Why I love rural EM

[Guest Paula]

separate pts....he ended up being mostly psych...did get a chest ct to eval for PE and security had to go with him because he was getting...you guessed it....squirrelly....:)

 

Ha ha,that is funny. I once went out with a guy who took me to his friends house WAY out in the woods. They fixed squirrel, rabbit, duck and venison. Looking back, they remind me of Duck Dynasty guys, if you've ever seen them. I tried it all and remember squirrel as tough and stringy. Needless to say, the 2 guys and the other girlfriend were kind of strange, and I never dated him again. I wonder what they were REALLY doing WAY OUT THERE IN THE WOODS? this was about 30 years ago in the early 80s.

[EMEDPA]

today, male with priapism x > 10 hrs. no urologist within 3 hrs.

did the intracavernosal phenylephrine injections myself after a quick referesher in roberts and hedges. never done it before. easier than I thought, tolerated well and effective.

[rcdavis]

today, male with priapism x > 10 hrs. no urologist within 3 hrs.

did the intracavernosal phenylephrine injections myself after a quick referesher in roberts and hedges. never done it before. easier than I thought, tolerated well and effective.

 

Ya know, I've never done one either.. Strange, we see a few priaprismic pts a year, and somehow always have a urologist.. What would you have done if it didn't work?

[MedicinePower]

Sounds like a dream. Small town, kind people, bartenders who know your beer. Where can I sign up?

[EMEDPA]

Ya know, I've never done one either.. Strange, we see a few priaprismic pts a year, and somehow always have a urologist.. What would you have done if it didn't work?

the next step is aspirating out all the excess blood with a butterfly needle and 20cc syringe...seen it done once.

[EMEDPA]

same day @ change of shift(of course)

seizing child being worked up by doc.

o.d. pt arrives having taken a bottle each of soma, valium, and amitryptiline 1-2 hrs earlier. walks in totally oriented. 5 min later resp arrest, I intubate , no response to narcan(had to try) start the workup and look for an icu bed. nope none available, needs to be transferred...2 hrs later transferred out on propofol and bicarb drips. ekg qrs never widened so don't know how many tca's they actually took. charted 1 hr critical care time.

[rcdavis]

Did you consider romazicon? Already incubated... Would seem suz risk minimal.

[MediMike]

The ALS service I work for stopped carrying flumazenil prior to my beginning employment here, citing high risk of sz with no ability to resolve them...Is this a concern in the ED as well?

[EMEDPA]

Did you consider romazicon? Already incubated... Would seem suz risk minimal.

considered but figured if they started to seize it would get nasty. I think most of the pts sx were from soma and tca's. I have seen bigger od's on valium before without resp. arrest. of course the cocktail was what did it but isolated benzo od's usually can protect their own airway.

[EMEDPA]

The ALS service I work for stopped carrying flumazenil prior to my beginning employment here, citing high risk of sz with no ability to resolve them...Is this a concern in the ED as well?

yup. rule of thumb I learned was only give it if you gave the benzo yourself( procedural sedation for example).

[Just Steve]

I was stationed on an aircraft carrier in the mid 90's, it was not uncommon for active duty patients to be on low dose TCAs for chronic headaches, back pain, that sort of thing. One evening this gentleman ambled into Medical with an empty bottle of TCAs that he received that same day and admitted to taking all of them. I don't remember the number, but it was enough. Our on call doc that evening was very new to the whole "treat real patients on your own" (read: first assignment after med school) and ordered us to give this patient Ipecac. There were a few Corpsmen in the sick bay and all of us looked at the Doc like he was speaking in tongues. We gave a weak protest, said it's probably not the best idea, Doc was an O-3 and we were just enlisted. While it is quite noble to not follow direct orders because it may bring detriment to the patient, the actual application of such gallantry is a horse of a different color when you're in the military, on a ship, in the middle of nowhere.

 

Dude seized about the same time the Ipecac kicked in. We danced that tango for awhile, he bought a tube and ended up on a vent for three days. All while in the middle of the Persian Gulf, not a lot of resource hospitals to get this guy to. He lived to see his discharge from active duty despite our best efforts to expedite the arrival of the Grim Reaper. Ahhhh good times.

[EMEDPA]

F/U ON O.D PT FROM LAST MONTH:

survived episode, back in the er requesting rx for soma...denied......

[primadonna22274]

F/U ON O.D PT FROM LAST MONTH:

survived episode, back in the er requesting rx for soma...denied......

 

Silly E, GOMERs never die :)

[jsfelder0417]

You could give them a Darwin Award candidate button though.

[PAruby]

Thanks EMEDPA and others for sharing!

 

Here, urban ER PAs do very little. Almost exclusively fast track, urgent care, family practice type patients. The second a patient is identified to have something more acute, they are transferred to a doc. If a PA or NP admits, the hospitalist will sometimes pre-judge it as a "scared midlevel". That's the experience I've noted in the hospitals I've worked at/with/shadowed. Coming from a paramedic background, it's a big reason I had nearly ruled the ER out as a PA. Urgent care, family practice and fast track are important, but I know I'll miss the urgency and emergency of true life-threats. Throughout school though, there are few areas I enjoy as much as emergency medicine, so it is good to see that the rural setting affords a little higher acuity and the opportunity for a real PA role in emergency medicine. It would take me less than a 60 minute commute in any direction to land at a rural clinic with a small "ER" and the opportunity for more autonomy and higher acuity when I'm ready for it... so it's so good to see that PAs in that role are really loving what they do. (and makes me look forward to my rural rotations :o)

 

Thanks for sharing!

[EMEDPA]

very true about urban vs rural. all the really sick folks I have seen and managed in the past year have been at my rural job. at my urban job once they are flagged as critical they get swept up by er docs or intensivists.

I have never ordered bipap for example at my regular job but do at my rural job on a regular basis. had a pt yesterday with b/l pe's sating in the 70's who I managed from presentation to icu admission without the doc ever evening sticking their head in the room.

[Guest Paula]

^^^^^^^^ EMEDPA describes another good reason for PAs to apply for EM residencies and get your CAQ. That way you will be ready for a rural hospital and will have the credentialing to help you get the jobs.

[jsfelder0417]

I'm sold on a PA residency. I want to practice in a rural ER, and feel this will give me the skills and knowledge to do so.

[Nonlegit]

Hey all, I have a question for you. I'm currently pre-med/pre-PA, leaning PA. I have been an EMT/Tech for close to 10 years now, almost always at large level 1's. I am delving more into pertinent PA issues (such as rural medicine) so as to help with my indecision. I was looking into some of these tiny western hospitals in the middle of nowhere (CAH for loan repayment purposes), and some of them are advertising a "Trauma Receiving" certification. I can put two and two together and realize that this means they can initially stabilize traumas before transfer, but am curious how this actually works in practice. I worked on the East Coast before where this was not a reality; you were picked up by a helicopter then straight to the trauma center. Even here in central Ohio, surrounded by open rural area, you are really never more than a helicopter ride away from a trauma center. Functionally, its very rare for traumas to be taken to a smaller facility before transport to definitive care. Is it that different in say, rural Montana?

 

I have read the rest of this thread and frankly, its appealing to me. I guess I would just be curious as to the breakdown of a 24 hour shift and perhaps then what a string of shifts might bring? Apologies for asking a question that has been quasi-answered already...

[Just Steve]

My local hospital is located 60 miles east of a trauma center. Those 60 miles are through the Columbia River Gorge which LOVES to ice over in the winter, sometimes closing the freeway. Of course when it does ice over, helos are not a fan of flying. So when the local hunter puts a 30-06 round through their leg or wraps their arm up in some piece of farm machinery, you could be THE one hanging out with that bloody mess for a bit. Even more "interesting" is when the minivan full of kids are crushed by the log truck. Fortunately, those events are few and far between. Some can be considered once in a career events.

 

The more average day is ACS, UTI, URI, fx, lacs, GI, diabetes...patient an hour average give or take. There is a call room attached to the ER so when there are no patients, you can retire to your "cave" and chill out/nap/sleep for a bit. The trick is to get your techs/nurses dialed in to have all the obvious needs done before they come get you. Things like x rays for obvious skeletal issues, IVs for those in obvious need, lab draws done. Some nurses may say "we can't do anything until you order it" but those details can be worked around in the right team environment.

[Nonlegit]

Steve, thanks for the reply. I have heard and read anecdotal accounts of rural medicine, and I appreciate your view. It holds in line with what I have heard in the past. I am not necessarily looking for 10+ trauma alerts a shift (I do that now, and while some can be exciting and interesting, it does all become very similar), but I would be disappointed working at a place where a portion of emergency medicine is neglected. I am having a hard time articulating exactly what I am looking for in a practice and why a PA practicing rural EM seems to fit the bill, but suffice to say I would still like to be exposed to a full spectrum of injuries and disease.

[EMEDPA]

these rural jobs are typically not ideal for a new grad. I just got hired into such a position after 10 years of hitting up the director of this particular facility and I have 27 years of experience working in em with 10 as an er tech/paramedic and 17 as a pa. I think I am the least experienced pa on staff there....

these positions are generally solo coverage or alongside a doc and seeing every other pt as a second provider, not as an "assistant". I would discourage taking a position like this unless you had some significant prior experience and great backup. I didn't work solo as a pa until I had been put of school for 5 years working in positions of increasing scope of practice and autonomy..

[Nonlegit]

these rural jobs are typically not ideal for a new grad. I just got hired into such a position after 10 years of hitting up the director of this particular facility and I have 27 years of experience working in em with 10 as an er tech/paramedic and 17 as a pa. I think I am the least experienced pa on staff there....

these positions are generally solo coverage or alongside a doc and seeing every other pt as a second provider, not as an "assistant". I would discourage taking a position like this unless you had some significant prior experience and great backup. I didn't work solo as a pa until I had been put of school for 5 years working in positions of increasing scope of practice and autonomy..

 

I appreciate that thought, and the idea would be to do a residency post PA school. The University of Iowa one looks ideal. Of course, at this point that's putting the cart a little before the horse. Not to harp on this, but EMED you said you see sick people most every shift. Well, my tertiary care hospital does as well, but with much larger volumes than a rural hospital. We also probably do 1-5+ level one trauma activations a day with many more level 2s.... so I'm trying to make a mental comparison here. How many traumas would a CAH see in a 24 hour period? A week? Or would a level 1 trauma be a once a year sort of thing. I'm far from a trauma chaser at this point, I'm genuinely curious. I figure its streaky, but what do I know?

[EMEDPA]

the issue is that at the level 1 trauma center the trauma team does most of the heavy lifting. I have worked at level 1 and level 2 trauma ctrs for over 12 years and EM PAs have very little involvement with traumas in these settings because there are so many resources around to deal with them. the opposite is true at a rural job-you are the resource, there is no trauma team. it's not the # of cases, it's the # the em pa can be involved with. I have never run a case in the trauma bay at the level 1 or 2 trauma ctrs I worked at as that is the sole territory of the er docs and trauma teams. the er docs at the level 1 only manage the airway and the trauma PAs and surgeons do everything else. occasionally they might ask the em pa to suture a few lacs but that is about it as far as involvement with the case.

now at my 2 critical access hospital/rural jobs I either have a 100% chance of being involved(at the solo job) or a 50% chance of being involved at the job I work double coverage. I have personally been involved in many more traumas at the rural jobs working part time than at trauma ctrs or community er's working full time.

If trauma is really your thing you should be looking for a trauma surgery/critical care job, not an er job. the trauma pas do all the chest tubes, central lines etc at the level 1 job I used to work at but they worked for the dept of surgery, not the dept of em. there are trauma/critical care pa residencies out there as well but then all you do is trauma and floor care so you don't get the cool medical cases that the em pas get so you need to figure out what is most important to you. either way, do a residency.

[Nonlegit]

the issue is that at the level 1 trauma center the trauma team does most of the heavy lifting. I have worked at level 1 and level 2 trauma ctrs for over 12 years and EM PAs have very little involvement with traumas in these settings because there are so many resources around to deal with them. the opposite is true at a rural job-you are the resource, there is no trauma team. it's not the # of cases, it's the # the em pa can be involved with. I have never run a case in the trauma bay at the level 1 or 2 trauma ctrs I worked at as that is the sole territory of the er docs and trauma teams. the er docs at the level 1 only manage the airway and the trauma PAs and surgeons do everything else. occasionally they might ask the em pa to suture a few lacs but that is about it as far as involvement with the case.

now at my 2 critical access hospital/rural jobs I either have a 100% chance of being involved(at the solo job) or a 50% chance of being involved at the job I work double coverage. I have personally been involved in many more traumas at the rural jobs working part time than at trauma ctrs or community er's working full time.

If trauma is really your thing you should be looking for a trauma surgery/critical care job, not an er job. the trauma pas do all the chest tubes, central lines etc at the level 1 job I used to work at but they worked for the dept of surgery, not the dept of em. there are trauma/critical care pa residencies out there as well but then all you do is trauma and floor care so you don't get the cool medical cases that the em pas get so you need to figure out what is most important to you. either way, do a residency.

 

EMED, I am far from a trauma junkie these days. I merely would not want to be relegated to never seeing another one again, both for an undeniable bit of excitement and for not letting old skills get rusty. I was genuinely surprised that some of these CAH get the trauma volume you guys mention, as I am very unfamiliar working in the rural setting. As far as the rest of your advice, it hasn't fallen on deaf ears. A competitor hospital here in the area has in my estimation one of the most badass midlevel groups (all NPs currently) I have ever encountered in all my travels cross country. They more or less run a trauma service for an absolute traumarama of a hospital in the hood. Again though, I'm not sure if this is my cup of tea. In any case, I have to get into and complete school first!