The intubating PA

[taotaox1]

About halfway through my general surgery rotation I started asking to intubate on every case I scrubbed in for.  Find the CRNA/Anth for the case BEFORE it starts and talk to them.  I found they let my intubate about half the time (in the setting of a large teaching hospital, ymmv in places not used to students.).   I wish I had started asking eariler.

[GetMeOuttaThisMess]

an em pa residency would be cheaper than a SECOND program...you would earn a (low) salary instead of paying a tuition.

I had a good em/trauma experience in pa school and was forunate to have several jobs with lots of cme over the years so have taken almost every 2 day "merit badge course" there is at least once. some were great(atls, abls, apls, difficult airway, also) and some I found totally worthless(BDLS, NRP).

Ah, but here we get into semantics where some institutions won't hire you just because you're BS only (literally). I don't know that a residency would level that playing field. That's an interesting thought; BS only but residency trained...

[rcreek]

... instead of 50 IV pokes, place an IO or CL. ...

 

Seriously! Those are very under-utilized. I also find that lots of these venous access problems could also be solved by simply doing an EJ - but now only our charge nurse can do those. In the big push to do what's "least invasive" in some cases we have lost our common sense - what's ultimately better for the patient? It certainly isn't torturing them with continued IV attempts when the three most experienced IV starters have already failed, and CT has been waiting for 1/2 hour for someone to get an IV large enough to push contrast.

 

[EMEDPA]

Ah, but here we get into semantics where some institutions won't hire you just because you're BS only (literally). I don't know that a residency would level that playing field. That's an interesting thought; BS only but residency trained...

our lead pa until fairly recently was an em pa residency grad with a cert only. no degree of any kind. we have 15 PAs with credentials from cert to PhD with most now having an MS.

[AREID]

People keep saying that PAs aren't trained because they don't need it. The reasoning they don't need it is because it won't be included in their scope. Well, if we can adequately teach PAs how to intubate, so that it becomes as routine as suturing, maybe it will be part of the scope? Obviously much easier said than done. But if we want to expand the profession and show we are proficient, we need to be trained FIRST. The days of OTJ training aren't as common as they used to be. And unless you have done a certain number of procedures, hospitals will not allow you to perform those procedures. Its people like the OP that will make are profession continue to grow. I hope you can put something together for your program

 

 

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[EMEDPA]

agree with above. tough to learn a new skill on the job. doable but tough. very few SPs want to be teachers today-most want cheap labor.

[Guest Paula]

I agree with ARIED.  Adding a course  would be helpful.  My school offered a brief course in the EM section.  We tried on a mannequin.  Then, in ACLS after PA school when I was certified.  I never thought it was helpful at all.  In my surgical rotation the anesthesiologist said I could try an intubation, but without him really showing me first.  He described how to do it, gave me the "whatever it is called" and I looked at it, turned it over in my hand, and my dyslexic brain was thinking...."what the heck?  is this up, down, sideways?  how on earth does this go in when I'm looking down at the mouth?  It seems upside down?   The anesthesiologist calmly grabbed the "blade" and said, here I'll do it."

 

I'm laughing now but I was mortified then.  Never tried again.  Never was asked  again and was never offered a day in the surgical suite to just learn intubation.  I spent some time doing locums in rural ERs but there was always an MD/DO present, so I never needed the skill, and of course if asked I would have said no way...not in my scope.

 

I'm starting to think any PAs who want to work EM should be EMT and Paramedics first.....better training for some of this stuff.  And go to a residency.

[EMEDPA]

 

I'm starting to think any PAs who want to work EM should be EMT and Paramedics first.....better training for some of this stuff.  And go to a residency.

the vast majority of the em pas I know who work in high acuity or solo situations are either former medics, residency trained or both. I know I couldn't do my current job without my prior medic training. pa school teaches you enough em to be a safe beginner in a fast track with a doc available for consults. I think those folks who take high acuity/solo positions right out of school without significant prior em experience are doing themselves and their pts a disservice.

[Guest Paula]

^^^^^^^ One of the reasons why I eventually left EM locums.  The area I live in was not equipped to give us OJT and even when I asked for more training it never happened.  I kept up with ACLS, CALS and  PALS but never felt like I could ever be completely competent and rarely used the skills.  Don't use = lose skills.  I looked into taking the EMT course but couldn't fit it in. 

 

It was a nice gig for the 6 years or so and paid for the kids college but the longer I worked the more I knew I needed to know more for the true emergencies, and would not have been able to step in if the doc keeled over and died in the middle of a crisis.  I spent so much time studying and doing CME, plus had another full time other job in urgent care and was then offered a FT job in Family Practice on the rez.

 

So decided to go back full time to family practice where I really shine!!!  (where are the emoticons?)

[TheDude]

People keep saying that PAs aren't trained because they don't need it. The reasoning they don't need it is because it won't be included in their scope. Well, if we can adequately teach PAs how to intubate, so that it becomes as routine as suturing, maybe it will be part of the scope? Obviously much easier said than done. But if we want to expand the profession and show we are proficient, we need to be trained FIRST. The days of OTJ training aren't as common as they used to be. And unless you have done a certain number of procedures, hospitals will not allow you to perform those procedures. Its people like the OP that will make are profession continue to grow. I hope you can put something together for your program

 

 

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AREID,

 

I appreciate the compliment.  I am in the process of setting up a meeting with my program director about this, and have also contacted a local anesthesia group that employs CRNA's as well AA's (anesthesia assistant) as well MD/DO attending's.  Their medical director is a former flight medic who is an advocate for what I have been pushing for.  He said the group would be on board and would be a good teaching/learning environment for everyone.  I am not looking at getting every student to be able to get a difficult tube like they are some rockstar gasser, but at least the ability to use a BVM properly, or an LMA/CombiTube/ or supraglottic airway.  It is sometimes just using a basic skill as mask ventilation that can save a life.  I remember as a flight medic doing my bi-annual Or training where a super salty old CRNA made me mask-ventilate an entire case, 1 hour and 8 minutes to the T, my hands remember.  It paid off, later that week, had a situation where we could not get this guy intubated, was a short flight so elected to drop an OPA and mask ventilate (guy drank gas and bleach, combitube was out of the question.)  It worked, the attendings had to use a flexible scope to tube the guy, even the anesthesia attending waiting in the ED was happy with what we did.  I just see this as an important skill, basic and advanced.  It might be a big leap, but at least it's a step in the right direction.  I just see an importance in a proper skill set to practice as a well rounded PA.

[EMEDPA]

_{I did an interfacility transport on a guy in the early 90s before we got our transport vent who I had to bag for well over an hour. I set my watch on his chest and gave him a breath 12 times/min. I still remember the cramping fingers. agree that bvm use is a critical airway skill.}

[GetMeOuttaThisMess]

OkieMed, your specific observation is dead on. People tend to associate airway management with the use of an airway tube. It could not be further from the truth. Good airway management is just that, good airway management. An oral pharyngeal airway and a BVM maybe all that is necessary. Heck, even a jaw thrust maneuver without any other support may be enough to make the difference between life and death.

[EMEDPA]

 Heck, even a jaw thrust maneuver without any other support may be enough to make the difference between life and death.

funny you mention that. about a year ago I was visiting friends at a very remote cabin in the woods and an older gentleman  fell > 10 feet from a loft, hit his head, and had a loss of consciousness. he had stridorous respirations and looked like he was circling the drain. no medical equipment of any kind there. I did a jaw thrust and held c-spine until the medics arrived > 30 min later. just that minimal airway intervention was enough that he was able to continue breathing unobstructed on his own. he is fine today with no deficits. I think if I had not been there that day that he likely would not be alive today.

another older friend was not so fortunate. I did not attend his 85th birthday(was invited) at which he aspirated a piece of steak and died of hypoxia before medics were able to removed the fb with macgill forceps. I think if there I might have been able to dislodge the fb with a heimlich or abd thrusts or do a crich with a steak knife and ballpoint pen or something similar.

[True Anomaly]

It's actually amazing to see how much a simple jaw thrust allows for proper airway opening and closing- just working with an anesthetized patient in the OR can help demonstrate this, if not outrightly looking at someone's airway under fluoroscopy.  It definitely reinforces what everyone else here has said- good airway management foundation is proper airway opening and manual ventilation- master that, then we'll talk advanced airways.

[TheDude]

Well, I got shot down by my program director.  Was asking for a small meeting to just discuss it.  Was told to stop thinking like a Flight Paramedic and start thinking like a PA.  I see the point, but I also see the lacking of certain skills sets in PA's, and especially if some are going to practice in the rural setting, they need this and other skills.  Not giving up on it though.

[True Anomaly]

There are plenty of mechanisms in place for those people who want to get additional training and education beyond what PA school has to offer (if they didn't already have that prior to PA school). I'd rather make those opportunities more available and ensure they are taught to a certain standard, rather than change the dynamic of a PA program.  

 

But if you're bound and determined to set up opportunities in PA school for those who wish to have additional training, here's an idea- if you are somehow connected to a medical school, see if they have an "ER club" for future ER physicians.  If so, strike up a relationship and see if they'll let PA students in.  My PA program had such a club and they made opportunities available for intubating on manikins and cadavers, and actually opened it up to any med or PA student who wanted to do it.