow you legally to use the title "associate," without affecting insurance and other regulatory codes that recognize the "assistant."

I like the term Physician Associate. I am an associate of the physician, a colleague. In no way do I "assist" physicians, other that to assist them in increasing their revenue and occasionally provide input on patient care questions. In professional school, I studied the theory and application of clinical medicine, not how to assist physicians. In practice, I evaluate patients with acute and potentially life-threatening complaints, order diagnostics, interpret tests, order treatments, perform invasive procedures, evaluate the effectiveness of said treatments, consult specialists, and make diagnoses and patient dispositions. Somewhere at the end, somebody signs off on the chart. Nope...not alot of assisting going on here, but rather a lot of practicing medicine. Been doing it for 14 years. Yes, personally I would like the title change, since it more accurately reflects the work I am doing.

So the change would be appropriate, but is it worth the risks? What are the negative consequences? How will the change benefit the profession down the road? These are all questions that need to be addressed before moving forward on the issue.

Tuesday, April 6, 2010

Just Say No: Drug-Seekers in the ED

One of the daily frustrations of working in the ED is dealing with drug-seeking patients. Presentations of these patients will vary, but with some time and experience most providers will generally be able to differentiate the "seekers" from patients presenting with legitimate pain. Regardless, it is important to always provide care appropriate to the patients immediate needs and to facilitate appropriate follow-up care. When these patients continue to repeatedly visit the ED for on-going chronic pain control, it is appropriate to just say "No."

The EMTALA definition of an "emergency" in the prudent layperson standard specifies "acute" complaints (which includes pain). When a complaint is not "acute," then the prudent layperson definition (and therefore EMTALA itself) does not apply to that patient encounter. However, it is still important to perform a history and examination sufficient to reasonably exclude any potentially serious problems.

In my experience, the "seekers" will generally present with a limited number of complaints. Most often, there and on-going complaints of back or other musculo-skeletal pain, toothaches, headaches, etc. A few may present with a myriad of minor complaints and then address their medication-seeking with an "oh-bye-the-way" type of request. Unlike most patients with actual acute pain, these patients tend to either be fairly nonchalant with their 10/10 pain, or overly dramatic. The vital sign abnormalities generally associated with acute pain (i.e. mild tachycardia, elevated BP, etc.) are often absent. Medication allergies are typically extensive and usually include all analgesics that the patient doesn't want. Toradol is almost always listed. Historical inaccuracies with these patients are common. Some may weave a story based on a thread of truth, while others will outright lie. Several could easily qualify for an Oscar-winning performance. One recent example that comes to mind was a patient that came to my ED for pain complaints stemming from being "injured by an IED in a Humvee in Iraq in July of 2002." Having been in Baghdad myself and knowing that the US didn't invade Iraq until March of 2003, I was able to get a handle on this one pretty quickly and had him bounced from the ED PDQ.

In less blatent cases, it is important to deal with the apparent acute need for pain management and reasonably attempt to facilitate appropriate follow-up care. Observing my own persoanl "three-strikes" rule, I will order appropriate analagesia for the complaint, and refer the patient back to the primary care provider (or refer to a primary care practice if the patient has no PCP) for continued outpatient management of the pain. I will give a short-term prescription for analgesics, generally a 4-5 days supply and tell the patient that the emergency department will not be able to provide ongoing care for his/her pain control needs. All of this is documented in the patient's record and spelled out in the discharge instructions that the patient signs.

On a second visit, I will do the same thing. Administer analgesia, refer again, but provide only a 2-day prescription for analgesics. Again, the encounter is documented and spelled out in the discharge instructions, with the statement that additional prescriptions for controlled medication will not be issued from the ED.

On a third visit, I will adminsiter only a single dose of oral analgesic medication and provide no prescription. I will tell the patient in no uncertain terms that there will be no prescriptions issued for his/her chronic pain on this or any subsequent visit to the ED and remind him/her of my prior referrals and instructions.

On subsequent visits for the same complaint, I will perform the H&P, document that the patient has no acute issues or emergency medical conditions, and will offer or provide only an oral dose or a non-controlled analgesic and discharge the patient without a prescription. If the "give them what they want" mentality hospital administrators disagree with my approach, I would invite them to head back to school to become qualified and licensed to do what I do. Otherwise, they can feel free to stay behind their desks.

With limited resources, the emergency department cannot be "all things to all people." EMPs cannot assume the role of both the acute and chronic care provider for the community, much less the prescription drug supplier. Trying to do so results in a disservice to all of our acute patients.

Thursday, March 25, 2010

Topic of the Week: The Health Reform Bill

For those of us working in the ED, you can't NOT SEE the impact of the broken health care system. About 80% of what we do in the ED is treat problems that really could have been treated in a typical doctor's office, out-patient clinic or urgent care center more quickly and less expensively. Some of these patients's are insured. Some of these are looking for something their doctor's office didn't give them, but many are there because they have no other access into the
health care system. Short and simple, it's next to impossible to gain access to a primary care provider unless you have decent insurance. While the ED is there, it is not even mediocre as a substitute for primary care. I can't manage your diabetes, high blood pressure, cholesterol, etc. in the ER. I also can't follow you up to make sure that you are getting better. Lots of folks fall through the cracks and these are often catastrophic. This was former President George W Bush's idea of a health care system...and it's failing miserably.

Without insurance it can be an uphill battle getting admitted to the hospital for inpatient care. Unless you have a problem that's obviously life or limb threatening. Even if you do get admitted, you're likely to be discharged as soon as possible. Your follow-up care will likely be less than stellar. In short, as a non-payor you're the equivalent of a medical "hot potato," and no one wants to be the one left responsible for your care. Sometimes my role in the ER includes "guilting" physicians into do the right thing for patients. Nobody wants to sign up for a job they know they're not going to get paid to do. Many doctor's attitudes are no different from the average laborer on this point. Hippocrates should be rolling over in his tomb.

A former girlfriend's uninsured mother was admitted with pneumonia. She had a large effusion on chest xray. She did not receive thoracentesis or CT despite a long smoking history. While visiting her cousin in another town several weeks later, she got sicker and was hospitalized again. Then she was transferred to another major medical center. She underwent bronchoscopy and was in the hospital for a week or so. A physician told my girlfriend that her mother would be in the hospital for weeks, but she was discharged within 24 hours of the discussion. The patient again got sicker and was hospitalized again. Finally, after now months of symptoms and five hospitalizations, she was diagnosed with lung cancer beyond any hope of surgical cure or
chemotherapy. She died shortly thereafter.

A major NC medical center recently refused an established patient's liver transplant after his employer changed insurance companies. The patient was there in the hospital. The liver was there. The hospital refused the transplant because they thought there was a chance that they wouldn't get paid. Because of this fear, they essentially condemned the patient to certain death. The insurance issue later straightened out, but the patient died before getting another liver. The wrongful death payout for this will be huge, but because it involves one of the largest urban healthcare systems in the state, you'll never about it in the news. Reimbursement drives US health care and the insurance companies drive reimbursement. In essence, the insurance industry drives health care and despite an ever-increasing number of uninsured, the industry produces record profits year after year.

The Health Reform Law is an attempt to reform the health insurance industry. This not only provides an avenue for over 30 million uninsured to gain private health insurance, but also benefits Medicare recipients and State Medicaid programs over the next decade. For those with insurance, it provides protections that guarantee you won't be dropped if you get sick and that there will be no benefit limits to keep you out of bankruptcy from medical costs. The law does NOT create socialized medicine in the US. Hospitals and Providers will not work for the government and there is no single-payor system for health care costs. Despite the rhetoric from conservatives and the Fox Lie Network, there are no government panels that decide who gets care and who doesn't. What the law does is place health care decisions back into the hands of providers and patients. The law isn't perfect to be sure, but it is a step in the right direction. A step that has long been overdue. Every journey begins with a small step. I guess we'll see where this journey takes us. Regardless, it is better than where we are now.

Saturday, March 13, 2010

Top 100 Resources for Physician Assistants

I've recently been introduced to a great site for PAs. It's the "Top 100 Resources for Physician Assistants," and there is no better place to find such a wealth of information and website links for and about PAs. You could spend hours browsing information through this site...essentially a web clearinghouse for PAs. Enjoy... Scott

Sunday, March 7, 2010

Ouch, Managing Acute Wounds

Certainly we see a lot of wounds in the ED. From scrapes to avulsions, the ED is THE place to get experience dealing with acute wounds. Despite such massive experience, misconceptions and improper practices abound in ED wound management. As EMPs, WE should become the hospital’s experts in acute wound management, practice accordingly, and avoid dogmatic and potentially detrimental practices.

Fortunately, the skin is a very resistant organ to injuries and the basic premise of wound management is to facilitate this organ’s ability to heal itself. In most cases this will require only minimal work, such as wound cleansing or approximation of wound margins. Only in rare cases are any specialized techniques required. I basically classify wounds according to their depth, superficial or partial-thickness, full-thickness, and puncture wounds. I am excluding penetrating injuries of the head, neck, or trunk in this blog article.

Superficial wounds would include such injuries as abrasions and partial-thickness lacerations. These wounds require little care. They should be appropriately cleansed and dressed and left to nature. Wound cleansing is simple; wash or irrigate the wound thoroughly. Remember that ED wounds are far from sterile and studies have shown that copious cleaning and irrigation with tap water is just as effective as using sterile solutions. A mild soap is sufficient. Betadine is a great skin disinfectant, but is highly cytotoxic and should never be used on non-intact skin. Said another way, it’s great to cleanse the skin before a procedure (chest tube, central line, IV) through intact skin, but it should never be put on an open wound.

If cleaning an abrasion is painful to the patient, I would suggest putting some viscous xylocaine on the wound before serious cleaning. Since this is water soluble, it will easily irrigate away. Partial thickness lacerations may be either left as is, or approximated with fingertip pressure and coated with cyanoacrylate glue. Unless the wound is glued, it may be treated with antibiotic ointment or cream. I recommend that if you use such an agent, a cream (water soluble) is preferable to an ointment for ease of cleansing. I also do not recommend any preparation with neomycin to avoid common and sometimes serious skin reactions (sorry Neosporin). None of these preparations have any real effect on the rate of infection, but epithelial migration in the early stages of wound healing is theoretically aided by maintaining a slightly moist, but not wet, environment.

Full-thickness wounds will likely require approximation of the wound margins to speed healing and reduce scarring. Initial treatment is the same as for superficial wounds, just more cleaning. In wounds where suturing will be required, local anesthesia should be performed after initial irrigation if any significant exploration or debridement will be needed. The patient will be grateful. Wounds must be explored until you can see the bottom of the wound. After all visible foreign material is removed, irrigate the wound thoroughly again. Debride only severely traumatized, non-viable tissue from the wound and avoid revising the margins or under-mining the skin unless absolutely necessary.

When suturing, remember that no void should be left deep to the surface. This will only increase the rate of infection or abscess formation after suturing. This may be accomplished by various methods depending on the thickness of the skin. Sometimes a well-placed simple suture is sufficient. In deeper wounds, the vertical mattress is an excellent method of closure. In very deep wounds, a layered closure with an absorbable suture deep to the surface may be required to eliminate voids. I will almost never use glue for primary closure of a full-thickness wound, but I have had excellent results using these products to approximate skin tears common in the elderly.

When closing the skin, approximate carefully and with only enough tension to bring the margins to approximation. The wound edges should be slightly everted if properly done. This is best accomplished by placing each suture in a single motion and at a uniform depth. While holding the needle driver essentially at the center of the wound axis, place the needle tip perpendicular to the skin and simple roll the needle driver 190 degrees through the skin until the needle reappears opposite the entry point. When the suture is tied, the skin should be well approximated and slightly everted. Rinse…repeat. With a little care and attention to detail, every wound should close nicely. Be careful not to place the sutures too close together, as this can compromise blood flow.

Occasionally there will be a question of how long after an injury can a wound be safely closed. Opinions vary from 6-12 hours depending on the location and other factors. In truth, almost any reasonably clean wound can be sutured within 24 hours if there are no signs of infection. Over 24 hours, or if the wound is grossly contaminated, it is a reasonable strategy to thoroughly clean the wound, dress carefully and delay closure for 72 hours. If there are no signs of infection at 72 hours, the wound may be closed with little effect on cosmetic outcome. Infected wounds should be cleaned and treated with appropriate antibiotic therapy. There is no evidence that prophylactic antibiotic therapy prevents wound infections and I generally reserve this practice only for those at extremely high risk (bites, punctures, significant wounds on diabetics, etc.).

A lot of providers often wonder when they should call plastics for a wound. In truth, with proper experience, most EMPs could close almost any wound quite well. Remember plastic surgeons mainly inflict and then repair wounds to achieve a cosmetic effect with a bit of pre-injury planning. For most ED type wounds, the results of a plastic surgeon will be no better cosmetically than that of a decent EMP. Even simple wounds of the lip can be closed quite well, as long as meticulous attention is paid to approximately the vermillion border. I will consult plastics in specific facial situations. These include the following:

· Wounds involving the eyelid margins, periorbital fat, canthal structures around the eyes;
· Wounds involving the full thickness of the lip, or at the corners of the mouth;
· Wounds injuring the cartilage structures of the ears or nose.

Once your wounds are closed, the final consideration is suture removal. Suture duration, along with excessive suture tension, is one of the most important considerations for cosmetic outcome. Sutures in areas that heal faster need to be removed sooner. The following guidelines generally work well:

· Face 3-5 days
· Scalp and trunk 7 days
· Extremities 10-14 days

Puncture wounds are generally treated as any other wound, with two exceptions; Bites and puncture wounds that penetrate through the sole of a shoe and into the foot. Wound cleaning remains basic. Wash and irrigate. If there are gaping wounds, these can be approximated loosely by suture. A snug closure may become problematic in the event of an infection. If the EMP elects to perform a meticulous skin closure following a bite injury, then a drain should be placed in the wound and follow-up arranged in 2 days. Simple wounds to the face are exceptions, as these are less likely to become infected because of excellent facial blood flow. Bite wounds to the hands, particularly joints, should be urgently evaluated by orthopedics and dog bites should be routinely radiographed for fractures or retained tooth fragments due to the bite forces even smaller canines can produce. These injuries are less likely from felines or humans and your clinical exam can be your guide in these cases.

In addition to routine would care, with or without closure, patients should be started on an antibiotic regimen for a minimum of five days with close follow-up evaluation. The agent(s) of choice are oral ampicillin or Augmentin. For potential open joint injuries, Unasyn or Rocephin are acceptable choices pending orthopedic evaluation in the ED.

Puncture wounds to the foot, particularly through the sole of a shoe may be problematic injuries. These punctures may carry foreign material and pathogens from shoe material into the foot and cause severe infections in the soft tissues or osteomyelitis. These injuries should be considered high-risk. Like canine bites, radiography may show any radiopaque foreign bodies or bone injury. Extensive exploration of the wound is generally unproductive, but a single incision at the entry site may reveal superficial foreign material. Antibiotic therapy should cover pathogens such as pseudomonas. Ciprofloxacin would be an acceptable initial choice.
The final consideration in wound care is tetanus prophylaxis. If the patient has current tetanus immunization status (full primary series and a booster within 5 years), then no booster is indicated. If the patient is not current (no primary series and/or no booster within 5 years), then a dose of TIG should be given along with the tetanus toxoid booster.

Sunday, February 28, 2010

Days and Nights in Baghdad

I left for Iraq in July of 2008 and working as a PA for the Baghdad Embassy Security Force was unlike any of my other jobs. Sure, we had regular “sick call” clinic hours and often had to be called to the clinic after hours for urgent or emergent problems, but our responsibilities didn’t end at the door to the clinic. I guess it was about 0630 or so when I got the call on my Asia-Cell phone. Our eastern checkpoint for the road in front of the embassy had received rocket fire and we had at least two security force casualties. I donned my body armor and met one of the paramedics at the ambulance in front of the clinic. Together, we responded to the scene of the attack.

When we arrived, one guard was down in the street. The other was sitting nearby, and a third civilian casualty was also sitting nearby. The fire department had just arrived on the scene, and the EMTs were covering the more seriously injured guard with a blanket. I went to this guard first. He was conscious and talking, but had a penetrating shrapnel wound to the upper mid-abdomen. Fortunately, he could move all extremities. There was no exit wound. I asked the EMTs to package him for transport and place him in our ambulance, leaving my paramedic to supervise. The second guard seemed OK, he had sustained a head wound from shrapnel. He was also conscious and talking, if a bit dazed, but he seemed to have escaped more serious injury. I had another member of the guard staff escort him to our ambulance. I then went to the civilian, a female, who had sustained a wound to the left chest. She seemed to be in only minimal discomfort, with no respiratory difficulty. When I palpated the chest wall, I could feel a large fragment in the soft tissues superficial to the ribs. Her abdomen was fine. I directed that she be transported by a civilian ambulance arriving on the scene at that moment. With the first two patients already loaded in my unit and my paramedic yelling that we needed to “get off the X,” I left the civilian in the care of the EMTs and we began transport to the nearby Combat Support Hospital.

The first guard seemed to be doing poorly. He was getting restless. Though there was minimal external bleeding, I was sure that he was hemorrhaging in the abdomen, in addition to having any number of other injuries. I adjusted his oxygen, started a large bore IV and administered 10mg of Nubain for pain. The second guard was doing fine, less dazed now, so I stayed focused on the first guard until we reached the hospital.

At the ER, the patients were evaluated expeditiously. As I suspected, the shrapnel had penetrated deeply into the posterior upper abdomen. This likely injured large and small bowel, stomach, pancreas, as well as any number of vascular structures. Fortunately, the chest looked OK and he was holding his own with IV fluid at this point. Soon, he was whisked off to the OR. He did well and was eventually evacuated back home. The second guard and the civilian were luckier, with only superficial shrapnel wounds and a mild concussion for the guard. He returned to duty after a few days. A little while later, we responded to a second attack nearby to the hospital. Fortunately, there were no injuries.

I get a lot of questions about what I did in Iraq. Sure, I provided clinic care, and also urgent care for sprains, strains, wounds, etc. I also dealt with the same emergencies that I would see in the ED, appendicitis, asthma/COPD, diverticulitis, kidney stones, MI, seizures. I would also respond into the field, triage patients and provide care on the scene and en-route to the hospital. Seems I did a little bit everything medical and I did it all in a very interesting and diverse environment. I made a lot of new friends in the process and wouldn’t trade this experience for any other that I have had. I left the desert for good in September 2009, but I think that a little part of me will always be back there.

Saturday, February 20, 2010

Happy Birthday Victoria - February 24th, 2010

Today is my daughter’s birthday. Victoria is six years old. I cannot fathom how life would be without her. In many ways, she has transformed my entire life. Through her, I have learned to love more fully and to enjoy the moments I get to spend with the people I really care about. In my job, she has taught me more about relating to children and with other parents that I ever could have learned in any classroom. The joy she has brought me permeates every aspect of my life.

Today, I dedicate this blog to Victoria. My most precious baby, finest teacher, and my most devoted supporter.

Happy birthday Victoria. Daddy loves you.

Wednesday, February 17, 2010

I'm the Patient

On Monday, I made my foray into the realm of the patient. I had surgery on my right shoulder as a result of an injury I received while serving (non-military) in Iraq. We took mortar and rocket fire off and on and responded to those wounded in the field, but my injury was nothing sexy. I wasn’t “hit” or anything. One of the embassy guards had collapsed and I was moving him into the building to render care. I have moved many patients in the past, but when I moved this guy I felt something give in my shoulder. The pain quickly numbed down and I thought it was a strain. I iced it and scored some naproxen from the clinic, but it kept on hurting worse and for days (now months) longer than it should. Our PT tried range, exercises and TENS to little avail, so I started getting the first round of two trigger point injections and continued PT at the clinic. With no improvement, the second injection and finally a third injection came. No good. I slept in a brace and continued to eat bowls of naproxen like cereal and still managed to finish out my rotation. Finally I came back to the states where I received an MRI, more injections, more PT and finally my surgery. I know it’s not EM, but I plan to blog along on my surgery experiences just for those of you who like to live vicariously.

I had my pre-op consult with orthopedic PA Steve Smith. Nice guy. He gave me an A-C joint injection back in November that helped briefly, but ultimately, when all was said and done, my shoulder was still only about 50-60% normal function. Steve and I talked briefly about the procedure, got my consents all signed and such, but mostly we chatted. Soon after, I was ready to go. The bad part approaching surgery is I had to stop taking naproxen. Despite the commercials folks, taking Tylenol for any real pain is a severe joke. The naproxen actually worked OK. I generally shun any type of opioid, but lacking napoxen for a week really put me in touch with my inner nociceptors. I didn’t appreciate how bad the shoulder was until I had to decrease it’s use to prevent the discomfort. With this fresh in mind, I dropped off the Percocet prescription Steve gave me for post-op pain on the way home.

I worked the Smithfield ED on Saturday and Sunday and managed to get out Sunday at midnight. Made the 30 minutes drive home and then off to bed for about three hours. I had to be at Rex hospital for my surgery at 0515. My dad came to stay with me for a few days and shuttle me around, but mostly he cooked for me. This was a major morale booster. Anyway, check-in at Rex was smooth, as was my pre-op prep. Last thing I remember was Bob Wyker, my surgeon, helping get me positioned on the table, then I was in post-op with a completely dead numb right arm from the regional block. No pain, until that wore off…then I was in Percocet city for a couple of days, with a cooling unit attached to me like one of those astronaut life support systems from the 1960’s. The Polar Care 300 it is called…isn’t that just cute. Gradually, over the next couple of days the pain got better and I am getting a bit more use of the arm as time goes by. Today I am still using the Mercury-era cooling unit off and on and taking Aleve, so if anyone wants Percocet, I have extra for $ 10 a pop (just kidding).

I have my first post-op visit on the 25th, but so far so good. I worked at Rex Hospital in the ED for three years, but this was my first experience as a patient and Kudos all around. Also, as far as Dr. Bob Wyker, PA Steve Smith, and the rest of the crew at Raleigh Orthopedics, and PT Greg Hogan at Raleigh Ortho Rehab…all those guys (and gals) are the greatest in my humble opinion.

Oh, bye the way, I'm a patient and have no other association with Rex Hospital, the Raleigh Orthopedic Clinic, or Raleigh Orthopedic Rehabilitation. They're just terrific folks.

Wednesday, February 10, 2010

Pediatric Proficiency

I have always liked children, but even more so since I have had the opportunity of raising a little one of my very own. Victoria has put me in touch with the changes that take place as she has grown and has developed into this neat little miracle of a person. Through her I understand much more than I could ever have appreciated by studying developmental psychology and pediatric medicine texts. My experience with my daughter also has helped me to identify with and appreciate the attitudes and behaviors of parents in the ED. I also know the feeling of frustration a parent can have when your baby is sick or hurt.

Many EMPs are uncomfortable dealing with sick children. Perhaps this is because of their limited exposure to this special population or perhaps it is a lack of experience with children of their own. Perhaps it’s a little of both. Simply taking PALS will not close this gap. While there are some important differences to remember regarding our pediatric patients, the basics of caring for them are really very similar those of our adult patients.

1) Establish a rapport with your patient. Enter the room calmly, so as not to startle the child. Interact with the parents. If the child sees that mommy and daddy are comfortable with you, then most likely they will be too. Smile at the child and approach at their level. Talk to them, even if the parents are the ones that answer.

2) Unless the child is really ill, relax the pace of your exam. Tell the child what you are doing as they often understand more than they can verbalize. I’ll often reverse my exam and go from toe to head. Smaller children are sensitive about stuff up in their face, so by the time you get there they have figured out that you're not going to hurt them. Little children can be distracted with a tongue blade, a penlight, or a glove balloon. Older children cooperate better (usually). If a verbal child has a pain compliant, ask them to show you where before your palpate there and make it the last thing you do. Blow gently in their ear before inserting the otoscope (it tickles) and don’t dig the speculum in there. When you’re palpating the belly, give a little tickle. If they giggle it’s a good sign. If the tickle hurts, it’s more likely something serious. Getting good breaths during chest assessment can be a challenge in a pre-verbal child. Try putting a little pressure over the upper belly for a couple of seconds while you place the chest piece. It doesn’t hurt and they’ll reflexively take a deeper breath.

3) Watch the child during the evaluation. Give them a toy or a book or some other fun stuff. If they’re pink, act normal and attentive, drink the pedialyte (not that unflavored stuff), juice or the popsicle, then they’ll likely be fine. If they look puny or uncomfortable, won’t drink much, then they’ll need a more extensive exam. If a child is listless, lethargic, pale, mottled, refuse po and even worse, virtually ignore the blood draw or cath UA, then you have a seriously ill child.

4) To a degree, you can blow off a little tachycardia with a fever or some other pain/discomfort as long as the patient is active, pink and drinking. These should resolve with the appropriate medications and modest oral rehydration. If not, watch closely for other signs of trouble; persistent tachycardia, tachypnea, delayed capillary refill are all significant signs. Children compensate for illness very well, right up to the (very) bitter end. It's important to intervene early in these cases.

5) Children get a lot of rashes when sick. Most will be a light viral rash. Amoxicillin may case a rash, but if there is no urticaria, it’s likely not allergic. Don’t over look the important rashes; the streptococcal “sandpaper” rash, the desquamating rashes of staphylococcal infection and Kawasaki disease, and the “tick” rashes. Be especially vigilant for the petechial rash of meningio-coccemia.

6) Unless you suspect a surgical issue, let the child drink. If they can’t and there are clinical signs of dehydration, use an IV and hydrate them well. If time permits, use EMLA at procedure sites (IV, LP, etc) and lots of “vocal anesthesia”. If they’re really sick and you can’t get an IV, use the IO before it’s too late to help. “Hydrate to urinate” or “drink until pink.” Don’t neglect the glucose. Kids need sugar and sick ones go through a lot of it. Most kids don’t store glycogen well and have less body fat to weight ratio (or at least they used to).

7) Know the color-coded (Broselow-type) tapes and get in the habit of using them. As a rule of thumb, if you can’t weight the patient and they look a little bigger than average, go up to the next tab. If they’re really bigger than normal, consider going up a couple.

8) For trauma, know that kids have big heads and weak necks, that they can get severe chest injuries without rib fractures and that their liver and spleen are very vulnerable to injury. Know the numbers for fluid resuscitation (20cc/kg) and blood (10cc/kg), and for the nearest trauma center. The drugs you can dose from the tape as appropriate. Know the differences between the adult and pediatric airway, and remember that it takes less absolute blood loss to produce profound hemorrhagic shock.

9) If everything looks fine, but something doesn’t sit well in your gut, call the pediatrician. Even if the child doesn’t get admitted, make sure that they will be seen within a day. If the pediatrician can’t make it happen, have the parents return them to the ED for recheck. If you think the child should be admitted, and the pediatrician won’t get on board, consider keeping them in the ER until you can discharge them directly to the pediatrician’s office.

10) Never forget the other patient(s) in the room. Like the child, the parent(s) have a lot of fear and uncertainty when their child is sick or injured. Talk to them. Tell them what you are doing and why. Explain study results with them and the necessity for each intervention. They need to be kept informed and involved in the care of their child at all times. Let them know that this is what you would expect for your own child. In exchange, they will give you the confidence and trust you need to care for their child.

Tuesday, February 9, 2010

Emergency Medicine Practitioners

I received an email asking me, “what is an EMP”? I use the term rather frequently in publication to identify emergency medicine practitioners, hence EMPs. An EMP is a physician (MD or DO), Physician Assistant, or Nurse Practitioner who engages in the practice of emergency medicine. Other publications might differentiate between physicians and some term like “Mid-level practitioner” or MLP. I’ve never quite understood the term MLP. Mid-level between what? I understand that an MLP is between a physician and a nurse, hence mid-level. It is mainly a regulatory term and has no application to the clinical practice of medicine so I personally shun the term.

Nursing is nursing. Medicine is medicine. These are two entirely different disciplines. Although the knowledge base of nursing and medical providers overlap to some degree, there is no in-between area of practice. As a PA, I practice medicine, specifically emergency medicine. I practice under the general supervision of a physician, and I am actually providing physician-level services. In a similar fashion, an NP is a nurse, but has advanced education to include the practice of medical acts. NPs also have some type of supervisory arrangement with a physician and they also provide physician services. There is no such thing as a “mid-level practitioner.” The term itself implies that there is some middle, or lower level of acceptable care. The accurate term is, “non-physician practitioner.” All practitioners provide physician services, and there are no studies that demonstrate the superiority of care provided by one type of provider over another (i.e. MD v. NP v. PA).

If you were to compare the work of a PA and a physician resident, you would find many similarities. Both practice in a supervisory arrangement following graduation from their respective training programs. For the resident physician, there is a more structured path of experiences and progressive responsibility leading to completion of the residency program. For the PA (or NP), the educational process is less formal and more self-directed as we learn, “on-the-job.” Like our resident counterparts, we also gain experience and progressive responsibility in our practice. In the end, the physician resident graduates and continues into independent practice. The PA continues to practice in the supervised role, albeit with an ever-increasing level of autonomy within that role. In essence, the PA role is akin to that of being a “permanent resident.”

I am a specialist in emergency medicine. I am a licensed and nationally-certified PA (PA-C) and I am qualified by over 13 years of EM experience, a post-graduate Masters degree with a concentration in my specialty, and I hold all the requisite life-support credentials, ACLS, PALS, ATLS. I have very similar experience to that of an emergency medicine resident and provide physician services to the full spectrum of emergency department patients in my practice. I am an emergency medicine practitioner.

Monday, February 8, 2010

Tribute to Emergency Department Nurses (All of you)

The emergency department runs on nurses and a good nurse is worth his/her weight in platinum. While the EMPs (emergency medicine practitioners) go from patient to patient, taking histories, doing exams and ordering diagnostic studies and therapeutic interventions, it is the nurses that do the majority of the actual work by far. Not only do we depend on them to do this work, we also depend on them to keep us apprised of our patients’ conditions and to prompt us to make an appropriate disposition when our phase of care is complete. I have long held that ED nurses are the probably the best in the hospital.

In my 30 years in emergency medicine; EMT to PA, I have become acquainted with many excellent nurses. I’ve even married a couple, but I digress. Most of the ED nurses I have worked with have been RNs in my latter years of practice. Often overlooked are the contributions of LPNs, now a minority in ED. I have noticed that many of these fine nurses have been “phased out” of ED’s as time has gone along. This is largely driven by the concept that one can expect a higher level of competency from an all-RN nursing staff, but I am aware of no objective data that supports this view. My personal experiences, as both an EMS provider and PA, have shown me that an experienced ED LPN is at least as competent as their RN counterpart. In either case, the variety of experience the ED provides, the opportunity to hone skills, or the constant close relationship with providers somehow combines to produce a group of highly competent nurses.

One nurse in particular that stands out in my mind was Bobbie. Bobbie was an EMT, as well as a nurse and was one of the most intelligent and capable nurses I have ever worked with. When I was a basic EMT and EMT-I working on the Outer Banks in the early 1980’s, nurses from the local medical center (basically a free-standing ED) would occasionally accompany us on transports of the more critical patients. Bobby accompanied me on the transport of a patient with an acute AMI headed into cardiogenic shock. There we were, an EMT-I and a nurse with this patient on a slow slide South loaded up the ambulance with a portable cardiac monitor/defibrillator, a drug box and three IV med infusions. The patient deteriorated en-route and required medication adjustments. He thrashed about and pulled out the IV lines and required restarts. In the end, we and the patient made it to the hospital alive. On that and many other occasions, Bobbie never ceased to amaze me with her poise and professionalism. Bobby was an LPN.

I work with some fine LPNs in my current ED. Again, they are highly skilled, caring, experienced and professional. Both of those I have recently worked with are pursuing their RN credentials. Ultimately, they will be better compensated and have vastly more career opportunities available to them. Regardless, I cannot imagine that they could be any better nurses than they are right now. In the grand scheme of things, I think I would just rather have the most competent nurses taking care of my patients than rely solely on the letters behind their name. RN or LPN, the emergency department nurse is a breed apart from the rest. For all that you do, this blog is for you.

Sunday, February 7, 2010

Dealing with Disappointment

Sometimes there is nothing quite so bad as when your peeps let you down. I have alot of peeps...fellow PAs, NPs, Docs, Nurses, Secs and Techs, etc. However, the peeps I generally hold most near and dear to my heart are the EMTs. If you haven't skimmed my profile, I'll just say that my medical career begain as an EMT. That was WAY back in 1980, while I was still in high school and I subsequently started working with local volunteer rescue squad. I got hired by the county EMS agency shortly after my graduation and within a year started training as an EMT-Intermediate and over the subsequent years as an EMT-Advanced Intermediate (essentially a cardiac care technician) and finally a paramedic. I worked mostly prehospital EMS, with several years spent as an EMS aeromedical team and, while in PA school, as a critical care transport Paramedic for the University. I also had the opportunity to serve as the training coordinator for a county EMS system and lead instructor for advanced EMS programs for the local community college. It is safe to say that, with almost half of my medical experiences being as an EMS care provider, I still hold a special fondness for those that still make house calls and do their best to provide life-saving care under conditions that many in the ED cannot begin to fathom.

Recently though, my peeps let me down. I was working in the ED when EMS brought in an elderly couple from a high impact MVC. Trauma is disproportionately devastating to the elderly and the mechanism of the crash was significant, but these factors were apparently lost on EMS and the problems were immediately noticeable. The driver, with noticeable head and upper extremity orthopedic injuries has rolled in the ED in a wheelchair. Later I learned that EMS had even told the nurses that the driver's seatbelt failed during the collision. The passenger was at least lying on a spine board, but not really secured to it. Both patients wore cervical collars...literally wore them. Neither collar was correctly fitted or locked and were therefore ineffective. Despite the mechanism of injury, neither patient had an IV. Fortunately both were talking and had fairly stable vital signs.

Through evaluation, the driver was fortunate to have no potentially life-threatening injuries, but the passenger wasn't quite so lucky. In this patient we found that she had not only suffered a fracture of C1, but also three (3) severe liver lacerations, an unstable pelvic fracture and an associated rupture of the urinary bladder. Though she remained hemodynamically stable in the ED, she has three potentially immediately deadly injuries. I had her choppered out to the closest trauma center, during which she fortunately remained stable.

I was profoundly disappointed in my EMT peeps. For whatever reasons, none good, all of the basics of trauma care that we have tried to teach since the late-1960's...the very impetus for the development of EMS itself, were all but ignored. I am trying to find a way to deal with this issue in a constructive, rather than critical way. My peeps can do better, and I'll do everything I can to help them achieve that.