Advice for Upcoming PA

[ace17]

I am looking at applying to PA school in January of 2019 after graduating from my undergrad and had a few questions regarding PAs in trauma. This is the area that I'm interested in, and knowing that it is an area of surgery, I realize that I won't be the number one in the room - which is fine. However, as a PA how involved would I be able to be in higher risk scenarios such as trauma? Also, I know that I may not be that heavily utilized in traumas right away but do they tend to have more opportunities for helping in more complicated procedures as they gain more experience? If so, what sort of procedures might this involve and how could I be utilized as I gain more experience? Thanks!

[cg02186]

I did a rotation in Trauma/ICU and can tell you there is a ton of different ways you can go. For one, there is an entire Ortho trauma teams that deals with all the intense fractures and dislocations. As far as general trauma the PA wasn't always in on all the surgeries but was standard 1st assist when he was. The times I was there however, it was him running codes on crashing patients while the surgeon was finishing up another case.

 

When I asked why he's not in surgery he said most PAs aren't in surgery for trauma because they're almost always needed. If they're both in surgery and a MVA or GSW comes in crashing, the PA will have to break scrub and run down to run the code so sometimes it's just easier to not scrub in. Hopefully someone that works in trauma will give you a better answer because I'm sure it varies greatly

[south]

I work in Trauma Surgery Critical Care at a teaching hospital with a large residency program.  The comment that you will find a lot of variation is correct.  I had a choice among a couple of jobs, as the Level 1's are the new thing now.  

 

At private hospitals, PAs will be in the OR some but will generally be focused on rounding and maybe covering the ICU.  It seems like a fairly tense business with longer hours (again really just based on my interviews).  I'm sure there are PA's found doing the 30 hour call crap that a couple of my classmates had to pull back in school on their trauma rotations.  I am held to 40 hours a week per my contract and they take that very seriously. :)

 

I personally will never see the inside of the OR, don't think I even have privileges, but the PA (me or whoever is working) is the continuity / catch-all / acting chief of the rounding and surgical ICU division as the surgeons come and go as needed (trauma surgeons will be backing up/covering Gen Surg or some other thing as traumas do not happen constantly).  I also write the majority of the notes and run the trauma clinic (wound care follow up and stuff like staples removal) for a few hours a week.

 

I'm pretty over the OR and prefer the rounding and stuff, this is where the demand for PAs is centered, and this is why I was hired.  Most folks hate rounding and want to get back to the OR to do cool surgery stuff.  Each to their own.

 

Speaking of which, in a "real" level 1 trauma center like we are, when a trauma comes in, something like 12 or 13 MDs get paged and show up and are standing around, with 3 or 4 working on the patient directly, minimum.  So there is zero chance that a PA would do anything, even with multiples, which does happen from time to time.  We generally will fill out the H&P, catching all the information that is thrown out onto a form, which I think is kind of fun.  Maybe put lab orders into the computer if things are running at a slower pace.  

 

(With Level 1, there are certain rules, you have to have certain specialties respond personally to every trauma like anesthesia, trauma surgery, vascular surgery, neurosurgery, etc). 

 

I have heard of other situations where they are much thinner and claim level 1 status, wink wink nudge nudge.  PAs might be more active there. 

 

As far as procedures go, lots of variation here as well.  Some places might get the PAs really going right away, but I personally have a lot of competition with residents for chest tubes and what not - so I'm going to wait a while before speaking up.  However, if it's my patient for the day, especially in the ICU, I have first right of refusal, made very clear to me, but I am a new graduate so not signed off on anything yet so it's not an issue.  Having to drop a line or a tube into someone outside the OR is fairly uncommon anyway.

 

My point is that you would have to ask and put pressure to be taught these things.  No one is going to hand you a lesson plan and send you off to a class. But people do it.

 

So yeah...kind of a lot of different ways to do it.  I like it; I find very sick / injured patients clinically interesting, and I like managing stuff acutely (like etoh withdrawal - very common to have a real dedicated alky with BAL 700+, two just last week) .   And - in trauma, we generally don't have half-ass outcomes.  People generally are minding their own business when they get hit by a car or whatever.  We do our thing, and they generally sort of get better and move on with their lives. Or sometimes not, and move on somewhere else for comfort care or worse outcomes.  Not too much in the middle. 

 

Sorry for the book...I do that.

[south]

That could have been a lot shorter, but just wanted to also add your procedures will typically (in order of commonality) be chest tubes, a-lines for monitoring, bronchoscopy, intubation, maybe central line.  These last two are for declining patients, which you probably won't be screwing around with until you have a lot of experience.  This isn't counting d/c 'ing stuff as patients improve, like removing trach or extubating or removing chest tubes which is quite common.

[DizzyJ]

Agreed, much variation in trauma.  You can find a job being vary involved and in the OR vs zero OR time and always taking the back seat to residents.  I did a trauma rotation at a level 1.  When a trauma was called 3 PAs would respond, one resident, and one attending.  Often one PA would be the scribe, resident and one PA would be examining the patient and verbalizing their findings for the scribe, other PA would be putting in orders.  The attending often observing as most of the traumas where pretty stable actually (but not always).  If patient had to go to OR the PAs would rarely scrub in and if they did it would be as 2nd assist.  The PAs rounded and did notes on patients and then rounded with the attending.  Procedures would mostly be suturing simple lacs.  The fun procedures where mostly done by resident as s/he needed the experience. 

[ace17]

dizzyjon,

So when the PAs were called into the OR during a trauma as a 2nd hand man, how were they typically utilized in the OR? Would they be stabilizing secondary wounds first hand or is it more along the lines or guiding laparoscopic cameras and closing the patient?

[ace17]

south,

So would you say that the PAs usually aren't as directly involved in incoming traumas, but work more with critical care patients in the ICU after the initial stabilization? I like the idea of running codes and post trauma care, but I was also wondering if there was any way that I would also be able to be involved in incoming traumas as well. I am attracted to the adrenaline of the trauma position and would like to be involved in the rougher traumas as they come in if possible. I know everyone was saying that there is variability in the position, and working at a teaching hospital may be a decent factor involved, but from what you have heard do you think it may be a possibility to work directly with traumas here and there or do you think that the majority of trauma PAs work more on the ICU side of things? Thank you!

[DizzyJ]

Mostly holding a retractor.  The surgeon and resident generally were the only ones with their hands in the patient. 

[charlottew]

Where I work there are ICU PA/NP's (who manage trauma patients in the ICU), and trauma PA/NPs (who mostly manage trauma patients on the floor/trauma outpatient clinic). 

 

The emergent trauma bay stuff is done by the attending, supervising residents. The trauma OR stuff is done by the attending and residents.

 

The ICU PA/NP's do perform some 'adrenaline-inducing' management of trauma patients, in the ICU. Especially if the pt emergently needs a specialty service overnight, and there's no attending in-house coverage on that service. ICU PA/NP's place lines (central, A-line), very occasional chest tube.

 

One thing I have learned about trauma - while random traumas do happen to random people, it's also the case that the trauma population skews towards less-functional people (social, psych, substance abuse issues). 

[south]

 

 

One thing I have learned about trauma - while random traumas do happen to random people, it's also the case that the trauma population skews towards less-functional people (social, psych, substance abuse issues). 

 

This is absolutely true.  You guys should SEE my patient population.

 

I think in the great majority of cases, to get really involved with the traumas directly, like you describe, you are going to have to either go to medical school or get really, really lucky in a position, and that's probably after forcing your way in there for several years.  Not many places are just going to hand you that kind of training.  

 

Are they out there?  Can you find PA's doing all of that stuff?  Yes, I'm sure - but it's rare.  That kind of specialized training and liability isn't going to be just handed out.  Most of the demand is in rounding on patients after they are stable - whether it's ICU or a step down from that.  Keep in mind these are super sick and/or injured patients and occasionally something does happen, but it's mostly all about the upward trend and next step on discharge.  

 

Just the other day I was taught to do a central line - on a brain dead patient we are preparing for organ donation.  I manage stuff every day most people never see, and I will be looking the "I've never heard of that and how did you manage to break it?" stuff up daily for years to come I'm sure.

 

A slightly - I say slightly - easier route to the exciting stuff is through EM.  You can do a PA residency/fellowship in that, and at the better ones, some of the stuff they have Fellows doing over in that forum section will knock your socks off. There are several members here - the illustrious EMEDPA is but one example - who work independently in very high acuity situations, including traumas.  In fact, the work of our traumas are "done" by EM physicians, with a Trauma surgeon overseeing them.  The surgeon (my SP) stands off to the side and orchestrates the whole thing while they work and sweat and get nasty.