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ERCat

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Everything posted by ERCat

  1. I would absolutely not test the patient for COVID-19. This wouldn’t even be considered in my hospital. Clinically I don’t think it makes sense (but would like to hear rationale for why it does make sense?) VERY very sad scenario.
  2. I work in the ER. Been a PA for 4.5 years. There’s no “requirement.” We have slower PAs and faster ones. The docs love us all equally - we all do a good job. But nursing staff and hospital admin? They like the fast ones. The speed of the providers does get brought up in meetings. We do hear complaints sometimes. But really, no one has been threatened to be fired for not being fast enough unless they were realllllly slow (I.e. one patient per hour slow). We’ve actually had more issues with providers (not PAs... NPs specifically... just being honest) who were way too fast and careless and ended up with bad outcomes. I work at one hospital where the patients are mostly old and medically complex. Sometimes takes fifteen minutes just to get a damn history! Usually these patients are admits or involve complex discharge processes (calling multiple specialists, involving the PCP, calling family, etc). At that hospital I am honestly busy at 1.5 patients an hour. At our other hospital we have more lower acuity patients. In the main ED, where I see a mix, I usually see 1.5-1.75 an hour. In the fast track I can easily see a little over two an hour and be good. Downside of being slow is we won’t hit our productivity target. We have a minimum target of RVUs we need to hit and beyond that we take in an extra 25 bucks an RVU. RVUs and patients per hour don’t necessarily correlate but on average, to hit the target and start making RVUs, it is around 1.5 patients an hour.
  3. Sorry if this has been posted before. I am involved in quality improvement at two hospitals and already review charts as a lead PA. Thought it would be cool to take a side gig reviewing charts. Anyone know any companies that would hire a PA? My Google search doesn’t come up with much.
  4. The abdomen was checked an hour and a half prior. During that hour and a half, I saw maybe five other new patients and talked to a few other specialists, followed up on labs, discharged old patients, etc. I did my initial examination and was in the room with the patient updating them on results and was about to reexamine them when the surgeon called...
  5. Of course I did my belly exam...this is the ER. I wouldn't have ordered a CT without doing a belly exam in the first place. This was an hour and a half later when everything came back. I was in the room talking to the patient about their results when the surgeon called me. He asked for a repeat belly exam, which I hadn't done because I had done my exam an hour and a half before and moved on to other things.
  6. The other day I was in a patient's room letting him know he had a small bowel obstruction and that I had put a page out to a surgeon for him. The surgeon called me while I was in the room, so I answered and politely mouthed to the patient "This is the surgeon!" I sort of stepped aside in the corner of the room to have my brief conversation with him but stayed near the patient in case I needed to ask the patient questions on behalf of the surgeon. The surgeon asked me a few questions that I already knew the answers to, and then asked me another question I needed to run by the patient. I told him, "Let me ask!" then quickly put the phone to my waist, asked the patient the question, and relayed the message the surgeon. He asked if the patient was still tender and I pushed on his belly and then told the surgeon over the phone, "Yes." Later on, he reprimanded me and said that it was "bad form" that I talked to him in front of the patient. Most of the time I don't, but as he had so many questions I thought it was okay if I was standing by the patient. He seemed really pissed about it. To me it's a matter of efficiency...instead of hiding in my office and running back and forth between my office and the patient's room to ask them questions. Plus I don't want to be rude by keeping the surgeon on hold!!! I feel like I cannot win. I suppose in some cases I should be better prepared by anticipating questions the surgeon will ask, but sometimes I don't have a free second to get all my ducks in a row before the surgeon calls. Any thoughts on if this is truly rude or not?
  7. I have not had any issues. My pay checks and my employee name at work is my legal married name. But my charts and prescriptions show up as my maiden name. DEA and NPI are maiden name. No issues.
  8. I agree that it is probably mainly about liability. When the gynecologist gets sued because he screws up someone’s toe after doing an ingrown toenail procedure the first thing that he will he asked in court is “What kind of doctor ARE you? A gynecologist? Is ir within the scope of practice of a gynecologist to treat an ingrown toenail...” I agree with you. But realize so many providers choose to “stay in their lane” not because they don’t care and want to shrug your concerns off; it’s all about FEAR of potential malpractice.
  9. HOLY CRAP. Are you joking me? You are the ONLY one for a good chunk of the day? In all honesty I can't even fathom that. So you're running codes, sticking in chest tubes, intubating, starting pressors...by yourself? One thing I lack as a PA less than four years out is critical care skills. Even though I work in the ER...I never have to do that stuff because the docs do it. I legit can't imagine. How long have you been a PA? Thanks, everyone, for the responses. Never thought about working in a lower volume facility but it sounds tempting and maybe worth the drive...
  10. So much of what you’re describing is... my life. I have been doing ER for three and a half years and still usually feel like I am running around like a chicken with my head cut off because there’s six things to do (I need to discharge room six, close the laceration over there, and crap - I am getting a phone call from the orthopedist). It’s like that all the time. I stopped eating on my shifts and am lucky if I get one bathroom break or a drink of water. I also get very annoyed when patients perseverate. You have the ones who seek needy and hold you hostage with questions... and you swear they’re just trying to come up with inane questions to keep you there (“So... Um. Do I ice or heat?Um... Um... like is it normal that it still hurts? Um... like when will it get better?”) Or you have the ones with the positive review of systems and you want to rip your hair out. Or you have the ones who tell every single detail (“I got up, walked to the kitchen, ate a sandwich, sat on the couch, turned on Golden Girls. Then my right knee hurt so I got up, walked to the bathroom, openee the cabinet...”) These patients make me so anxious because I want them to STOP because I have a million other things to do...and I then feel like I am pushing them out the door rather than connecting with them. People always ask me why I walk so fast - because I don’t have time - and why do all of the others have time to eat lunch, chat about their weekend...AND LEAVE FIFTEEN MINUTES EARLY? I suspect that you may be like me, trying to be very thorough in your history, trying not to blow stuff off, making sure concerns are addressed AND making bullet proof documentation. Don’t have words of wisdom but uh... I am gonna say you’re not alone and you actually sound like a smart, dedicated and hardworking PA.
  11. I just wrapped up a fourteen hour day today. I am frigging exhausted. My shifts are twelve hours, but I stayed late charting. I only saw about 26 patients, but a lot of them were nightmares and very labor and time intensive (huge dog bites on the legs, two distal radius and ulnar styloid fractures that required multiple attempts at reduction, a cervical laceration that would not stop, a hypotensive upper GI bleed... I could go on and on). I have been staying super late in the last year, and I am sick of it. Usually an hour, two in a blue moon. I think it all started when we started to get RVU pay. I make an additional 30 to 55 per HOUR just for the RVUs, so it’s tempting to try to pick up an extra patient here or there. We don’t get paid for the hours we stay late, but you’d assume the RVUs would more than make up for it. That’s what I have been telling myself but I am sooooo tired of staying late. I have been blaming myself for “picking up too many patients for the RVU” but here’s the weird thing; I am not actually seeing significantly more patients than I did before we got RVUs. So I am staying substantially later because... God knows why... I don’t know. Does anyone have any tricks for getting out on time? I don’t think what I am doing is sustainable.
  12. Thanks for this. Strangely it is comforting to realize maybe the expectation is I am a representative of the APPs rather than a manager. That kind of takes a little bit of the pressure off. Maybe I am the one creating unrealistic expectations.
  13. You are not a jerk! I am confused by what my role means. I think I am a little more than a scheduler, though. I do the interviewing and hiring (hiring with approval of the head doc, of course), chart reviews, working with the hospital to determine credentialing requirements, helping find coverage in emergencies, addressing behavioral issues, setting up educational lectures, those kinds of things.
  14. I have been the lead PA for my small group of ER PAs for a couple years now. I think I was chosen because I am smart, do a good job taking care of patients, I don’t miss things often, and I was the one who gave a crap about the group and going to meetings. Unfortunately I am finding these traits don’t translate into being a great leader because I lack other traits that matter. I am disorganized at times. Not very proactive. When I’ve tried to be proactive in the past a few times, I ended up making a decision that was overruled by the physician director, which has totally killed my credibility, and now sometimes my team goes above me for questions and concerns which kills me. Ultimately nothing is really up to me and gets overruled by the lead docs so I just feel like I am constantly deferring to them. Leaders hold meetings - I am not the type of leader to have meetings just to have meetings (but I check in with my APPs from time to time to see how they are, and we all attend the group meetings with the physicians so I feel like that counts). I make their schedules, which thank GOD, they seem happy about...and show up to meetings at the hospital where I provide zero useful feedback or insight. The way I would describe myself as a leader is lame. Ha. The worst part is I feel like a bad role model in that I am not the wonderful, professional provider who floats in and out of the ER with a smile on my face, drama free. I still get “talking tos” occasionally about the way I am in the ER. Once I asked that a patient with swelling of the perineum not be put in the fast track zone (which didn’t seem fast track appropriate and I am apparently allowed to make those calls) and did so in a VERY nice fashion (I will say for all my faults I am genuinely nice to coworkers) and I was complained about by the nursing director directly to the CEO who called me a bad role mode for refusing patients. Since then I feel like I am on nursing’s bad side. I have been also reprimanded for having long discharge length of stays (which I worked on) and ordering too many tests. Today I upset the charge nurse who said I was picking up too many patients (we are damned if we do and damned if we don’t) and therefore not going to the rooms to dispo in a timely manner. I also apparently walked away when she was talking to me - inadvertently, my mind was elsewhere, and she called me on that too, which was valid. But it only takes so many of things like this to make me feel like a scatterbrained, unprofessional idiot - NOT fit to be a leader. I had really high hopes for this leadership role but I don’t feel like I am growing much within it. It is getting easier but I still hate it - because who likes something they feel they are bad at? I fantasize about stepping down from the position and just being able to go to work just to take care of patients! Only crappy thing is I would lose control of my schedule and it wood also be like demoting myself. I really do want to be a good leader but it’s hard to to like it and be motivated when you feel bad about it. I have thought about talking to the lead ER doc about this but I don’t know what that would accomplishe. As an aside - this entire post seems self deprecating but I do recognize I have many qualities that make me a rock star PA. I know I am smart and have good intentions. There are just a lot of things that aren’t translating well into leadership. Not sure why I am even posting this but it’s oje of those nights that it kind of hurts and stings to think about and I guess I am just looking for some insight to get me out of this frame of mind and move forward (or backward if need be).
  15. Yikes, this thread is making me think twice about my documentation of EVERYTHING I do for the patient. My entire chart for every patient is CYA. If they have an allergy to penicillin and I am giving ceftriaxone, you'll see a note in there that states something like "reaction to penicillin is a mild rash; has had cephalosporins before" (even though we all know the low rate of crossreactivity - CYA!). If I have given a patient a narcotic, I document that they said that they had a ride home. I document reasons for delays in labs and CTs. Therefore it is obvious that I document anytime I spoke with a physician for advice and what they said, even if they didn't see the patient. Is that really bad? If I speak to my attending physician about a case and ask for advice on what to do, I will absolutely put in my chart that "I discussed this case with Dr. Bob." If I spoke to a surgeon regarding a surgical case, I will document everything he said and what his recommendations are. If I spoke to a pharmacist regarding antibiotic recommendations, his name is going in the chart as well. It is not so much about displacing responsibility (although it is nice to have my attending MD backing me up on a chart) as it is related to my habit of documenting very thoroughly, so that if anyone ever needs to pull my chart they can see exactly why I thought what I thought and acted how I acted. I was told once by a hospitalist that my documentation was "beautiful." What can I say, I am a beautiful documenter...or maybe an a-hole documenter!
  16. Try dealing with this in the ER. The triage nurse CAN'T turn anyone away for fear of an EMTALA violation. So a patient will come in for something like an IUD removal (I don't do that...see a gynecologist), an MRI of the knee "because mine isn't scheduled till next Thursday," or a skin biopsy of a mole that has been on their arm for a year...he or she will be brought back...and will be told, by me, "There's nothing we can do here because this is an emergency department and these things are done on an outpatient basis...please see this doctor...okay...bye" and get the cursory brief physical examination because we all know this is not an emergency, and get discharged after four minutes... Then they walk out and pay their 250.00 copay (or worse, a lot of these people come into the ER without insurance and will undoubtedly be billed HUNDREDS of dollars for this crap). I had a guy check in with requests for a therapeutic drainage of his knee, which didn't even have an obvious effusion. He had knee pain for years and had plans to see his ortho for the arthrocentesis THE FOLLOWING MORNING, but "my wife is here passing a kidney stone and it's going to take a few hours for her CT to be done so I thought I might as well get this done now because I was just sitting there." He tells me he has insurance but a really high copay. I do my cursory knee exam, notice nothing wrong and this guy is walking around without a hitch. I told him there's no need for an emergency arthrocentesis and that he needs to just see his orthopod tomorrow. His response - "that makes sense...are you guys going to charge me for this visit?" Didn't have the heart to tell him that his misguided (and kinda delusional and self-centered, if you ask me... this is a freakin' ER) act was going to cost him hundreds. Yes, for us to do absolutely nothing.
  17. I am in shock reading that article. In shock. I have never believed that physician assisted suicide is okay, because it literally involves someone "playing God." Stop treatment if the patient wants, and do not resuscitate. But it is not a physician's job to end someone's life. I understand why someone might consider this if they had a terminal illness, but depression? In a SEVENTEEN year old girl? Her brain has not even been fully formed yet - how can she make a decision that she wants her life to be over? Not to minimalize her trauma because it sounds terrible, but many teenagers go through issues with anxiety and depression and we often grow out of it after we gain more experience, confidence, and wisdom. How a doctor could assist in killing a child because she's depressed, rather than actually help her with that depression, is beyond me. How a parent could consent to this...is disgusting. This is absolutely disgusting and horrifying to me. I feel bad for the girl, along with the system (and parents) that completely failed her.
  18. Wow... ArmyVetDude... I think “somebody has a case of the Mondays.” No need to be a jerk to BoatSwain. It seems you advocate for PA independence so that the nurse practitioners don’t overshadow us and take our jobs. But is it right to advocate for independence just because the NPs are doing it? No - not a good enough reason. How can a PA or an NP a year or even five years out of school practice without supervision? It’s ludacrous and dangerous. Personally I think the fact that we are supervised only adds to our credibility over NPs. Anyway, I am not independent and if I wanted to be I would have gone to medical school...
  19. They asked you for malpractice info?! I would have crapped my pants... like... why do you need that as a Good Samaritan?
  20. Pay off your own loans you chose to take out or pass the burden onto taxpayers? I don’t mean to sound judgmental, but if you think about it, that’s exactly what these programs do. The debt doesn’t just vanish. Of course the right (and probably wiser, especially given the uncertainty of the program) thing to do is to just pay off the debt meaning you just live within your means and make paying off debt a priority.
  21. Great post. I have been thinking about this a lot myself lately. Some of the stuff we do in the ER we know damn well is fluff but we keep doing it. For chest pain with URIs? I often don’t order any labs at all if the history suggests a viral URI and the patient is young and healthy, and looks well (ie doesn’t look like they have myocarditis... LOL) Usually just a chest x-ray, and sometimes an EKG for these patients (and a flu swab) but otherwise not a lot. For asymptomatic hypertension, you’re completely right but I cannot get away from ordering my EKG, BMP, and urinalysis. Nothing I ever find changes management. I feel like it’s more reassuring for the patient if anything. If their own doctor sends them in for management and I didn’t do jack it doesn’t instill a lot of confidence for the patient. Often times I check this stuff, it’s back in an hour, and by that time the BP is back to normal without any meds given. Then they just get to follow up with their PCP. First trimester bleeding with a known IUP? Yeah, I am always getting an ultrasound on that to assess fetal viability. If the patient does eventually miscarry even though there’s nothing that could have been done, it’s easy to criticize the PA who just checked FHTs and kicked them out. OB stuff is high risk territory and we are dealing with two lives and not one (sorry, one life if you’re in New York now apparently) so it’s not worth the risk in my opinion. Epigastric pain - I always do check labs like LFTs, pregnancy test, and lipase...if the patient is truly NOT tender, the story is reassuring, and there’s no history of worrisome symptoms like fevers or emesis then I might not image them either. I completely agree with hitting the cyclic vomiters hard off the bat. I usually slam them with two liters of fluids, Reglan, Benadryl and a GI cocktail right off the bat. Plus capsaicin cream on the belly for the cannabis users. I do the same thing with migraines and back pain - why screw around? Migraines get fluids, Toradol, Benadryl, Reglan and dexamethasone early on and if that doesn’t work, Tylenol and IM Haldol (but usually it does work). Back pain patients usually get Toradol and Robaxin and a lidocaine patch! Usually feel better fast. Sometimes when I have a patient that may need multiple imaging studies, I don’t have a problem calling the radiologist to do a brief look over the images to tell me if anything is abnormal. So even if their formal report doesn’t come back for a CT scan of the abdomen for another half hour, I can already be ordering the ultrasound if the radiologist didn’t find an etiology for the patient’s belly pain on that CT (for example).
  22. So I think the salary is really, really low for the ER - probably the lowest I’ve heard of in a long time to be honest. The benefits are amazing. Paid vacation? Sign me up. You get holiday pay? Believe it or not these things are not common for all ERs. So those things are great. But still, if you calculate them into an hourly rate, it’s somewhere around 50ish bucks an hour which is, again, low AF for the ER. THAT SAID! ER is terribly hard to get into as a new grad, and when you do get into it, it’s easy to get into a situation with minimal support. Having residents and an attending MD with you at all times is a huge benefit! I took a job in the ER for around the same amount an hour as a new grad three years ago. Things changed, and now I am in the same ER making over twice that per hour when my RVUs are factored in, plus full benefits (without vacay). I am so damn glad I took the job even though pay was lowest in town because it got my foot in the door and here I am today. I love my job and I get adequately compensated for it. I would keep looking for other jobs because I guarantee you there are other ER jobs that will give you a hell of a lot better pay. But ultimately if you don’t find something better I think this one is worth taking to get your foot in the door. If you do take the job it is definitely worth negotiating and do NOT be afraid because they are low balling you big time and they know it. DO your research so you know what the going rate is in town. Stay calm and collected, and simply state: “I am very excited about the possibility of working with your group and I think I would be a great fit. I was hoping that we could discuss a higher starting salary of X dollars per year” (give an exact number, not a range as it makes you look more confident and knowledgeable about the industry) “as that is more in line with the salaries for other ER PAs in town.”
  23. Just wanted to chime in here. So I bought a house right out of PA school and only put five percent down (I know, I know). My mortgage is 30 year at 3.6 percent (And yes, I have been paying PMI for a few years but given that the house has appreciated in value I might be able to stop that soon). As soon as I started making dough I had anxiety about paying off that mortgage ASAP! Making extra payments! However I spoke to a financial advisor about this and his response was WHY? He said my rate is so low I am far better off investing. Even with the historical average of 6 percent return a year I come out ahead. I am 29 - what do I have to lose with investing at this point (well, a lot, but I have my whole life to make up for it in the event crap hits the fan). I currently have 90K invested in mostly index funds and plan to invest more. I have an individual stock portfolio which has gained 14 percent in value over two years. I max out my retirement plans. I was able to pay off my PA school debt within a year because my cash wasn’t all directed to a down payment on my house. Now I’ve got no debt. Of course in the 30 years of my mortgage I will have paid a crap ton of interest. But if I invest aggressively I am hoping I will come out ahead this way. OR maybe I am just delusional. I do have a lot to learn.
  24. Thank you so much for your very helpful tips.
  25. I consider to be myself a good PA and have always thought I was one of the high performers. I am in terms of productivity, but just found out today that my discharge length of stay sucks. Any tips on how to decrease that number? The problem is I feel like I am already working my fastest and hardest. I see people at work laughing with each other and chatting about their weekends but I literally don’t do any of that. I barely even have time to run to the cafeteria to go to the bathroom. I feel like I am busy every single minute of the day. So decreasing my times seems kinda insurmountable... I know that one of my problems in admin’s eyes is trying to make patients completely comfortable before they go. Especially with back pain or migraine patients, if they say they still have pain even if it’s better I am likely to keep giving them meds until they feel A LOT better. The med, reassessment, med, reassessment, etc just isn’t helping my numbers.
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