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What did you think you were getting into when becoming a PA?


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Morning all,

It's a lovely morning here in northern New England, snow is on the ground, the ER is quiet (for now), and the hospital side and clinics downstairs are hopping.  As I peruse the threads, I keep seeing a common theme pop up, both on the professional and student/prospective student side - People don't seem to realize what medicine is, or didn't understand getting into it, and they feel stymied by it.  My questions is: why?  

When you train for a license to practice medicine (that is what we train for - with the caveat of having physician involvement at some level of our care depending on where you work), you aren't training to be a manager, an administrator, an HR director, a marketing person, or any of these other ancillary services.  You are training to practice medicine.  You are training for perhaps the most important job someone can have - to enter into someone's life and either guide them in their decisions on how to live a healthy life, treat their underlying chronic ailments, or when the SHTF, intercede to make sure they see another day and if not, comfort those they have left behind.  That's it.  Anything and everything we do revolves this basic concept, and anything beyond this requires more training, experience, or a different approach to how one wants to approach a profession.  

So I find it interesting that we get frustrated when we see others in healthcare (MDs, RNs, NPs, whomever) move into administrative positions and we think we are being left behind.  Most of the good admins I have known over the years have had other training - not just their basic PA school, medical school, or nursing school training.  Most have advanced degrees in management, administration, etc, and the ones who have failed miserably are the ones who think they can do it better than others, lack the fundamental training to do the job in the first place, and then end up stuck in their positions and wind up being detriments to building a good system - not part of a good system itself.  I know there are exceptions to the rule... this isn't about them. 

I understand the idea of upward mobility, wanting to "further our careers," and any other label we want to put to something like this, but fundamentally, our first, best destiny is to take care of patients.  And I think a lot of us lose sight of this.  We train to practice medicine.  If one wants to go further, do other things, branch out, etc - train for it - and go for it.  But here is the reality check that comes with any position in medicine:  You are training for a dead end job.  To be a PA is TO BE A PA.  to be an MD is TO BE AN MD.  To be an NP is to BE AN NP. Want to do public health?  Get an MPH.  Love EMS?  Be a medic or do an EM/EMS residency.  Want to do administration?  Get an MHA (or take the appropriate coursework to qualify you for whatever it is you seek). Because like it or not, the shell game is what degree do you have, what do our collective resumes look like on paper, and do you LOOK like you can fill a position - it doesn't matter what we think individually - that's not how the system works.

So as I am enjoying my morning quiet, I am reading about emergent open thoracotomies, Becks Suture and the Sauerbruch maneuver with foley insertion and purse-string closures of cardiac wounds, because I don't know what is going to walk through the door at any time, the closest trauma center is 90 minutes away by ground and 40 minutes by air, and if a penetrating chest wound comes in and they arrest in front of me - their chest is getting opened.  And I have to know how to do this quickly, efficiently, and what to do with it if I get them back.  Because that is what the full scope of my license as a PA is - and I practice to it and love doing so - and it is why I became one: to take care of people.  

G

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Hmmm....Yes, you are partly right.  I agree that a PA (nor an MD or RN or NP) is trained to be an administrator in our formal programs.  However, by just having the letters MD or RN behind your name automatically open up doors to lead to management.  I’m actively trying to get in to administration and I’d say 80% or more specifically require RN degree.  Why?  Just because they run the show basically.  A PA has far fewer options to get into admin.  Just saw a posting last week I think I’m very qualified for.  Manager of Employee Health Clinic.  However, the posting specifically wants an NP.  I got a rejection letter stating I didn’t meet the required licensure/education for the position.  

Most PAs have no desire to go into admin or education, but for those of us that do, there should be options available.  That’s why we all need to be advocates for each other in trying to open this door for those PAs who want in.  Even if you hate admin/leadership if you are ever presented with the opportunity to suggest that a PA be considered it would be helpful for the future of our profession.  

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You gonna open the chest without a CT surgeon in house to put everything back together?  

Open thoracotomy is recommended within minutes of a traumatic arrest, but I think the guidelines say ONLY when CT is immediately available.

I just intubate, open both chest cavities with finger thoracotomies, US to determine need to needle the heart, and squeeze blood.  If that doesn't work then it's a quick call.

 

Am I wrong? 

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15 hours ago, Boatswain2PA said:

You gonna open the chest without a CT surgeon in house to put everything back together?  

Open thoracotomy is recommended within minutes of a traumatic arrest, but I think the guidelines say ONLY when CT is immediately available.

I just intubate, open both chest cavities with finger thoracotomies, US to determine need to needle the heart, and squeeze blood.  If that doesn't work then it's a quick call.

 

Am I wrong? 

Nope... you aren't.  And with all blunt trauma arrests this is my standard approach.  However, the recommendations are for a trauma surgeon, or general surgeon, to do damage control surgery first and then follow-up with definitive care.  In the penetrating wound traumatic arrest scenario, the only scenario where this can and should play out, it takes time for my general surgeon to get in-house.  Additionally, if signs of life are re-established, it is within reason to grossly close the chest for transport to the tertiary center for care.  This has been done extensively in the past in those patients needing cardiac care beyond the care of local facilities treating patients who decompensate as well as those patients who have been successfully resuscitated in the ED environment from penetrating injury.

Here are the current EAST recommendations on open thoracotomy (2015):

"In summary, we have provided six evidence-based recommendations using GRADE methodology (Fig. 7) and several well-described EDT survival predictors. First, we strongly recommend that patients who present pulseless but with signs of life after penetrating thoracic injury undergo EDT. Second, we conditionally recommend EDT for patients who present pulseless and absent signs of life after penetrating thoracic injury. Third, we conditionally recommend EDT for patients who present pulseless but with signs of life after penetrating extrathoracic injury. Fourth, we conditionally recommend EDT for patients who present pulseless and absent signs of life after penetrating extrathoracic injury. Fifth, we conditionally recommend EDT for patients who present pulseless but with signs of life after blunt injury. Lastly, we conditionally recommend against the performance of EDT for patients who present pulseless with absent signs of life after blunt injury."

I think of it like a peri-mortem C-section:  Do I know the steps to do one?  Yes.  Would I do it if I have to?  Yes - I wouldn't think twice about it.  Do I ever want to do it?  God no... but I still need to know it because one never knows what comes through the doors on any given night...

G

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Okay, I just looked at the EAST guidelines and didn't see what I expected....a caveat that this should only be done if CT surgery is quickly available.  Not sure where that entered my head at, but since I don't work anywhere NEAR a CT surgeon (and rarely even have a surgeon) I have focused my mental readiness on the ptx/tamponade treatment. 

Maybe after the PANRE I'll study up on EDTs.  I'm guessing that, except for one place I work (that has EPs who HAVE done EDT, but not when I've been there), nowhere I work even has the right equipment to get into the chest.  

Regarding peri-mortem C-sections....that seems a lot simpler.  I've done about a dozen of them (all in my head, of course) and it just seems simpler. Could be that I have done a bunch of c-sections so that helps with my comfort level there.


Back to your OP:  We have the same problem that physicians do.  We want to practice medicine instead of the management crap, but then we complain when management is too screwed up to let us practice medicine.  Nurses, however, promote NOT on their ability to nurse, but to write esoteric management papers.

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