DogLovingPA

New to the ER (and surprisingly not really liking it, but that's another post) and wondering what sedation protocols are like at other places. Have only had 2 cases so far where sedation was needed (both kids with complicated lacs that would not cooperate) and frankly, it's a giant PIA. For deep sedation (eg. ketamine, propofol, etomidate) protocol requires RT, 2 nurses, pharmacy, 2 providers (one to monitor the sedation and 1 to do the procedure) in the room. These seems insane to me, but maybe it's normal? It brings the ER to a grinding halt and the provider doing the sedation must stay in the room until patient fully alert. In a small ER where there are only 2-3 providers at any one time this is difficult. Moderate sedation (eg. versed) is similar protocol but only requires 1 provider. Unfortunately, the PA can be the provider doing the procedure but can not be the provider doing the sedation (at least that is my understanding so far). Last night plastics was trying to repair a lac and we ended up just sending the kiddo to the OR because we didn't have the staff in the ER to manage a sedation per protocol. Is the the norm most places? I asked yesterday what happens when only 1 provider is in the ER (1 MD only 0200-0700 every day) and they said they have to either call in anesthesia to assist or wait until another provider comes on shift.

No. Not required for NP's. VA also signed a bill in 2018 allowing independent practice for NP's after 5 full years of clinical practice. I live in VA and feel stupid, I had no idea they had such asinine requirements to get a license as I've had mine since graduation (and it was a breeze to get). I knew this state was starting to piss me off..... sigh... I will say they no longer require PA's to submit a practice agreement detailing the involvement between them and their SP to the state board. You just have to be prepared to give them your SP's name if they ever ask.

SEMPA - I can't attend the conference this time. Do you ever offer workshops throughout the year?

Sadly we have no ophtho where I'm at.

Anyone know of any conferences or workshops geared towards ocular complaints and exam? Preferably Including use of a slit lamp. Thanks

I am going to disagree. I feel like those distances are actually pretty mild. I can understand your frustration given it wasn't discussed with you and just an assumption you would do it. That is poor form in my mind and hopefully not how things will be. It sounds like the job otherwise is great and you are very happy with it, the salary and the benefits. Therefore, I feel like this is pretty minor. If I understand correctly, the furthest clinic would be an extra 12 miles away? In my mind that is piddly. But maybe I just have a different perspective because I drive 70 miles a day to and from work.

Chief complaint "right leg swelling". Triage notes says pt stepped in a hole 1 week ago and now complaining of RLE pain and swelling. Dropped off by family who stated that he "doesn't take care of himself". That should of been my first clue. Naive me thinks I'm walking into an ankle sprain or r/o DVT. Nope...... necrotizing fasciitis of RLE with osteomyelitis of multiple toes complete with full sepsis. Notable labs include glu 572, Hgb 6, Na 120, procalcitonin 26.9 As a newbie in the ER, this was waaaay over my head. Obviously got attending involved. One of the more impressive and horrifying things I've seen.

This. The line is difficult. And if you do run every test on these folks I feel like to some degree you feed their anxiety as well. Definitely a very difficult group of patients. Along with the pan positive ROS folks. It doesn't help that most of these folks tend to try our patience so we are already more likely to pay less attention to their complaints. It takes a lot to check our own biases.

I have MD calc on my phone with my favorite "rules" marked. Love Medscape, I find this much easier to navigate than up to date. GMOTM and Lt, thanks for the additional tips, I appreciate your knowledg and experience. Ohio - thanks for the reassurance. Every day I am astounded by how much I realize I don't know. Which is ironic, because the main reason I moved to the ER was to take care of actual sick people (in UC I was at the point that if one more "sinus infection" checked in I was going to poke my eye out) and expand my knowledge and pt care abilities. Now that I'm here, I'm like "FARK! These people are sick". Lol. EmedPA - Appreciate the support! I found Iraq to be much more like EMS, which I find to be the easiest of all my jobs. Stop the bleeding, make sure they are breathing and get them on an ambulance. Lol.

Good to know. Certainly easy enough to add to the workup. I imagine this would hold true for other infectious dx of the abdomen as well? Diverticulitis, etc?

We can get sono at any time but our radiologists would apparently prefer that we not for appys as they don't feel comfortable reading them (at least for peds). I have zero sono experience beyond abscess vs cellulitis (looking to change that). A handful of my attendings will pull it out for a look at a gall bladder or a FAST exam, but beyond that we don't use the bedside sono much. I can get reliable pelvic US at all times which is nice. For kids, I certainly have them jump up and down, etc. The dramatic frequent flying adults however get a lot more complicated. Thanks for the tips.

Thanks for the tips. For old folks, are you getting CTA of abdomen to include mesentaric ischemia dx? Good to know about the mag, will add to my ever growing arsenal.

New to the ER as of 6 weeks ago after spending 6.5 years in urgent care. Before PA school spent 14 years as a volunteer medic (full time job was not medical). This transition to the ER has been a lot harder than I expected (and my "training" was shadowing another PA for 16 hours). The amount of resources I now have at my disposal is at times overwhelming (when do I really need to order all these tests? What the heck are some of these anyway?!!!). The "burden of proof" the ER has is at times also overwhelming. I have plenty of book resources. I am trying to follow the workups being done on other patients by other providers when I am working to get a sense of how things are done by other folks. But any tips on adjusting to that ER mind set? I have seen patients I feel I would of sent home in UC but here in the ER I'm doing CXR, fluids, blood work, blood cultures, etc. And the schedule. Holy crap, I'm exhausted. My shifts are either 0800-1800 or 1600-0200 but I have almost an hour commute on either end. And I may or may not get out on time. Tips for coping with a crazy schedule? Overall, my attendings are helpful. The nurses are generally good and helpful. I have a scribe (how did I ever live without them?). But the transition has been tough. Some shifts feel smooth. Other shifts, I'm convinced I killed everyone I ever saw in UC and I'm up all night questioning my work up. Maybe this is just a normal part of transition? I am trying to remember how I felt when I first started at UC. Probably similar. It also hasn't helped that a couple zebras have trotted through the doors recently (my last shift I had a 5 yo male with a possible renal abscess? Yeah, I can say that wasn't on my differential. And radiology called it pyelo, it was only when my attending stopped me after looking at the images herself that that the possibility of abscess entered).

Resurrecting this post as I just started in the ER 1 month ago after 6.5 years in UC. And we have a LOT of frequent flier abdominal pain patients. Some have gotten so many CT's that radiology refuses to scan them anymore. Their exams are always difficult because they are overly dramatic and histrionic. Obviously, we can't scan them every single time they come to the ER. Tips on risk stratifying these folks to avoid making them glow? I feel like CBC is unreliable (I had a abscessed appy the other day, wbc 7.0). Are you guys checking lactate or procalcitonin on these folks to help? And what about your chronic migrainer/pseudoseizure patients? Do the best neuro exam you've done since school? And the nurses are so burnt out on these folks it's difficult to do anything.

Agree the CME allowance is a little lean (do your license and DME fees come out of that?). But depending on whether health insurance is included, I personally don't think that's a bad offer. I live in an area of the country though where it seems (based on what people post on the forums) pay is a bit lean for PA's.