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Rural Single Coverage PA job question


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I know a few of you work in single coverage ED gigs in really rural areas. I am interested in this because I like the idea of 48-72 hr shifts to maximize my off time with my family. I have worked at a teaching county hospital for about 4 yrs in the emergency room where we get maybe 1-2 main ED shifts every other month and another smaller ED where I have worked in the main for the last 6 months. I have intubation a few times put in a couple central lines but I would not say I am by any means comfortable. I am comfortable at seeing critical patients but not as comfortable with the procedures/codes although I know how to do them for the most part. I feel I hit a ceiling at my jobs. I would appreciate any opinions on wether or not that is adequate training for a rural ER gig for single coverage.

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I would think you have answered your own questions. Does not sound like you are ready yet. Otherwise, you wouldn't even ask the question.

 

How about finding 2 provider gigs for a year and see where you are again?

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My problem is the same when i used to fight mma. I had over 50 amature fights and fought and beat a couple of ufc guys but i never felt i was ready to take the leap to the pros. I guess my question is when did you feel you where ready? How many procedures do you do in a month? Besides LP, central lines, intubations, any other procedures do you do? Chest tubes? Do you ever crack a chest? are there double coverage sites that use 2 providers for extended shifts 48 hr plus?

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very few places have 48 hr shifts. I think Boatswain is the only pa on this site who works 48s and 72s. I work 24s.

sounds like you should consider an em pa residency, then you would know you are ready for solo coverage. doesn't sound like you are there yet. most rural places doing a thoracotomy wouldn't make sense because you need a ct surgeon and a trauma icu to receive the pt on the off chance that the thoracotomy is successful (<1% are). I have participated in them at a level 1 trauma ctr as part of a trauma team and never seen a save. 

working solo is about a lot more than procedures, it's about judgement and setting priorities with limited resources and that just takes lots of practice. I think the thing that helped me prepare for this kind of thing more than any other single factor was being a paramedic before pa school. medics are used to minimal resources and improvisation to make things work.

you have to be able to do your job and the nurses job at many rural sites. if there are 2+ sick pts at once you sometimes need to be doing some of the "nursing skills" like starting IVs and IOs, pushing meds, etc.

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Thanks for responding. I have 3 small kids and live in northern California which is extremely expensive, so em residency is out of the question. I am pretty comfortable with starting IVs, placed a handful of chest tubes in my time in Iraq, comfortable with PTAs/LPs. Central lines without US freak me out though. LP is not an issue. I worked at a semi rural hospital with 1 other provider about 5 shifts a month. They didnt have an US machine which blows. Is there any conferences or training programs that you know of focused on rural emergency medicine? If I had it all over to do again, I would have became an MD. Personal time off with the family in emergency medicine is greater with the docs.

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with new trends in the management of sepsis, central lines are becoming less critical a skill to master. a few IOs will work in almost anyone with poor access. I have done 1 femoral line in the last year, but have put IOs in lots of folks in need of immediate access (codes, etc).

Pick up more shifts at the rural facility. That is how I got my foot in the door. I started at 2 days/mo, then went to 3, then went to 4, then picked up a second rural job where I work several times/mo as well. My primary job lets me cut way down (only have to do 80 hrs/mo for benefits,although I do 100-120 most months) because I am a senior pa there now with over 10 years on the service. I still am only 4th on the seniority level,but there are now > 10 folks under me in terms of seniority.

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Thanks for responding. I have 3 small kids and live in northern California which is extremely expensive, so em residency is out of the question. I am pretty comfortable with starting IVs, placed a handful of chest tubes in my time in Iraq, comfortable with PTAs/LPs. Central lines without US freak me out though. LP is not an issue. I worked at a semi rural hospital with 1 other provider about 5 shifts a month. They didnt have an US machine which blows. Is there any conferences or training programs that you know of focused on rural emergency medicine? If I had it all over to do again, I would have became an MD. Personal time off with the family in emergency medicine is greater with the docs.

once again, it's more about judgement and setting priorities. work more in a 2 provider rural dept.

Take ATLS, FCCS, and The difficult airway course. Consider the ALSO course (adv. life support in obstetrics), etc.

Talk to intensivists about why they try diltiazem over lopressor, or why they decide to cardiovert some folks early and some folks later or not at all.

When you are comfortable with a hypotensive 85 yr old diabetic with renal failure on 22 meds who is tachycardic, and has an altered mental status and might have had a fever earlier in the day you are ready to start thinking about solo rural er jobs. I see this pt almost every shift at one of my rural jobs. and it's always a different guy. one time he was using meth too(not kidding).

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Everything EM stated above rings true. I was a paramedic for nearly ten years before PA school and have worked in solo ED coverage for nearly 7 years.

My first job was working in FM 2 days a week and covering the rural ED 24h/week and 2 weekends (62 hour shifts) a month. To say I was nervous would be an understatement, and, at the time I felt comfortable with codes, multisystem trauma, airway management, etc.  I was honest during my interview. The doc agreed to train me and be within 5 minutes of the hospital when I was on. for the first 3 months I had to call him for every pt, after, only for pt's other then UC, worried well, drug seekers, etc. (or any time I felt I needed to) we would discuss the pt and plan, he would the decide to come in or not. I think I spent more time looking things up and "studying" the first 2 years then treating pt's

 

EM residency would be your best bet, but that can be tough with a family. I considered it but was in the same boat.

At the time I was scared s#&less, looking back I did get good training, not residency training by any means, but decent training. not only with pt work up but procedures as well. This may be an option. the kicker is you need a dedicated doc who is willing to train.

 

I still work part time at that hospital and have done locums at several others. Currently I work in 2 ED's as the solo provider. one I work 24 hour shifts, the other I work 48-72, some times longer.

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Would a person be able to work ED rural solo coverage after just a residency if they have no prior ED experience?

probably if they focused on that goal while in the program. Iowa has that as a specific goal for all grads.

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Ok speaking of solo coverage, from business point of view, do you guys think it is smart to take all the risk of malpractice that the doctors take while earning possibley 3x your rate

I get the point of having that autonomy and helping the underserved. I am strictly looking at from business aspect

 

Sent from my SCH-I535 using Tapatalk

 

 

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Ok speaking of solo coverage, from business point of view, do you guys think it is smart to take all the risk of malpractice that the doctors take while earning possibley 3x your rate

I get the point of having that autonomy and helping the underserved. I am strictly looking at from business aspect

 

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Where I work solo the docs make only slightly more than the PAs, like 1/3rd more. remember they are mostly FP docs, not EM.  also, malpractice is paid by the hospital, not by me.

honestly, I think it is easier to miss something in fast track than in seeing folks who are all sick. I know from the start that the 85 yr old with chest pain , fever, and hypotension isn't going home. I just need to figure out why. much easier to send home the 22 yr old female with "chest wall pain after volleyball game" that was really a PE who didn't mention she takes oral birth control because mom was in the room during the exam.

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I would assume that rural areas sue less, same as county facilities. When I know I am covering main ED with a provider that let's me do whatever, I tend to get the test I would possibly not get or admit playing it safe.

you should practice that way in every setting. One of my attendings early on taught me that if a pt would get a test in main then they should get it in fast track too. where pts are placed is often a matter of triage rn choice/judgement, which is not always an accurate representation of how sick a pt is. the pt in question in my scenario needed an LP in fast track, got one after my consult, and had HSV encephalitis.....I actually said to my attending when he asked what the pt needed , " well, if we were in main they would need an LP" and he said (very patiently) " well, ok, so what do you think they need in fast track....."

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you should practice that way in every setting. One of my attendings early on taught me that if a pt would get a test in main then they should get it in fast track too. where pts are placed is often a matter of triage rn choice/judgement, which is not always an accurate representation of how sick a pt is. the pt in question in my scenario needed an LP in fast track, got one after my consult, and had HSV encephalitis.....I actually said to my attending when he asked what the pt needed , " well, if we were in main they would need an LP" and he said (very patiently) " well, ok, so what do you think they need in fast track....."

Although, I do agree with you. In my my county ED sometimes it can take 16-17 hrs to get a bed. We sometines havd chest painers in the waiting room for 12-13 hrs. Alot of these borderline admissions such as cellulitis, I tend to give maybe a dose of iv abx, out pt abx and recheck in 1-2 days. Although, my other ER, I would just admit.
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I know a few of you work in single coverage ED gigs in really rural areas. I am interested in this because I like the idea of 48-72 hr shifts to maximize my off time with my family. I have worked at a teaching county hospital for about 4 yrs in the emergency room where we get maybe 1-2 main ED shifts every other month and another smaller ED where I have worked in the main for the last 6 months. I have intubation a few times put in a couple central lines but I would not say I am by any means comfortable. I am comfortable at seeing critical patients but not as comfortable with the procedures/codes although I know how to do them for the most part. I feel I hit a ceiling at my jobs. I would appreciate any opinions on wether or not that is adequate training for a rural ER gig for single coverage.

 

It would depend greatly on the practice environment.  In my primary workplace (this year) we don't have an ICU, so for the very sick who need secondary or tertiary care I just stabilize and ship.  You are used to doing that in the field with people potentially shooting at you, so you would have no problem doing it in my shop. 

 

 

Thanks for responding. I have 3 small kids and live in northern California which is extremely expensive, so em residency is out of the question. I am pretty comfortable with starting IVs, placed a handful of chest tubes in my time in Iraq, comfortable with PTAs/LPs. Central lines without US freak me out though. LP is not an issue. I worked at a semi rural hospital with 1 other provider about 5 shifts a month. They didnt have an US machine which blows. Is there any conferences or training programs that you know of focused on rural emergency medicine? If I had it all over to do again, I would have became an MD. Personal time off with the family in emergency medicine is greater with the docs.

Where in norther Cali are you?  I lived in Crescent City for a year a lifetime ago and LOVED it.  In my shop we don't do central lines.  If I need a pressor then we hang it peripherally or IO and ship.  LPs and most intubations are done by the CRNA.  Thoracotomy?  Will never be done in rural shops because there is no one there to put the chest back together.  I have had to reduce some horrible orthopedic injuries, put in chest tubes, intubate, pace/cardiovert/shock, but never really needed CVAs.  That being said, I would like to get more exposure to them!

 

 

Would a person be able to work ED rural solo coverage after just a residency if they have no prior ED experience?

 

You MUST have some level of "emergency decision making" experience.  It doesn't necessarily have to be prior ED experience, but you have to be able to quickly differentiate "sick" from "not sick", and you have to be able to efficiently use critical decision making skills.    I think with the OP's experience he would do fine as single coverage in rural America. 

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It would depend greatly on the practice environment. In my primary workplace (this year) we don't have an ICU, so for the very sick who need secondary or tertiary care I just stabilize and ship. You are used to doing that in the field with people potentially shooting at you, so you would have no problem doing it in my shop.

 

 

Where in norther Cali are you? I lived in Crescent City for a year a lifetime ago and LOVED it. In my shop we don't do central lines. If I need a pressor then we hang it peripherally or IO and ship. LPs and most intubations are done by the CRNA. Thoracotomy? Will never be done in rural shops because there is no one there to put the chest back together. I have had to reduce some horrible orthopedic injuries, put in chest tubes, intubate, pace/cardiovert/shock, but never really needed CVAs. That being said, I would like to get more exposure to them!

 

 

 

You MUST have some level of "emergency decision making" experience. It doesn't necessarily have to be prior ED experience, but you have to be able to quickly differentiate "sick" from "not sick", and you have to be able to efficiently use critical decision making skills. I think with the OP's experience he would do fine as single coverage in rural America.

Thanks for the response fellas, makes it seen much more comfortable.
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You MUST have some level of "emergency decision making" experience.  It doesn't necessarily have to be prior ED experience, but you have to be able to quickly differentiate "sick" from "not sick", and you have to be able to efficiently use critical decision making skills.    I think with the OP's experience he would do fine as single coverage in rural America. 

To be fair, I did specify AFTER doing a residency (I would assume that residencies would provide one with emergency decision making experience).

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I know a few of you work in single coverage ED gigs in really rural areas. I am interested in this because I like the idea of 48-72 hr shifts to maximize my off time with my family. I have worked at a teaching county hospital for about 4 yrs in the emergency room where we get maybe 1-2 main ED shifts every other month and another smaller ED where I have worked in the main for the last 6 months. I have intubation a few times put in a couple central lines but I would not say I am by any means comfortable. I am comfortable at seeing critical patients but not as comfortable with the procedures/codes although I know how to do them for the most part. I feel I hit a ceiling at my jobs. I would appreciate any opinions on wether or not that is adequate training for a rural ER gig for single coverage.

I would maximize that small ED, main side shifts gig for at least another year or 2.

Everything that has been said prior is good advice, you likely could get through a rural ED shift alone right now. Fast forward a year or 2 and you would feel even more comfortable.

Bottom line is that you need to be comfortable making the decisions. You can have all the procedures in the world under your belt and still technically fail in performance of one. The real question is do you know what to do then? That requires a high level of mature medical decision making that actively needs to be pursued over a career.

Keep working towards this goal, you likely will get there, you just will have to pull the trigger at some point and just take a leap of faith that you can do it.

G Brothers PA-C

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residencies will not be the "be all end all" for training for these positions.

 

You are either comfortable working independently or you aren't.  Its that simple.  When you can go weeks without asking an attending a question, care for your patients, etc, you may be ready.  Maybe.

 

The most successful folks Ive seen transition to these positions are prior medics.  And even then it is boom or bust.

G

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agree with above. the medic mindset is invaluable when transitioning to solo em pa positions. medics are used to working with minimal backup and help and making decisions without having to mother may I anyone higher up the food chain.

lesson 1 as a medic: it's easier to ask forgiveness than ask permission...:)

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