Patient Satisfaction and the Emergency Department: An Elusive Goal

I've been practicing emergency medicine exclusively for almost 19 years now, with the exception of my overseas deployments in Iraq (2008-2009) and Afghanistan (2014-2015), where the practice was a combination of emergency/urgent care, occupational medicine and some primary care.  During this time, I estimate that I've seen somewhere around 70,000+ patients in this time, and have not gotten many patient complaints.  If fact, I could count the number of written patient complaints that I have received with the digits on my hands.

When I think about those complaints, and about the experiences I have had in treating 70-thousand-plus patients, I am surprised that I haven't received more.  Don't get me wrong...I am not an ogre or something, but everyone does have an "off" day now and again.  In fact, I'm a pretty out-going and friendly guy, and I enjoy my work.  I also generally like people, which I suppose is one reason that I decided to practice medicine for a living for the past couple of decades.

Hospitals are working hard to improve patient satisfaction.  The reasons are clearly tied to increased income for the hospital, although on very solid ground I can say that this was a really stupid idea. For this reason, we started seeing the guest / patient services-type of people being introduced twenty-something years back.  Then TVs started showing up in the ER.  Then paper and eventually tablet-based patient satisfaction surveys became the norm.  Patients are now being categorized as clients or customers.  There are issues with that, particularly in the emergency department, where the purpose and environment of care are vastly different from other out-patient and departments and inpatient units.

The Emergency Department exist to treat emergency medical cases.  That's why they call it the "emergency" department.  The emergency department does not exist because you want your knee MRI today, rather than have your doctor schedule it.  The emergency department does not exist to refill your chronic medications, and certainly not to function as your pain management clinic.  Americans, by and large, are uninformed, unrealistic consumers of health care services.  Patients seem to liken the ER to a medical convenience store,  Americans want what they want, preferably want to get it for free, and they want it right now, and they expect it to be completely error-free.  In short, they have unrealistic expectations of what they can get from the E.D. and many have no idea of what should even constitute a legitimate reason for coming to the E.D. is the first place. Just because you want it now, does not make it an emergency.

Girl comes into the E.D. because she missed a period and thinks that she could be pregnant.  She has absolutely no symptoms (nausea, vomiting, bleeding, abdominal pain, etc.).  I have difficulty with this because, "I want a pregnancy test," is not a valid reason to seek attention in the E.D.  In general, I'll advise the patient to either; 1) go to the health department for a free test, or 2) go to any pharmacy or store and buy a pregnancy test.

Similarly, I have had girls come to the E.D. because they decided to have unprotected sex the night before and "just want to get the morning-after pill."  Not to champion the cause of rank stupidity in American society, I'll advise the patient to go to a pharmacy and ask the pharmacist for "Plan B."

An obese patient comes into the emergency department with chronic knee pain.  It's worse when the patient walks. there has been no trauma / injury, and there are no significant exam findings.  The patient expects an Xray of the knee(s) and some magic pill to pop that will magically cure the fact that the human knee is simply wearing down due to years of supporting weight that the joints of their 5'3" frame were never designed to support.  The proper treatment in this case would be weight-loss and exercise, with likely OTC analgesics.  No matter how you phrase it, the patient's complaint will say something like, "he said my knees hurt because I'm too fat."  There's no way you're going to get a good satisfaction score here, or in any of a dozen examples that I could give you.  However, despite that fact, the medical care was appropriate and sound.

I have provided some very sick patients with very good care, only to have a relative make a complaint for some vagary, often not even related to care provided.  If the patient was a conscious, competent adult, I generally ignore these complaints altogether.  If a complaint comes from someone associated with a competent adult patient (a second-hand complaint, if you will), I'll generally just toss it in the nearest waste receptacle.  If the actual patient has an issue, I am happy to address it.  If the complainant isn't the patient, then it's simply a waste my time.

Many years ago, I learned that "you can make some of the people happy, some of the time, but you can never make all of the people happy all of the time."  True words then, and the since an increasing number of Americans have gone the way of the "people of Walmart," it is even truer today.

A few helpful tips I can offer on satisfaction, with a degree of confidence from managing to have so few complaints over the course of my career, are as follows:

1. Be nice from the outset.  Both to the patient and to the family.  During the time you do have with them, get to know something of them other than just the medical facts.  Find a commonality. Use their name.  I like being on a first name basis with my patients.
2. Let them know who you are, what you do, and if opportunity permits, how long you have done it.  Let them see what you do and have the opportunity to experience you as a professional.
3. Keep them informed of their progress, and especially of any unusually long delays in their care and disposition.
4. Involve them in the decision-making process and be sure to explain any procedures you are doing.  Talk with them while performing procedures.
5. Give them realistic expectations, without dashing hope.
6. Be empathetic to their situation and allow them to feel that from you.  It doesn't make you weak or unprofessional, just human.  It never hurts to hold someone's hand.
7. Honor their requests, when appropriate.  They may ask you to call their doctor.  Even if they're not on staff, it's just a phone call.
8. A touch of humor doesn't hurt...just remember your audience.
9. Do the best job that you can do, and finally...
10. Don't worry about the scores.

Plaintiff Vs. Dr. Jon's Urgent Care, Martinsville, VA

* Skip to the bottom for an Update

Almost a couple of years ago, I was contacted by an attorney with a request to review some medical records and for my opinion about the medical care she had received at Dr. Jon's Urgent Care in Martinsville VA.  The attorney that contacted me had found an article I had published in 2001 while I was completing my Masters in PA Studies that was appropriate to the cause of death in this case.

In seems that a young woman had received a trauma to her right lower leg when she was inadvertently hit by a crate of heavy photographic equipment.  On the day of the injury, she was seen at a clinic on the site of the injury and followed up the next day.  The young woman had a significant blow the the right calf, and was pain, even though she was still able to ambulate on the leg.  (Now, any clinician with any diagnostic and prognostic ability worth squat already should have an idea of what happened in this case, so just write it done now so there will be surprise at the end.)

She rode an hour from the site of the injury to Atlanta, took a relatively short flight to Charlotte, and then a 2+ hour car trip to Martinsville, VA.  During the next several days, she sent text messages to her friends and relatives around her leg, still being in significant pain, despite taking elevating her leg and taking Tramadol.  Eight days after the injury, she was seen again in follow-up at another work-site clinic where it was documented that her symptoms were not improving and referred her to Dr. Jon's Urgent Care clinic, where she was seen the same day.

The complaint was right foot and ankle pain with history of the injury as noted above.  She was seen by the attending PA, an exam was performed and it was noted that the patient had bruising and moderate pain in the calf with tenderness on palpation.  (If you still don't now what happened, you might consider going back to school).   An Xray was performed and closely scrutinized until  a possible small avulsion fracture of the talus was diagnosed, but apparently all the soft-tissue trauma and swelling to the injured calf readily apparent on the Xray was overlooked entirely.  So she was splinted, placed on crutches and suffered a fatal pulmonary embolism less than 72 hours later.

In my review of the patient's visit to Dr. Jon's Urgent Care, it was my opinion that the patient way at high risk for DVT and tha she should have been referred to the ER for further evaluation (i.e. an ultrasound of the affected limb).  I don't like being in the posiiton of being critical of a colleague's care, but if I said that consideration of of the possibility of a DVT was not reasonable in this case, then I would have been intellectually dishonest.  Not only was it possible, but it was very high on the list.  That it wasn't even considered at all, is incomprehensible to me.

A suit was brought on behalf of her estate by her mother, and I participated in the proceedings as an expert witness for the plaintiff.  The defense contention is that they never considered the possibility of this patient having a DVT, despite having the obvious risk factor of a serious trauma to a lower extremity, with continuing pain for 8 days that was "not improving," according to the work-site clinic that saw her earlier the same day.  An employee Jon's as well as the evaluating PA claimed that the patient has insisted that only her ankle was hurting and that she didn't want her calf examined (how likely is that since she was sent there because her leg was "not improving" and despite her multiple text messages about her leg pain though-out the week, despite being on Tramadol.  Did I neglected to mention that she was on NuvaRing.  Of course none of this was recorded in Dr. Jon's medical record of the patient's care and has all being asserted post-mortem.

I will admit that the defense attorney leading the case is smart and skillful.  Her attempts to excuse the oversight of the significance of the patient's injury and the failure of the clinician involved were based on trying to confuse the jury.  The inferences were that if the patient didn't have  a coagulapthy, cancer, CHF, age over 60 or any of a litany of established risks, then the clinician had no reason to suspect a DVT.   However, the  patient has a lower extremity trauma, the pain is persisting, she has a bruised, swollen and tender calf, and she's on NuvaRing, a contraceptive that has a higher-than-average association with DVT that traditional oral contraceptives. This, to me literally screams DVT. However, jurors are not well-versed in medicine, have no understanding of how the practice of medicine is conducted, and they are easily misled by a bright attorney being well-paid to misdirect them.

Only this evening, I was informed that the verdict was returned in favor of Dr. Jon's Urgent Care. I should not be surprised by this for the reasons I stated above, but I can also say with all honestly that I am not completely surprised.  These same people that complain about a long wait, or the fact that they were not given water in a timely manner or that they're lab work is taking too long...the one's that don't understand and are easily misled, are the same people that, 75% of the time, will give a provider a free-pass for missing  a condition that ultimately resulted in an untimely and clearly preventable death.  I suppose that should give providers some re-assurance that, if we make a similar mistake, we can also get the same free pass that Dr. Jon's Urgent Care got in this decision.

My sympathies to the family in this case.

Update:  I was informed by the Plaintiff's attorney that the court had vacated the defense verdict and that the case will be re-tired.  Hopefully, the new jury will make a more informed decision.  When sloppy or incompetent medicine contributes to the death of a healthy young life, someone needs to be held accountable.

Patients never cease to confound

During a recent shift in minor care (44 patient in 10 hours...Ugh!)

Complaints (as written by the patient)

Coold - Cold or URI

Trought - Throat pain or pharyngitis

Left (then scribbled out), right (something unreadable scribbled out) shoulder

Constipal - Constipation

Absest - Abscess (?Incest, obsessed?)

Absens seizurs - Not too hard

Urinary and progressive agressive behavior - cystitis and bipolar

Fell bab and stuch - Turns out an esophageal obstruction

I had one patient today that was seemingly named after a Laptop computer.

Re-posting: Reflections on the effects of Medicaid from another Emergency Medicine Colleague

The link below is a Op-Ed on the effects of Medicaid, from the perspective of another Emergency Medicine Colleague.  It is re-posted here without his expressed permission, but I do also recommend his blog at www.edwinleap.com.  However, every word of it is true and echoes some of  my own personal experiences in emergency medicine over the past 19 years.

http://journals.lww.com/em-news/Fulltext/2014/04081/Second_Opinion__The_Toxicity_of_Medicaid.1.aspx


Fixes:  Probably none, as many of those involved  share the traits of ignorance, entitlement, and apathy.  Society for many of these people, exists only to serve them, and we dare not ask them to lift a finger in order to improve their situation, as the latter might have a negative impact patient satisfaction scores (God forbid).

Suggestions:

• Continue to provider excellent care services and thoroughly document the encounter. Above all, be courteous.  
• Encourage the use of primary care by increasing Medicaid provider reimbursements and dropping the co-pay for the primary care visits.
• Institute a co-pay for non-emergent ED visits.  Having a co-pay does not violate EMTALA. Nor does discharging a patient with a well-documented non-emergency medical condition to follow-up with the primary care provider.
• Stop writing prescriptions for OTC meds.  
• Never tell anyone that they're clogging up the ER with minor issues, abusing the EMS system by using it as a taxi, or that they could buy the OTC medicine for less than the cost of the pack of cigarettes in their pocket.  

Just a few thoughts.

Johnston Medical Center ER Vignette Survey – January 29-30, 2018

On January 29-30, 2018, I performed a brief survey of the medical staff, nursing staff, and other ancillary staff during the night shift in the ED.  Each staff member was given the survey document below, and asked to consider the vignette below for a minute or so and then to write what they thought the most likely problem(s) could be.    With the exception of answering a question about ability to ambulate, (the patient could ambulate) No additional information was provided about the patient.

A total of 31 personnel were surveyed.

Surveys were provided to staff, who were asked not to discuss their responses with other  personnel. On returning the surveys,  the participants, in addition to their answers, indicated only their credential  (MD, PA, RN, etc.)   The purpose of the survey was not disclosed to participants.

_________________________________________________________________________________

Patient is a 24-year-old female who presents to an urgent care facility for evaluation of right lower extremity pain.  8 days previously the patient had been struck on the right medial calf by a pallet full of heavy photographic equipment.   Patient has pain and swelling to the leg with worsening since onset.

Past history:  No significant medical issues

Medications: NuvaRing contraception

Vital signs: Assume normal

Exam:  Extensive bruising and tenderness to the right medial calf and pain to the ankle

Survey Question:  What is your prime concern(s) in this patient?         

Survey Responses from thirty (30) licensed / certified personnel surveyed, were as follows, listed by each discipline: 

MD (ER) – DVTs

MD (ER) – DVT

MD (IM) – DVT

MD (ER) – DVT, Compartment syndrome

PA-C  (ER) – DVT

PA-C (ER) – DVT, Compartment syndrome

PA-C (IM) – DVT

PA-C (ER) – DVT

PA Student – DVT, Compartment syndrome

FNP (IM) - DVT, Compartment Syndrome, Hematoma, Vascular compromise

RN – DVT

RN – DVT, fracture

RN – DVT

RN – Compartment syndrome

RN – DVT

RN – DVT

RN – DVT

RN – DVT

RN – DVT

RN – DVT

RN – DVT

RN – DVT, Foreign body (if open wound)

RN – DVT

RN – DVT

RN – DVT, fracture

RN – DVT

LPN – DVT, fracture

RCP – DVT, Compartment syndrome,  Necrotizing fasciitis

RCP – DVT, fracture

EMT-Intermediate – DVT

EMT-Paramedic – DVT

Results:

96.8%    (30/31)                  Recognized risk for DVT               

19.4%    (6/31)                    Recognized risk for Compartment syndrome 

12.9%    (4/31)                    Recognized risk of Fracture

9.7 %     (3/31)                    Recognized risk for other conditions (Hematoma, Infection, Vascular) 

DVT Risk Identified by provider groups:

100%      Medicine Group:             MD, PA-C, PA-S, Personnel

 94%       Nursing Group:               FNP, RN, LPN Personnel

100%      Ancillary Personnel:       RCP, EMT Personnel

Advances in Trauma Care: Lessons from the Wars in Iraq and Afghanistan

While I was in Afghanistan (2014-2015), I researched and wrote an article regarding the advances in trauma care that have resulted in our wars in Iraq and Afghanistan.  I intended to publish this in Advance for PA's and NP's when I came home, but neglected to pursue submission due to other priorities and my inability to contact Mike at Merion Publishing.   I'm going to post the article here on my blog site, if for nothing else than to show I did actually write it and maybe someone will still get some practical benefit.   I would also like to point out that some of these lessons were instrumental in the phenomenal work of the Trauma staff in Las Vegas who were able to save many lives in the 2017 mass shooting there.

Lessons from the Battlefield: Damage Control Surgery, Resuscitation and

Tranexamic Acid (TXA) in Trauma Care

Roger S. Best, EMPA-C, MPAS

If anything beneficial has ever come from modern warfare, it has been the improvements in the survival rate of severely injured combat casualties.  These benefits eventually ring down to traumatically injured patients in the civilian world.  The wars in Iraq and Afghanistan have brought several major advances in trauma care¹: damage-control surgery (DCS), damage-control resuscitation (DCR), and the use Transexamic acid (TXA) in patients with massive hemorrhage. This article addresses these modalities, beginning with damage control surgery.

The concept of DCS^2,3 has been evolving since the 1990’s, but with lessons learned during the wars in Iraq and Afghanistan, the concept and practice of damage-control surgery has rapidly advanced in the war-time theater.  These practices are now gaining acceptance in civilian trauma care settings as well.  In DCS, patients are initially evaluated and receive any indicated emergent life-saving interventions (LSIs), i.e. definitive airway management, thoracostomy, initial resuscitation for hypovolemia, etc.  Once these have been performed, the patient is then taken to the operating suite for initial surgical interventions that are specifically designed to: 1) control hemorrhage; 2) prevent or mitigate contamination, and 3) protect the patient from further injury.

It is now well-established that trauma patients surviving their initial injuries are more likely to die from severe metabolic derangements than from the failure to complete the surgical repair(s) of their injuries.  These derangements, referred to as the “lethal triad,” include coagulopathies, which impair hemorrhage control, hypothermia and metabolic acidosis.^* Once these derangements are established, their management becomes problematic. Ironically, prolonged surgical procedures to complete repairs of injuries are major contributors to these derangements and to the corresponding increase in delayed patient mortality.  This realization requires a shift in the surgical mindset, where conventional surgical wisdom dictated that surgery is best provided as a single definitive procedure to one of staged surgical intervention(s).

Our collective wartime experience now shows that the best patient outcomes result from initial life-saving interventions, followed by abbreviated, staged surgical procedures, particularly laparotomy, to control hemorrhage, prevent further contamination and protect the patient from further injury.  Once these initial goals are accomplished, the patient is then transferred to the intensive care setting for management of coagulopathy, hypothermia and metabolic acidosis.  Once the patient’s physiologic condition has been optimized, they can be returned to the OR for completion of surgical care.  Best practices in trauma care now dictate a continuum of staged surgical interventions, interspersed with ICU care in order to optimize the patient’s medical condition between interventions.

Damage Control Resuscitation (DCR)^3,4, is emergent medical care provided to treat or mitigate the impact of coagulopathies, hypothermia and metabolic acidosis, either in concert with DCS, or while the patient is awaiting surgical intervention.  The initial, and most important aspect of DCR, is to optimize the control of hemorrhage.  Death from hemorrhage accounts for 30-45% of trauma deaths, but paradoxically is the most preventable cause of death among combat casualties. 

In contrast to previous approaches initially using direct pressure, elevation and proximal arterial pressure points for the control severe bleeding, the methods best proven for the control of potentially life threatening hemorrhage should be limited to direct pressure to compressible bleeding sites, the use of hemostatic dressings, and the effective use of tourniquets.

Direct pressure remains the mainstay of initial hemorrhage control measures. Hemostasis can be achieved quickly with a compressible wound.  Hemostatic dressings used in conjunction with pressure are highly effective.  In cases where an extremity injury results in severe bleeding and these techniques will not quickly bring this under control, then proximal application of a tourniquet is the intervention of choice. In the wartime experience, the use of tourniquets have shown several advantages, where the prehospital time is under six (6) hours, including:

·         Improved hemorrhage control

·         Decreased incidence of shock

·         Improved survival

·         Acceptably low rate of tourniquet-related complications

Non-traditional tourniquets (junctional tourniquets) have also been developed and have shown success in controlling hemorrhage from typically non-compressible sites, such as the iliac and axillary arteries⁵.  In areas of hemorrhage where bleeding is occurring from inaccessible sites, i.e. Pelvic fractures, non-compressible injuries not amenable to tourniquet application, therapies such as pelvic binders and also hemostatic dressings (i.e. Combat Gauze) have shown some benefit.  Ultimately, the goal of using more aggressive methods of hemorrhage control are intended to reduce the need for massive transfusion and address the resultant risk of coagulopathy.

Predictive indicators of the need for transfusion therapy include penetrating injuries to the trunk, systemic hypotension (SBP<90 and="" core="" hg="" hypothermia="" mm="">36°C or 96°F).  However, data from the National Trauma Data Bank has shown increased mortality with SBP of <110 10mm="" 4.8="" a="" abnormalities.="" absent="" altered="" are="" as="" at="" base="" begin="" combination="" deaths="" deficits="" defined="" drop="" early="" every="" following="" for="" heart-rate="" helpful="" heralding="" hg.="" hg="" hypotension="" identifying="" in="" increase="" injured="" is="" laboratory="" loss="" massive="" mental="" mm="" nbsp="" o:p="" of="" onset="" or="" patients="" perfusion="" pulse="" radial="" requiring="" sbp.="" sbp="" sbps="" severely="" status="" studies="" the="" therapy.="" this="" tissue="" transfusion="" trauma="" variability="" weak="" with="">

·         Base deficit > 6 or pH < 7.25

·         INR > 1.5

·         Hemoglobin <11 hematocrit="" o:p="" or="">

Even with what would have previously been considered “stable” levels of SBP (90-118 mm/hg), the insidious onset of the shock state can be seen in the increasing base deficit, declining pH, declining H&H values, and the early onset of coagulopathy. 

The next component of DCR is the prevention of hypothermia, which increases the risk of life-threatening hemorrhage and associated mortality, with a death rate of 100% in severe cases.  Strategies to combat the incidence and degree of hypothermia in the prehospital setting by focusing on hemorrhage control, limiting the amount of clothing removed, instituting passive warming techniques such as the use of wool, solar and warming blankets and the infusions warmed IV fluids.  Passive and active anti-hypothermic measures should be continued in the emergency and intensive care settings.

The final component of DCR is the management of hypotension, transfusion considerations and the mitigation of metabolic derangements.  Ideally, the goal would be to address all of these derangements simultaneously.  In prehospital settings, or at facilities where appropriate surgical services are not readily available, consideration should be given to “hypotensive resuscitation” in selected cases.

In hypotensive resuscitation, aggressive hemorrhage control of active bleeding is the focus, along with vascular access and conservative intravenous fluid administration, while a lower-then-normal SBP is permitted.  The intention is to avoid rebleeding and dilutional coagulopathy until surgical control of hemorrhage can be accomplished. This approach uses the body’s natural coagulation cascade, vascular spasm secondary to injury, and a degree is hypotension (SBP <90 1="" 2="" a="" and="" animal="" are="" b="" be="" beneficial:="" by="" care.="" cases="" clearly="" cns="" combat="" controlled="" current="" delayed="" felt="" field="" further="" hemorrhage="" hg="" hospitals="" however="" hypotension="" hypotensive="" immediately="" in="" indicated="" is="" mitigate="" mm="" nbsp="" non-compressible="" not="" of="" only="" operations="" operative="" or="" patient="" permissive="" practices="" quickly="" reaching="" reflects="" resuscitation="" s="" situations="" studies="" support="" surgical="" taken="" teams="" the="" there="" to="" trauma="" two="" war="" well-supported="" where="" will="" with="" zones.="">⁶

or in cases of impending vascular collapse. 

Where hypotensive resuscitation is not indicated, intravenous therapy may be instituted to support circulation.  Traditionally, crystalloid solutions such and normal saline (NS) or lactated ringer’s solution (LR) have been used for initial resuscitation.  In animal studies of these fluids in the treatment of traumatic shock, NS was shown to contribute to metabolic acidosis and worsening coagulopathy, whereas this was not observed using LR. Theoretically, either fluid in significant volume (>20 mL/kg) may result in dilutional coagulopathy, and while LR has been shown to be superior in animal models for trauma resuscitation, neither fluid is ideal and the administration of greater than 20 mL/kg is of dubious benefit.  Colloidal solutions, such as HES (Hetastarch) also contribute to dilutional coagulopathy, but has the added disadvantage of impairing the plasma activity of von Willebrand factor⁷.  These effects would make such solutions undesirable for resuscitation in the setting of continuing hemorrhage.

Vasopressor agents, though widely used in medical shock states, are generally eschewed in the case of acute hemorrhagic shock.   However, an exception may be the use of low-dose vasopressin, which apparently becomes deficient in advanced stages of hemorrhagic shock.  Theoretically, vasopressin may lower overall resuscitation volumes is hemorrhagic shock, reducing morbidity and mortality, but there are currently no studies to support its use.  Promising studies thus have shown enhanced survival from lethal hemorrhage in porcine subjects⁸ and reduced fluid resuscitation volumes in human subjects. More extensive human trials are planned involving the use of vasopressin in trauma.

The resuscitation fluids of choice for hemorrhagic shock include whole blood, or combination blood component therapy.  Whole blood has the advantage of volume replacement with an equivalent oxygen-carrying substitute, while concomitantly addressing coagulation deficiencies.  In the absence of whole blood, component therapy at a 1:6:6* ratio of platelets, PRBCs and fresh-frozen plasma respectively is the currently preferred option until patient stabilization has been obtained⁹.

*Concentrated platelets are equivalent to the number of platelets contain in 6 units of whole blood.  Administration of a unit of concentrated platelets per 6 units of PRBCs and FFP is equal to a blood component transfusion ratio of 1:1:1.

Massive transfusion is generally considered as the administration of 10 or more units of blood within a 24-hour period.  During massive transfusion, the patient will need to be under continuous surveillance for associated transfusion-related complications, including potential hyperkalemia and hypocalcemia, and treated accordingly¹⁰.

In patients who receive massive transfusion therapy, the early use of Transexamic acid (TXA) has been shown to improve survival¹¹.  TXA is an Antifibrinolytic agent that exerts a protective effect against the onset of coagulopathies (i.e. DIC). Studies using TXA in the setting of combat trauma have demonstrated improvements in long-term patient survival, despite higher injury severity scores in TXA-treated casualties requiring massive transfusion if TXA is administered within 3 hours following an injury¹².

Advances in the care of trauma victims continue to evolve from our dynamic experiences with combat casualties.   Simply getting the patient into the surgical suite is no longer the gold standard of care, but rather a part of a balanced multi-disciplinary approach that includes life-saving pre-hospital and emergency department therapies, staged surgical interventions, and intensive care optimization that will provide more substantial reductions in mortality and morbidity than seen previous decades.

1. Howell SJ. Advances in trauma care: a quiet revolution. British Journal of    Anaesthesia (2014) 113 (2): 201-202

2.       Wyrzykowski AD, Feliciano DV: Trauma damage control. In Trauma. 6th edition. 2008: 851-870. 

3.       Lenhart MK., Savitsky E., Eastridge B., Combat Casualty Care: Lessons Learned from OEF and OIF. Office of the Surgeon General, U.S. Army. Borden Institute, Fort Detrick MD. 2014.

4.    McLamb CM, MacGoey P, Navarro, AP, Brooks AJ. Damage control surgery in the era of damage control resuscitation. British Journal of Anaesthesia; (2014) 113 (2): 242-249.

5.       Kotwal, Russ S., et al. Management of Junctional Hemorrhage in Tactical Combat Casualty Care: TCCC Guidelines–Proposed Change 13-03. Journal of Special Operations Medicine; 13.4 (2013): 85-93.

6.  Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; et al. Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation. Journal of Neurotrauma 2007; 24 (1 Supplement): S7-13.

7.       Treib J, Haass A, Pindur G. Coagulation disorders caused by hydroxyethyl starch. Thromb Haemost; 1997; 78(3): 974-983.

8.       Karl H. Stadlbauer, M.D., Horst G. Wagner-Berger, M.D., et al. Vasopressin, but Not Fluid Resuscitation, Enhances Survival in a Liver Trauma Model with Uncontrolled and Otherwise Lethal Hemorrhagic Shock in Pigs. Anesthesiology; 2003; 98: 699–704

9.       Ho AM, Dion PW, Cheng CA, et al. A mathematical model for fresh frozen plasma transfusion strategies during major trauma resuscitation with ongoing hemorrhage. Canadian Journal of Surgery 2005; 48(6): 470-478.

10.   Kristen C. Sihler, MD, MS; Lena M. Napolitano, MD. Complications of Massive Transfusion. Chest; 2010; 137(1): 209-220.

11.   Rappold JF, Pusateri AE. Tranexamic acid in remote damage control resuscitation. Transfusion. 2013 Jan; 53 (Supplement 1): 96S-99S.

12.   Olldashi F, Kerci M, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: An exploratory analysis of the CRASH-2 randomised controlled trial. The Lancet 2011; 377 (9771) 

Roger Scott Best, EMPA-C, MPAS

Emergency Medicine Physician Assistant

Bagram Air Field, Afghanistan - Providing medical services in support of 401st Army Field Support Brigade

Lives in Garner, North Carolina.

NCCPA Wakes Up. Could somebody please shake the AAPA too?

NCCPA Responds to PA Concerns with Change to CME Requirements

At its meeting last weekend, the NCCPA Board of Directors responded to concerns from PAs and to a new analysis regarding the availability of self-assessment and PI-CME activities and reached a decision to relax the self-assessment and PI-CME requirements introduced with the new 10-year certification maintenance process.

Effective immediately, self-assessment CME and PI-CME are no longer required. However, in recognition of the value of these very interactive types of CME, NCCPA will weight those types of CME more heavily, awarding extra credit for these now optional types of CME.

Dear Colleagues:

From my perspective, this is a good adjustment and at least SOME evidence that our organizations actually listen to what we clinicians say to them.  I changed over to the 10 years cycle after my last (third) PANRE in October 2015.  In reviewing all the CME changes attached to the new cycle, I frankly couldn't discern anything that would make this a better process. The explanations of what constituted what, I found confusing.  It should like PI CME would be some collaborative process targeted to enhance the clinician's knowledge and skills in his/her practice setting, and that SA CME was simple that, self-assessment.  

Despite looking at the NCCPA site through it's changes over the past couple of years, a decent explanation of this I could not find.  That these have now been removed, serves to simplify the process for PA's who have been using a proven, flexible  and appropriate CME and re-certification process that has been in place for their entire career.  It wasn't broken, it didn't need to be "fixed" and now the failed "fix" has finally (and properly) been retired.  That's good, because it wasn't a good model to begin with.  

A major issue that I have with the NCCPA release on this subject if that the NCCPA is giving "extra credit" to the PI and SA programs it has previously approved / endorsed.  

"To encourage PAs to continue to pursue self-assessment activities, NCCPA will award 50% additional credit for all activities designated for self-assessment Category 1 CME credit (i.e., a self-assessment activity worth 10 credits will be converted to 15 credits by NCCPA). Also, the first 20 PI-CME credits logged during every two-year cycle will be doubled when logged with NCCPA."

I am not sure that the NCCPA can properly give Category I credit in excess of the number of hours for which that activity has been approved by the accrediting body.  If the AMA approves a program for 12 hours of Category I CME, then NCCPA can't simply give you six extra credits.  NCCPA is not an accrediting CME provider. It is a certifying body.  This policy might suggest that NCCPA somehow benefits from PA's purchasing these products.  Hopefully that's not the case, but certainly no stretch to see that as a real possibility.

AAPA and NCCPA need to work more cooperatively.  Ever since NCCPA stopped allowing PA's to log CME free through AAPA, there has been a running "pissing match" between the two organizations over one thing of another.  It's no wonder that may of my colleagues no longer maintain membership in the AAPA.  I am back and forth on the issue, mainly because there are few tangible benefits provided for us here in the trenches.  I have never seen a decent public service ad regarding PA's in my 20 years and people still ask me regularly about what PA's do.  The only recognition AAPA has provided is for the DFAAPA folks, mostly those involved in the politics of the profession.  You practice a couple of decades, train PA students, publish now and then, gain a specialty credential, that won't net you anything. Frankly I kinda roll my eyes at AAPA on that.  I think everyone certified PA member of the AAPA should be a FAAPA. The argument against this was that it wasn't like a "fellow" of a physician group, like FACS, FACEP, etc. Well, neither is DFAAPA.  I guess it makes some people feel special.  Certainly not the rest of us though.  

I'll give the NCCPA it's due on finally making specialty recognition happen after the AAPA turned a blind eye and deaf ear to AAPA members on the subject for years.  NCCPA used a great model that preserved the "generalist" credential along the way.  NCCPA kicking the mandatory SI and PI to the curb was another good decision.  Frankly, the "old method" allowed much more of the flexibility PA's need.  Hopefully, they won't try to further complicate the process.  PANCE - PANRE works just fine, places us at the top of chain in terms of maintaining currency and competence among health provider groups in the US.  My state doesn't require me to be NCCPA certified to maintain a license.  I like to have it, but if they muck about too much, I would NCCPA like a hot rock at then end of my current cycle.

AAPA's getting huffed up about the NCCPA and suggesting that they might seek an alternate certification model would be a disastrous move for out profession. That could lead to a fragmentation of our profession and bickering arguments about whose certification was valid or whether one was "better" that the other. I would hate to see us moving down the same road as our physician colleagues and their perpetual bickering about Board Certification. "My certification path is better than your certification path."  I can already see some of that affecting relationships among APN's.  We simply don't need that type of divisive rhetoric in our profession. PAs should always stand together.  Let the plethora of titled "doctors," argue, while we focus on providing the best possible care to our patients.

Let's try to get together on finding the most effective ways to train, certify and support some of the best and most dedicated medical care providers the U.S. has seen in the last 50 years (2017 is coming). It's either that or the possibility of letting our profession degenerate into something akin to the sad state of the 2016 Presidential Election.

Sincerely,

R. Scott Best, PA-C