Nomenclature

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.

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.

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.

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

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.

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.

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.