Advanced procedures during rotations

[FriarMedic]

I brought a patient into the ED yesterday and there was a PA student on her ED rotation, working with an MD. I have seen this student before in the ED, so I know it is not her first or second shift in this setting. Our patient was intubated shortly after arrival but the PA student did not play much of a part other than airway/neck manipulation while the MD identified which medications and doses were needed for RSI, then performed the intubation.

 

I know that its hospital specific as to whether PAs have priveledges to perform certain skills. Are all PAs trained in intubation? If so, does this situation surprise you? Can I expect to perform more advanced procedures in my ED rotation (LP, Intubation, Chest tube, ect), or I am expecting too much? From reading the EM subforum, i know that some of you have priveledges to perform these procedures in your practice setting as a PA-C, so was your first time on the job or in your clinical rotations (or a residency)? Other than surgery, I could not imagine there would be any other rotations in which a PA student could execute an intubation on a human vs sim man or model (which no matter how life-like they make these things, its just not the same).

[greenmood]

We were trained on all those things this year on dummies, but told that our opportunities to actually perform the procedures on humans would be location-dependent. A couple of the busier level 1 trauma hospitals that take us will allow students to perform emergent procedures. They get a lot of volume and are very good at managing these patients. Some of the slower EDs might only get a handful of patients requiring those interventions the entire time we're there, and the physicians prefer to handle it.

 

Besides surgery, womens' health also provides a good opportunity to do procedures, depending on where you go. Mine has a big surgical component. Plus your electives, if your school offers them.

[EMEDPA]

this depends on a number of factors:

some students don't want to do em and just cruise through the required rotation and never seek out opportunities

some students(like me) hound their preceptors for procedures and tough cases. I did femoral lines, intubation, chest tubes, 1st assist major trauma cases, lp's, etc

some locations say students may only do X

some preceptors like to teach, some don't

 

when picking rotations most places have a day that explains the sites so you can make a wish list. at hahnemann/drexel they came straight out and said" this is the best surgery/peds/etc rotation if you want to do em " and this is the easiest xyz rotation if you really aren't interested in this specialty...

 

at all of your rotations you should be treated at least as well as a 3rd yr med student. if you aren't , there is a problem and you should report the site to your school.

[Just Steve]

My school (medex) has been very straight forward in telling us that they WILL NOT be training us in advanced ER procedures as the school is based in primary care/family practice. It is their stance that advanced procedures can be learned on rotations with your preceptors or on the job should you choose an occupation where those skills will be required....

 

needless to say, I was a bit bummed. However, I have faith that should the opportunity arise during my clinical year I'll be elbows deep in that madness.

 

On a positive note...we've must have had at least 30 million or so lectures on ob/gyn. At least 30 million..maybe more :-| Bring me your PID and Tric...got ya covered.

[unewillow]

One thing that we were told is not to expect the docs you are working with to be like "oh, so and so is here today, lets have them do this procedure" because it's often faster for them to do it themselves or find the nearest resident/fellow to do it. If you want to do a procedure, FIGHT FOR IT. Get in there and say, hey, can someone teach me how to do this? Because that way the next time you can say hey, I've been taught how to do this can I give it a try. See one, Do one, Teach one.

[EMEDPA]

If you want to do a procedure, FIGHT FOR IT. Get in there and say, hey, can someone teach me how to do this? Because that way the next time you can say hey, I've been taught how to do this can I give it a try. See one, Do one, Teach one.

exactly.....

[VictoriaO]

So this is a subject that was very important to me as a PA student (it's your one chance to do these things), so excuse my rambling....

 

First of all, some of this will be luck but a lot of this will depend on your rotation site, preceptor, support staff and your personality as a student.

 

For your rotation sites, try and pick hospitals without many other students that still have high volumes and lots of sick patients. I did my ICU elective at a large hospital but one that did not have students or residents. I was paired with the ICU PA, I got to put in central lines pretty much every day, did LPs, thoracocenteses, A-lines (still suck at them), ran codes (we were the code team), etc, so needless to say, best rotation ever!! My rural ED rotation didn't get too many critical players, but I got a lot of time with the ultrasound, tons of complex facial suturing after the rodeo, and they set it up for me to go over the the OR to intubate when we got slow.

 

I did some rotations at our big academic center, and that was more of a crapshoot. My surgery rotation was "emergency general surgery" so I did lots of ED and floor consults and bedside I&Ds and wound vac changes, but not much in the OR because there was a pushy medical student and I couldn't give a hoot about surgery unless it was a really cool trauma case, crazy necrotizing fascitis or big post-pancreatits abscess or something. It really depends on your resident at the big academic center, I've had some good ones and some terrible ones who thought students should be seen and not heard. On Trauma at same Level-1 medical center part of the time my resident was a surgery resident who wanted to specialize in trauma. While he was great about quizing and teaching, he did all the central lines, chest tubes, bronchoscopy, ultrasound, etc though he "let me drive" the traumas after a week, doing the survery, choosing work-up, etc. My next resident wanted to do plastics, and was more than happy to let me do everything, chest tubes, bronchoscopy, trauma suvery, FAST exam etc as soon as I showed her I could. So alot of this is resident-dependent.

 

Part of the trick is knowing the procedure step by step before it becomes available. I won a chest tube out from a medical student because I listed every single step in detail including complications and watched the You-tube videos many times and had assisted on several. Before each of your rotations read through and watch any of the procedures that might be available and know any of the complications. Know all the intubation drugs and their complications down pat if you want to intubate, etc

 

Next, is make friends with the staff, anesthesia are great people to know if you like airway and line stuff like me, particularly in a rural setting where there's not 10 CRNA students lined up to do the intubation. Nurses and RTs are always your friends. On my OB/Gyn rotation most people went in expecting to be doing pap smears all day. Not so! Rural high-volume OB/Gyn was a blast, caught quite a few babies because the nurses would call me for the deliveries (leave your number at the nurses station in big letters). Bring cookies. Better yet, homemade lemon bars. The CRNAs were arguing over who's patient I would get to intubate on our gyn OR days. My rural internal medicine I also made friends with anesthesia, got to intubate and "drive" the conscious sedation for cases, it was really fun. So dust off that Betty Crocker book or go get some doughnuts. You want people to remember your name.

 

Next tip would be try and get a PA as your preceptor or at least as part of your teaching staff. The times at my big academic center I felt passed over for the medical student (standing on my tiptoes knowing the answer to the ventilator question while he hemmed and hawwed) the PA would advocate for me. The ICU PAs I worked with were fantastic about not just teaching me day-to-day work-life as a PA but making sure I get to do things like bronchoscopy and whatnot. Even the PAs in family medicine came to get me before the med student if a procedure was available, they were well-aware of our shorter clinical training time.

 

Most of all, it's your attitude that makes or breaks a rotation. There's something you can find to like about every rotation. Explain to your preceptor what kind of PA you want to be and how motivated you are to be the best at it. Come early, leave late. I had to be forcefully told to "go home and get some sleep" on my ICU, ED and trauma rotations because you never knew if you're going to miss something cool. Make a list of procedures you want to do, make sure your preceptor knows you want to do them if you get one. Even rotations some people think will be boring like OB/Gyn or surgery (for me it was family med), there are almost always procedures and fun stuff if you know where to look. It's all about being proactive, making friends, having a good work ethic and being prepared by knowing the procedure beforehand.

 

Sorry this is so long, I was very determined as a PA student to get procedures, these were my methods and I daresay they served me well so I wanted to pass on what I learned, hope this is helpful.

[LT_Oneal_PAC]

So this is a subject that was very important to me as a PA student (it's your one chance to do these things), so excuse my rambling....

 

First of all, some of this will be luck but a lot of this will depend on your rotation site, preceptor, support staff and your personality as a student.

 

For your rotation sites, try and pick hospitals without many other students that still have high volumes and lots of sick patients. I did my ICU elective at a large hospital but one that did not have students or residents. I was paired with the ICU PA, I got to put in central lines pretty much every day, did LPs, thoracocenteses, A-lines (still suck at them), ran codes (we were the code team), etc, so needless to say, best rotation ever!! My rural ED rotation didn't get too many critical players, but I got a lot of time with the ultrasound, tons of complex facial suturing after the rodeo, and they set it up for me to go over the the OR to intubate when we got slow.

 

I did some rotations at our big academic center, and that was more of a crapshoot. My surgery rotation was "emergency general surgery" so I did lots of ED and floor consults and bedside I&Ds and wound vac changes, but not much in the OR because there was a pushy medical student and I couldn't give a hoot about surgery unless it was a really cool trauma case, crazy necrotizing fascitis or big post-pancreatits abscess or something. It really depends on your resident at the big academic center, I've had some good ones and some terrible ones who thought students should be seen and not heard. On Trauma at same Level-1 medical center part of the time my resident was a surgery resident who wanted to specialize in trauma. While he was great about quizing and teaching, he did all the central lines, chest tubes, bronchoscopy, ultrasound, etc though he "let me drive" the traumas after a week, doing the survery, choosing work-up, etc. My next resident wanted to do plastics, and was more than happy to let me do everything, chest tubes, bronchoscopy, trauma suvery, FAST exam etc as soon as I showed her I could. So alot of this is resident-dependent.

 

Part of the trick is knowing the procedure step by step before it becomes available. I won a chest tube out from a medical student because I listed every single step in detail including complications and watched the You-tube videos many times and had assisted on several. Before each of your rotations read through and watch any of the procedures that might be available and know any of the complications. Know all the intubation drugs and their complications down pat if you want to intubate, etc

 

Next, is make friends with the staff, anesthesia are great people to know if you like airway and line stuff like me, particularly in a rural setting where there's not 10 CRNA students lined up to do the intubation. Nurses and RTs are always your friends. On my OB/Gyn rotation most people went in expecting to be doing pap smears all day. Not so! Rural high-volume OB/Gyn was a blast, caught quite a few babies because the nurses would call me for the deliveries (leave your number at the nurses station in big letters). Bring cookies. Better yet, homemade lemon bars. The CRNAs were arguing over who's patient I would get to intubate on our gyn OR days. My rural internal medicine I also made friends with anesthesia, got to intubate and "drive" the conscious sedation for cases, it was really fun. So dust off that Betty Crocker book or go get some doughnuts. You want people to remember your name.

 

Next tip would be try and get a PA as your preceptor or at least as part of your teaching staff. The times at my big academic center I felt passed over for the medical student (standing on my tiptoes knowing the answer to the ventilator question while he hemmed and hawwed) the PA would advocate for me. The ICU PAs I worked with were fantastic about not just teaching me day-to-day work-life as a PA but making sure I get to do things like bronchoscopy and whatnot. Even the PAs in family medicine came to get me before the med student if a procedure was available, they were well-aware of our shorter clinical training time.

 

Most of all, it's your attitude that makes or breaks a rotation. There's something you can find to like about every rotation. Explain to your preceptor what kind of PA you want to be and how motivated you are to be the best at it. Come early, leave late. I had to be forcefully told to "go home and get some sleep" on my ICU, ED and trauma rotations because you never knew if you're going to miss something cool. Make a list of procedures you want to do, make sure your preceptor knows you want to do them if you get one. Even rotations some people think will be boring like OB/Gyn or surgery (for me it was family med), there are almost always procedures and fun stuff if you know where to look. It's all about being proactive, making friends, having a good work ethic and being prepared by knowing the procedure beforehand.

 

Sorry this is so long, I was very determined as a PA student to get procedures, these were my methods and I daresay they served me well so I wanted to pass on what I learned, hope this is helpful.

 

This is great advice, all of it, that I can second from experience. Make friends, know the procedure before it comes up, and be motivated to ask for procedures. Show 'em you're hungry and somebody will feed you.

 

Two things. Never knew 10 SRNAs lining up to do an intubation. After my 500th intubation, I pretty much did not care about numbers of them and would gladly concede to the paramedic students or whoever else, as long as it was looking to be easy. While mastery can only come from practice, let those SRNA students teach you if you are having problems finding the cords or manipulating the tongue. Likely they just overcame your same problem and have some tricks up their sleeve to teach. I found that older CRNAs have just got it down so much in muscle memory it can be hard for them to explain the movements.

 

Second point. Learn to mask while working with anesthesia. Sure most people are easy, but it's likely that the guy you can't intubate will also be a difficult mask ventilation. Get those people with fat necks, no chins, and beards to really be confident in knowing you can establish an airway. Learn how reverse t-burg can really allow for a ton more air with those big bellies off the lungs and other little tricks.

[FriarMedic]

Awesome info VictoriaO! Thanks a bunch, very exciting stuff. What area of medicine did you end up in out of curiosity? We have similar tastes.

[EMEDPA]

VictoriaO is the first hospitalist PA hired by a major academic medical ctr on the west coast(strong work!).

[mainiac]

Wow VictoriaO!

 

I didnt do as well as you, but I tried:

 

During my rural ED rotation with PA preceptor.

I asked if I could do x/y/z, especially if we were slow! Or hey they just called in for a baby delivery can I go? (our shift is almost over?)

I also went into day surgery & started IV's; went from Bed 1 to End. I stick & you get it or ur done. Great experience all different types of people.

Then I went to OR & intubated. Also made friends with Anesth. When I had difficulties, asked for there help...ie. tricks of the trade.

I did tons of suturing! I eval'd the people 1st then presented to PA & reported what studies/labs/etc I wanted to do & why. Dx & tx plan. Read xrays/CT scans Offered to bring pts to xray/ct scan etc.

 

Make friends with the nurses! ask q's! Help them out! I set up the IV lines. Asked to start IV's. NG tubes. Foleys. Crutch fitting/instruction. Casting/splinting

 

Agree! Be proactive! Go out of your way! Be excited & happy! No matter the rotation, there will b something to learn/do!

c 1!

do 1!

Teach 1!

[rlp14]

The program I will be starting in this fall has a primary care focus, and the curriculum reflects this as there are no specific courses in any specialties. With this type of preparation, will I be prepared/ready to learn these kinds of procedures during my rotations? I really want to get the most out of them.

[EMEDPA]

you will find didactics and rotations to be very different. on a good rotation it's "see one, do one". most of these things could be taught to anyone with a medical background without the first yr of pa school. many of these things are, in fact, taught to nurses, paramedics, etc who have not had the benefit of the first yr of pa school.

[FancyPAntsy]

I was able to intubate patients while on rotations, both in the ER and the OR. I also got to do tracheotomies with the surgeon first assisting me so to speak (meaning I made all the incisions, did the sutures, inserted the tube as he directed me and helped). I also did CPR, started IVs, removed drains, lots of suturing, I&Ds, helped with fracture reductions. All sorts of things! I was in a small ER, which meant I was the only student and could do most of the procedures, but they had maybe 1 intubation the whole rotation because it was not a high trauma hospital. So I wish I had been at a bigger place, but then they might not trust you as much. The rest of the procedures were on surgery rotations, where you get a lot more hands on. Make sure your rotation is not more observation based. And like other people said, make friends with everyone! The nurses knew me and would call me when there was a procedure or to let me practice IVs. I got to intubate in the OR because I made friends with the anesthesiologists.

 

I was told one very good piece of advice regarding ACLS/BLS procedures: always rehearse them in your head because you may wait years to use it and you don't want to freeze when the opportunity finally comes. Good luck, rotations are what you make of them :)