Are you practicing very high acuity emergency medicine?

[piteog]

If so, I want to hear from you. For example:

 

Are you working in the highest acuity area of your ED?

Are you managing elderly patients with multiple comorbidities who present with sepsis, ACS, PE, respiratory failure, etc?

Are you doing all of this relatively autonomously?

Did you learn by doing, or were you specifically trained in a PA-residency?

Did you complete the CAQ?  Did it matter?

 

If so, I would love to hear from you.  I'm trying to establish what our group is interested in with respect to PA "implementation" and I'm trying to convince them to set a high bar.  It would help me to understand your experiences in your groups about how you got to do what you're doing (and whether you're one of many or the only one).

[MrsGPAC]

I'm in a level 2 trauma center.  We are a reasonably high volume ED and the only trauma center in the area.  We also cover 2 rural critical access hospitals and an urgent care.

 

It varies person to person but I have been working on the "main side" since about 5 months in (I was a freshly minted new grad when I started here).  We currently have 2 of our own "main side" shifts that mirror the doc schedules and we share a shift with the doc group (i.e. is covered by both docs and APS staff interchangeably--we will take that shift back as an APS shift once our newer folks are oriented).  Today I'm on a shift that I cover a main side pod alone for about 2 hours before the next provider comes in.  

 

At this point (2 years in) I am managing everything but multi trauma, imminent intubations and STEMI (only because the docs will fight each other for those and I can't be bothered).  Otherwise it is not uncommon for me to take "sick" patients.  With that said, there are very few healthy people in this area so they are all sick! The docs here are totally on board with us doing intubations and whatnot, we just generally don't take the patients being coded as they roll in.  Although truthfully if I said I wanted to and asked them to help the vast majority of them would be excited to help.  I'm 2 years in and haven't yet jumped in on one of those.  I'll get there! 

 

I ask questions when I need to but for the most part I practice autonomously.  If my SP is around he stands over my shoulder and grills me but otherwise I am on my own (with great support from the other docs/APS staff as I need it)

 

I learned by being thrown into the fire. I was double covering "fast track" type shifts for a month, working at our rural sites (with a doc) for a couple months and then solo covering fast track at 3 months. We are a pretty well established/well respected APS group (PA's/NP's, many with 20+ years of ER experience) with a group of very receptive docs. We are always encouraged to push ourselves and to take "sick" patients--knowing there is plenty of support.  With that said, I would be a little bit careful with tossing folks into the main side really early on.  Double covered shifts with an experienced doc/PA/NP may be a better way to integrate initially--particularly for the new-ish grads.  

 

I have just started the CAQ process.  There is a group of us (in my APS group) looking to develop an ER fellowship for PA's/NP's to hopefully "beef up" our training program (to prevent the turnover we are seeing).  We have had a lot of turnover, particularly new grads, who have not done well with the autonomy.  

 

Hope that helps!

[True Anomaly]

1. I work at a level 1 trauma center in a major city- very high-volume, and yes I work shifts in the highest-acuity area of the ED.

2. Yes I manage elderly patients with multiple comorbidities

3. Relatively, yes- the docs do the admission phone call so they also see my patients.  I don't manage significant trauma because our trauma service is immediately called for anything like that, and there's no role for me in that.  I also don't manage STEMI, codes or strokes that meet TPA criteria since those require direct doc-to-doc activation.  Like the above poster, depending on the physician I could likely run a code if I want, but I'm always swamped with other patients that I'm never just free to start working a code before the doc gets in there.  As far as procedures, the only ones I haven't done in the ER are thoracotomy, surgical airway or floating a pacer.

4. I did a residency, and it made a HUGE difference for me

5. Passed the CAQ almost 3 years ago.  I took it to pad my CV when looking for a new job at the time, but I don't think it factored into my being hired.

[GetMeOuttaThisMess]

From following this forum for years, if you get your satisfaction/adrenaline rush from high acuity TRAUMA cases I think the answer is to AVOID the trauma centers and go rural like EMEDPA and others. You'll always be the little fish in the pond it seems in the big city centers since the bigger fish will eat those cases. Go against the traffic flow. NOW, if you like high acuity medical cases then you can get that just about anywhere, and would probably like the hospitalist setting more. Me? Same folks day after day used to drive me nuts in the ICU/CCU setting.

[charlottew]

Yeah, this is a bit off the OP's original query but if it's acuity you're after as a critical care PA I deal with this regularly (academic hospital/level 1 trauma center) :

 

high acuity... check

comorbidities... check

relatively autonomous,..check - after all, we are responsible for care at the bedside. Can't call trauma/surgery resident about every little thing..

no residency, no CAQ - on the job training

 

When I first took the job, I thought that the ED or OR (I'm SICU) would only send patients up once their vitals were stable - nope. So that does get the adrenalin going.

[True Anomaly]

From following this forum for years, if you get your satisfaction/adrenaline rush from high acuity TRAUMA cases I think the answer is to AVOID the trauma centers and go rural like EMEDPA and others. You'll always be the little fish in the pond it seems in the big city centers since the bigger fish will eat those cases. Go against the traffic flow. NOW, if you like high acuity medical cases then you can get that just about anywhere, and would probably like the hospitalist setting more. Me? Same folks day after day used to drive me nuts in the ICU/CCU setting.

 

I really don't care about trauma.  But, I do work occasional shifts in more rural locations

[lightbearer06]

Are you working in the highest acuity area of your ED? Yes, there is no separation in acuities in my ER.

Are you managing elderly patients with multiple comorbidities who present with sepsis, ACS, PE, respiratory failure, etc? Yes, STEMI, Code Stroke, sepsis. I see most of what the physicians see.

Are you doing all of this relatively autonomously? Yes

Did you learn by doing, or were you specifically trained in a PA-residency? On the job training. The first job I took, I told myself that I am seeing that as my own personal residency. Lots of great physician mentors were the key.

Did you complete the CAQ?  Did it matter? Yes, No

[EMEDPA]

solo coverage of rural critical access hospitals. see every patient, do every procedure. run codes. give TPA, manage traumas, manage airways, etc.

I also have a double coverage position at another rural facility where I alternate charts with a doc. I started out 20 years ago doing high volume/low acuity fast track style work. have transitioned almost entirely to low volume/high acuity work. much less potential for burnout there. like many in EM, I worked as a paramedic for many years. I took the em caq the first day it was offered. I'm a big fan of residencies, but was not able to do one myself as none existed when I graduated. agree with those above who say you won't get a truly broad scope of practice (with few exceptions) if you work in an urban setting.

I'm in the process of going 100% rural/underserved. I'm expecting a job offer today, which will decrease my hours by about 25% while maintaining a very livable wage and benefits package.

[GetMeOuttaThisMess]

Ah, the joys of getting older. "You're offering X amount of dollars for these lesser hours? Done!" Thought bubble: I would've accepted less cash for the fewer hours!

[EMEDPA]

Ah, the joys of getting older. "You're offering X amount of dollars for these lesser hours? Done!" Thought bubble: I would've accepted less cash for the fewer hours!

yup, potentially looking at a bit of a salary cut, but going from 212 to 168 hrs/mo...and for the first time in a long time getting sick leave, 1.5x for OT, pay while I am on cme leave, etc.

[kargiver]

All I work is rural, solo shifts.  I occasionally have double or triple coverage but its with other PAs, no docs.

 

I see anything and everything that comes through the door.  The only things I haven't done are an open thoracotomy and a surgical airway (partook in several thoracotomies in medic and PA training - but never one on my "own").  I still have many years to go so I expect to do both at some point.

 

I manage newborns to 100+ year olds with all possible co-morbidities.  I learned critical care medicine working as a medic in the Boston area at a time when there weren't a lot of medics.  It was routine to do 15-20 calls a shift and 2-3 arrests a day was par for the course.  I learned primary care in PA school and some as a medic. I married the two in the first 8 months as a PA.  Have been working solo since.

 

I do everything autonomously. It is my call if I want to call a consultant at the tertiary center before I do something, and sometimes I do.  This is only to consult on best outcomes for patients, not looking for their permission to do anything.  As the consultants say who work with us - you are there, we are here, and we trust you.  Do what you think is right."

 

Never did a residency.  However, I would recommend it to ANYONE with less than 10 years hardcore paramedic experience in high call volume systems where they do it all.  I will however never go back and do one.  It would be redundant at this point.

 

CAQ was nice and all, but has been meaningless for job purposes. The only reason I have it is in the event I ever have to sit on the stand, I can say I am qualified at the highest level dictated by third party agencies.

 

G

[GetMeOuttaThisMess]

All I work is rural, solo shifts.  I occasionally have double or triple coverage but its with other PAs, no docs.

 

I see anything and everything that comes through the door.  The only things I haven't done are an open thoracotomy and a surgical airway (partook in several thoracotomies in medic and PA training - but never one on my "own").  I still have many years to go so I expect to do both at some point.

 

I manage newborns to 100+ year olds with all possible co-morbidities.  I learned critical care medicine working as a medic in the Boston area at a time when there weren't a lot of medics.  It was routine to do 15-20 calls a shift and 2-3 arrests a day was par for the course.  I learned primary care in PA school and some as a medic. I married the two in the first 8 months as a PA.  Have been working solo since.

 

I do everything autonomously. It is my call if I want to call a consultant at the tertiary center before I do something, and sometimes I do.  This is only to consult on best outcomes for patients, not looking for their permission to do anything.  As the consultants say who work with us - you are there, we are here, and we trust you.  Do what you think is right."

 

Never did a residency.  However, I would recommend it to ANYONE with less than 10 years hardcore paramedic experience in high call volume systems where they do it all.  I will however never go back and do one.  It would be redundant at this point.

 

CAQ was nice and all, but has been meaningless for job purposes. The only reason I have it is in the event I ever have to sit on the stand, I can say I am qualified at the highest level dictated by third party agencies.

 

G

 

The key to this statement is the prior experience and exposure.  If one takes a moment to recall, this is why the field was established to begin with; to build off the core knowledge and experience of field medics which can today be extrapolated to include high acuity EMS.  The only exception to this would be someone who has undergone a residency or started in EM early on and has been able to gradually build on their knowledge base with experience and guidance from those more experienced which in this type of setting would traditionally be the EM physician/trauma specialists.  Well, with the exception of the one trauma specialist from a couple years ago who cut off a tourniquet from an open femur fracture w/o first knowing the application time and later had the pt. bleed out from the open wound while covered with a sheet.

[EMEDPA]

The key to this statement is the prior experience and exposure.  If one takes a moment to recall, this is why the field was established to begin with; to build off the core knowledge and experience of field medics which can today be extrapolated to include high acuity EMS.  The only exception to this would be someone who has undergone a residency or started in EM early on and has been able to gradually build on their knowledge base with experience and guidance from those more experienced which in this type of setting would traditionally be the EM physician/trauma specialists.  Well, with the exception of the one trauma specialist from a couple years ago who cut off a tourniquet from an open femur fracture w/o first knowing the application time and later had the pt. bleed out from the open wound while covered with a sheet.

That's like the folks who used to cut off mast pants with trauma shears...um, you realize those cost a few grand, are not disposable, and are helping to maintain the patient's bp >80....for those too young to know what mast pants are look here:

https://en.wikipedia.org/wiki/Military_anti-shock_trousers

[fakingpatience]

Hopefully this doesn't derail the thread too much, but for those of you working in high scope ERs, where did you do your student rotations at?   I have the opportunity to go to a really well known big ER, which sees EVERYTHING, but the problem is that likely I'd just be seeing it, not doing a lot (huge amount of other student and residents there). Otherwise there are other smaller hospitals, where I'd probably be able to see more patients, rather than just shadowing, but the exposure, especially to trauma and zebras will be significantly less.  

My goal is to do a residency, but in case I don't get into one, I want to ensure my training is as good as possible  

[GetMeOuttaThisMess]

Hopefully this doesn't derail the thread too much, but for those of you working in high scope ERs, where did you do your student rotations at? I have the opportunity to go to a really well known big ER, which sees EVERYTHING, but the problem is that likely I'd just be seeing it, not doing a lot (huge amount of other student and residents there). Otherwise there are other smaller hospitals, where I'd probably be able to see more patients, rather than just shadowing, but the exposure, especially to trauma and zebras will be significantly less.

My goal is to do a residency, but in case I don't get into one, I want to ensure my training is as good as possible

You hit the nail on the head. Not going to get both in this type of setting as a student. Maybe it's just my old man syndrome but as a student in a non-academic setting I doubt you would have much hands on aside from basic stuff due to liability concerns on part of facility.

[Boatswain2PA]

If so, I want to hear from you. For example:

 

Are you working in the highest acuity area of your ED?

Are you managing elderly patients with multiple comorbidities who present with sepsis, ACS, PE, respiratory failure, etc?

Are you doing all of this relatively autonomously?

Did you learn by doing, or were you specifically trained in a PA-residency?

Did you complete the CAQ?  Did it matter?

 

If so, I would love to hear from you.  I'm trying to establish what our group is interested in with respect to PA "implementation" and I'm trying to convince them to set a high bar.  It would help me to understand your experiences in your groups about how you got to do what you're doing (and whether you're one of many or the only one).

1. Yes.  Primary job is rural ED, single coverage.  Also work at 40K visit double/triple coverage ED with 24/7 BC EP coverage.  I work main ED in that shop as well.

 

2. Yes.  If it comes in the door I handle it.  Sometimes that means I have to change my shorts afterwards....

 

3. Yes.  I consult with specialists if I need help, or with FP docs to get more info on patients and/or ensure follow up.

 

4. No residency.  Significant EM experience before PA school.

 

5. No CAQ.  Won't do anything for me in any of my jobs.

[Gaijyn]

Are you working in the highest acuity area of your ED?  Currently yes.  Previously it was mixed (some fast track, some main, some main with urging to see lower acuity of patients)

 

Are you managing elderly patients with multiple comorbidities who present with sepsis, ACS, PE, respiratory failure, etc?  I see all of those currently.  On a rough day I have a mix of those at the same time.  Do not mistake my statement for not enjoying them.  Those are the better days, the brief moments of calm mixed in with the chaos of helping actual sick people and not just slogging the seekers, sprained ankles, and work-note requests.  I gave up a lot of $ to take the position I have held for the past 1.5yrs and would do it again.  You do not realize what you are not comfortable with or can handle until it is force-fed to you.  Sink or swim is probably the only way to figure out if you can handle the real EM (CC is probably the same) patients.

 

 

Are you doing all of this relatively autonomously?  For the most part.  There are MD/DOs for back-up and they will gladly help out 99% of the time.  codes are typically run by them though I think that most would be cool with myself or a few of the other PAs running them while they were in the room.  But most of the complicated things or critical patients they prefer a heads-up (which really is warranted and fair). 

 

 

Did you learn by doing, or were you specifically trained in a PA-residency?  On-the-job.  I would have loved a residency but the problem was one of timing from graduation. If someone can go to a residency I think it is a good idea personally.

 

 

Did you complete the CAQ?  Did it matter?  No CAQ at this time.  No one has one with my group/system to my knowledge so it did not matter.  However, I am planning on getting it either this year or next and try to use it to benefit me financially.  At the very least it will help with the PRN or next job search.

[GreatChecko]

Are you working in the highest acuity area of your ED?

 

Mixed fast track and main

 

Are you managing elderly patients with multiple comorbidities who present with sepsis, ACS, PE, respiratory failure, etc?

 

It's my first year doing this, so I do with help. Sometimes in fast track after a poor triage with help available.

 

Are you doing all of this relatively autonomously?

 

I can, but tend to run things by attendings b/c I am still learning.

 

Did you learn by doing, or were you specifically trained in a PA-residency?

 

OJT - Applied to residencies and didn't get in. I was geographically limited due to family reasons, so did not apply as broadly as I would have otherwise. Still think it would have helped, but I got lucky with my current job.

 

Did you complete the CAQ?  Did it matter?

 

I will when the time comes. I know how HR works and it will matter when the time comes for a new job.

[EMEDPA]

Hopefully this doesn't derail the thread too much, but for those of you working in high scope ERs, where did you do your student rotations at?   I have the opportunity to go to a really well known big ER, which sees EVERYTHING, but the problem is that likely I'd just be seeing it, not doing a lot (huge amount of other student and residents there). Otherwise there are other smaller hospitals, where I'd probably be able to see more patients, rather than just shadowing, but the exposure, especially to trauma and zebras will be significantly less.  

My goal is to do a residency, but in case I don't get into one, I want to ensure my training is as good as possible  

surgery rotation: trauma surgery, level 1 trauma center. only student on rotation

peds rotation: Peds ER at peds referral hospital. only student on service ( I have never done a well baby check but have cardioverted 2 yr olds...)

ER rotation (required) level 1 trauma ctr, only student on rotation. 60 hrs/week

ER preceptorship/elective 12 weeks at community ER. only student on service.

[MrsGPAC]

You hit the nail on the head. Not going to get both in this type of setting as a student. Maybe it's just my old man syndrome but as a student in a non-academic setting I doubt you would have much hands on aside from basic stuff due to liability concerns on part of facility.

 

I think it's rare but not unheard of.  I did 2 rotations in a rural critical access ER and had my hands in everything.  I was the only student in a busy department and was involved in every critical patient that came in.  I was also the first student they had that had any interest in ER so they were pretty accommodating! This was in a farming community in the middle of nowhere with an incredibly sick population.  I know my situation was rare but the staff at the hospital I did my rotations at were really supportive/encouraging and pushed me to be involved in a lot of critical patients.  It worked well that I did my very first rotation with them and then one of my later ones.  I'm now per diem at that facility and they continue to push me to see sick patients, do intubations/procedures with excellent support.  A rare occasion I know but in speaking with my classmates who did rotations at trauma centers, my rotations had far more hands on than theirs AND I didn't have to compete with anyone.  They were hauling me out of lacs/anke sprains etc to see critical patients.  I mean I didn't have the knife and gun club stuff but did get the 250 gallon oil tank vs. acetylene torch patient as well as plenty of car v. moose, auto ped, end stage COPDers etc.  

[Guest ERCat]

Are you working in the highest acuity area of your ED?

 

In my ER we don't have pods and aren't assigned to any acuity levels or anything - all the docs and PAs just grab whatever charts are put on the rack. Most of the PAs just grab fast track stuff. I am a new grad and want to see everything so I usually grab a mix of patients. Including higher acuity complaints like chest pain, shortness of breath, altered mental status, etc. I staff all my patients with a physician - basically they are there to answer any questions I have but let me do all the work, then evaluate the patient at the end.

 

Are you managing elderly patients with multiple comorbidities who present with sepsis, ACS, PE, respiratory failure, etc?

 

Yes - but I do this with a great deal of MD support as I am only six months out!

 

Are you doing all of this relatively autonomously?

Did you learn by doing, or were you specifically trained in a PA-residency?

 

Learning by doing and having excellent training. My job IS like a residency although it's a regular paying job. The docs will literally explain anything I need, teach me whatever procedures I want to do, let me pick up whatever patients I want, let me go upstairs with them to codes, etc. Literally I feel my job is the most fun thing I've ever done - I love it!

 

Did you complete the CAQ? Did it matter?

No - but I want to in the future for sure.