Bad rotation?

[MaryPAs]

Hello all, 

I just want to get some advice, I’m currently on my geriatrics rotation at a place that is not great. We do rounds on 12+ patients by ourselves, no attending or PA in the building just the nurses. So today I go in and a patient is vomiting blood, non responsive the nurse told the family it might be a GI bleed his lungs have rhonchi and wheezing the family tells me they’re calling 911 so I tell them the PA doesn’t get there till 1:30 it’s was around 11:30 they said we’re not waiting that long. So I go to talk to the nurse (no where to be found) 
I go to the nurses station and ask about him the only one there tells me to wait she’ll find out about him and calling. she comes back and is like yeah he’s clear she asks me do you want to call 911 or do you want me to call in my mind I’m like I don’t have the credentials so I tell her you can call
Then the PA finally answers and is like why did you tell them to call I’m like I was just trying to find out what happened. He is very upset, said he had to beg to let me come back to the facility. I feel like this all could’ve been avoided if he was in the building when we do rounds, I panicked and I didn’t know what to do. My question is if I should tell my program about how unsafe I feel this is for patients and students since other students have loved the rotation because it’s only max 4hrs a day. 

[SedRate]

That doesn't sound like an environment conducive to learning and mentorship. 

[CAAdmission]

1 hour ago, MaryPAs said:

We do rounds on 12+ patients by ourselves, no attending or PA in the building just the nurses.

Your program cannot possible be aware of this. The ARC-PA would have a fit. Talk to your clinical coordinator immediately.

[TeddyRucpin]

This does not sound like a real rotation. Even besides the episode that happened. Talk to your clinical team ASAP.

[68WEMTto65DPAC]

8 hours ago, MaryPAs said:

no attending or PA in the building just the nurses.

This is when you should’ve realized you’re in no capacity to see patients. You’re putting your credentials at risk before you even get them. Regardless of the event, how poorly or exceptionally you could have handled it, or the outcome, you’re a PA student and are required to have direct, on-site supervision for any patient interaction.

That is not a rotation. Contact your program and don’t see a single patient until your assigned preceptor, or an adequate substitute per the clinical rotation agreement, shows up.

[MaryPAs]

Thank you everyone for the support. I’ve contacted the program and will give an update once I get a reply from them. Hopefully this won’t affect my grade  

[Boatswain2PA]

On 2/27/2024 at 6:55 AM, MaryPAs said:

Hello all, 

I just want to get some advice, I’m currently on my geriatrics rotation at a place that is not great. We do rounds on 12+ patients by ourselves, no attending or PA in the building just the nurses. So today I go in and a patient is vomiting blood, non responsive the nurse told the family it might be a GI bleed his lungs have rhonchi and wheezing the family tells me they’re calling 911 so I tell them the PA doesn’t get there till 1:30 it’s was around 11:30 they said we’re not waiting that long. So I go to talk to the nurse (no where to be found) 
I go to the nurses station and ask about him the only one there tells me to wait she’ll find out about him and calling. she comes back and is like yeah he’s clear she asks me do you want to call 911 or do you want me to call in my mind I’m like I don’t have the credentials so I tell her you can call
Then the PA finally answers and is like why did you tell them to call I’m like I was just trying to find out what happened. He is very upset, said he had to beg to let me come back to the facility. I feel like this all could’ve been avoided if he was in the building when we do rounds, I panicked and I didn’t know what to do. My question is if I should tell my program about how unsafe I feel this is for patients and students since other students have loved the rotation because it’s only max 4hrs a day. 

Your writing doesn't tell the story very well.  Sounds like you were doing student rounds, found a sick patient, told the nurse who asked if you wanted to call 911 and you said "I'm just a student" - which is legit. 

The nurse "is like yeah he's clear" - what does this mean??  Who is clear?  Clear for/of what??

When PA answers - are they upset because you told the nursing to call 911?  Or the PA?  Did you have the PA's number and try to call them directly on this? 

You were not "DOING rounds", you were a student practicing rounds and found a sick patient.  Your told the nurse who should have done their job, just as if the PA wasn't there - whether that was calling EMS, hospice , the PA, or the doc.  You were just there to watch and learn.

Yes, talk to your program about it.    And if you are emotionally upset about an elderly person with an UGI bleed...it's normal.  This can be a very, very disturbing way to die - especially to the family.  Learning note - if you have someone bleeding to death with an UGI bleed, and they are on comfort care, then drop an NG tube and suck the blood out before they spew it all over the white bedsheets and family members. 

 

 

On 2/27/2024 at 8:38 AM, CAAdmission said:

Your program cannot possible be aware of this. The ARC-PA would have a fit. Talk to your clinical coordinator immediately.

Why?  Because the PA student was there doing student-rounds without the PA being there?  That was very common in my rotations.  Sounds like the biggest breakdown was the nursing staff not knowing what to do when a student told them about a decompensating/actively dying patient.
 

 

22 hours ago, TeddyRucpin said:

This does not sound like a real rotation. Even besides the episode that happened. Talk to your clinical team ASAP.

Again, why?  I was frequently sent to nursing homes to do "pre-rounds" which consisted of doing the exam/writing the note, and then the PA/Doc would come in later, spend a few minutes with pt's, and then add something & sign my note. 
Same thing with hospital rounds.  I would do "student rounds" first and write a student note, then the hospitalist would follow behind me.
 

18 hours ago, 68WEMTto65DPAC said:

This is when you should’ve realized you’re in no capacity to see patients. You’re putting your credentials at risk before you even get them. Regardless of the event, how poorly or exceptionally you could have handled it, or the outcome, you’re a PA student and are required to have direct, on-site supervision for any patient interaction.

Direct on-site supervision meaning the preceptor has to be in the room with student at all times? Not how I learned, and not how I teach.  In the ED I give students a sheet with an area for their HPI, Exam, Orders, and MDM and tell them to go see the patient. 

I was on my 2nd rotation, a rural combined FP/ED/OB rotation when I was sent to the floor to help with a patient found down.  Turns out was in cardiac arrest.  I ran the code for about 10 minutes and got ROSC before the doc got there.  That wound up getting me my first job (in the ED) out of school.  I mentioned it to my program director and her eyes bugged out of her head and told me not to tell anyone about that again.

[68WEMTto65DPAC]

8 minutes ago, Boatswain2PA said:

Your writing doesn't tell the story very well.  Sounds like you were doing student rounds, found a sick patient, told the nurse who asked if you wanted to call 911 and you said "I'm just a student" - which is legit. 

The nurse "is like yeah he's clear" - what does this mean??  Who is clear?  Clear for/of what??

When PA answers - are they upset because you told the nursing to call 911?  Or the PA?  Did you have the PA's number and try to call them directly on this? 

You were not "DOING rounds", you were a student practicing rounds and found a sick patient.  Your told the nurse who should have done their job, just as if the PA wasn't there - whether that was calling EMS, hospice , the PA, or the doc.  You were just there to watch and learn.

Yes, talk to your program about it.    And if you are emotionally upset about an elderly person with an UGI bleed...it's normal.  This can be a very, very disturbing way to die - especially to the family.  Learning note - if you have someone bleeding to death with an UGI bleed, and they are on comfort care, then drop an NG tube and suck the blood out before they spew it all over the white bedsheets and family members. 

 

 

Why?  Because the PA student was there doing student-rounds without the PA being there?  That was very common in my rotations.  Sounds like the biggest breakdown was the nursing staff not knowing what to do when a student told them about a decompensating/actively dying patient.
 

 

Again, why?  I was frequently sent to nursing homes to do "pre-rounds" which consisted of doing the exam/writing the note, and then the PA/Doc would come in later, spend a few minutes with pt's, and then add something & sign my note. 
Same thing with hospital rounds.  I would do "student rounds" first and write a student note, then the hospitalist would follow behind me.
 

Direct on-site supervision meaning the preceptor has to be in the room with student at all times? Not how I learned, and not how I teach.  In the ED I give students a sheet with an area for their HPI, Exam, Orders, and MDM and tell them to go see the patient. 

I was on my 2nd rotation, a rural combined FP/ED/OB rotation when I was sent to the floor to help with a patient found down.  Turns out was in cardiac arrest.  I ran the code for about 10 minutes and got ROSC before the doc got there.  That wound up getting me my first job (in the ED) out of school.  I mentioned it to my program director and her eyes bugged out of her head and told me not to tell anyone about that again.

Direct supervision as in the preceptor has to be on site. Obviously not hovering over the student’s shoulder every second. Students have to see patients by themselves and then report to the preceptor, but the preceptor has to also see that patient. The patient is not being billed to see a student. The student has no credentials to bill for the visit. Who is signing off on the visit? A PA who is not on site and never saw the patient? Huge liability.

OPs post says that there were no physicians or PAs on site to whom OP could report to and discuss the case. A nurse is not an appropriate level of licensed professional to precept a PA student, as valuable as nurses are.

[Boatswain2PA]

1 hour ago, 68WEMTto65DPAC said:

Direct supervision as in the preceptor has to be on site.

Don't know if that's a hard rule or not.  I don't see that being necessary with "student rounding", especially NH rounding. 

I had a terrible cardiology rotation where the cards would have me go see admissions and write the H&P for him.  He literally just used PA students as scut monkeys.  Rarely ever saw him.

[CAAdmission]

2 hours ago, Boatswain2PA said:

Why?  Because the PA student was there doing student-rounds without the PA being there?

Absolutely. Unless something radically changed, students can't be on site seeing patients without a preceptor in house. They don't need to be in the room, but they need to be able to promptly appear. 

[EMEDPA]

1 hour ago, CAAdmission said:

Absolutely. Unless something radically changed, students can't be on site seeing patients without a preceptor in house. They don't need to be in the room, but they need to be able to promptly appear. 

Agree- and "preceptor" could be just another PA or licensed physician. My OB rotation was mostly overseen by senior OB residents. I saw the attending physician , who was the preceptor of record, rarely. The 4th year residents and I would see pts in clinic, L+D, and take them to the OR for sections, hysts, etc with me as first assist.

That being said, my training did not include a single day in nursing homes so I may not be fully aware of student dynamics there. I did home visits when on FP with the doc in the mornings before clinic.

[Boatswain2PA]

Is that a formal written rule by ARC-PA or someone?

 

[68WEMTto65DPAC]

3 hours ago, Boatswain2PA said:

Is that a formal written rule by ARC-PA or someone?

 

From ARC-PA Standards:

“A2.17 In each location to which a student is assigned for didactic instruction or supervised clinical practice experiences, there must be an instructional faculty member designated by the program to assess and supervise the student's progress in achieving learning outcomes.”

Even if you find a way to argue that this doesn’t mean the preceptor must be physically present somewhere on site and readily available to the student, do you really think having preceptors busy elsewhere is what’s best to graduate successful PAs?

Even if you think so, the question remains, if the preceptor is not on site and does not see the patient, who is billing for the encounter? Are we resorting to fraud?

Registered nurses are not included in the list of licensed professionals who may act as preceptors according to ARC-PA standards, which is another issue in OPs post.

[TeddyRucpin]

8 hours ago, Boatswain2PA said:

Your writing doesn't tell the story very well.  Sounds like you were doing student rounds, found a sick patient, told the nurse who asked if you wanted to call 911 and you said "I'm just a student" - which is legit. 

The nurse "is like yeah he's clear" - what does this mean??  Who is clear?  Clear for/of what??

When PA answers - are they upset because you told the nursing to call 911?  Or the PA?  Did you have the PA's number and try to call them directly on this? 

You were not "DOING rounds", you were a student practicing rounds and found a sick patient.  Your told the nurse who should have done their job, just as if the PA wasn't there - whether that was calling EMS, hospice , the PA, or the doc.  You were just there to watch and learn.

Yes, talk to your program about it.    And if you are emotionally upset about an elderly person with an UGI bleed...it's normal.  This can be a very, very disturbing way to die - especially to the family.  Learning note - if you have someone bleeding to death with an UGI bleed, and they are on comfort care, then drop an NG tube and suck the blood out before they spew it all over the white bedsheets and family members. 

 

 

Why?  Because the PA student was there doing student-rounds without the PA being there?  That was very common in my rotations.  Sounds like the biggest breakdown was the nursing staff not knowing what to do when a student told them about a decompensating/actively dying patient.
 

 

Again, why?  I was frequently sent to nursing homes to do "pre-rounds" which consisted of doing the exam/writing the note, and then the PA/Doc would come in later, spend a few minutes with pt's, and then add something & sign my note. 
Same thing with hospital rounds.  I would do "student rounds" first and write a student note, then the hospitalist would follow behind me.
 

Direct on-site supervision meaning the preceptor has to be in the room with student at all times? Not how I learned, and not how I teach.  In the ED I give students a sheet with an area for their HPI, Exam, Orders, and MDM and tell them to go see the patient. 

I was on my 2nd rotation, a rural combined FP/ED/OB rotation when I was sent to the floor to help with a patient found down.  Turns out was in cardiac arrest.  I ran the code for about 10 minutes and got ROSC before the doc got there.  That wound up getting me my first job (in the ED) out of school.  I mentioned it to my program director and her eyes bugged out of her head and told me not to tell anyone about that again.

We all pre-rounded in school. This person is rounding alone and functioning as a "kinda" PA. Ther description says it all.  There's a difference of being in a hospital with your preceptor somewhere in house. This does not sound like an actual rotation. 

[Boatswain2PA]

2 hours ago, 68WEMTto65DPAC said:

From ARC-PA Standards:

“A2.17 In each location to which a student is assigned for didactic instruction or supervised clinical practice experiences, there must be an instructional faculty member designated by the program to assess and supervise the student's progress in achieving learning outcomes.”

Even if you find a way to argue that this doesn’t mean the preceptor must be physically present somewhere on site and readily available to the student, do you really think having preceptors busy elsewhere is what’s best to graduate successful PAs?

Even if you think so, the question remains, if the preceptor is not on site and does not see the patient, who is billing for the encounter? Are we resorting to fraud?

So, no requirement for the "instructional faculty member designated by the program to assess and supervise the student's progress" to be on site with the student.

I see no reason why a student couldn't do "student rounds", followed by the preceptor who then completes the notes and does orders.  Certainly shouldn't be the ONLY teaching going on, but sometimes when precepting you are busy with other stuff and your student needs something to do.  Going and talking with/examining patients is a good thing for them to be doing.

In this case, the OP ran into something serious and reported it to the nursing staff (who was in charge of the facility).  The nursing staff should've handled it as if a bypasser, family member, or other student (nursing, OT, PT, etc) had found it.
 

 

2 hours ago, TeddyRucpin said:

his person is rounding alone and functioning as a "kinda" PA. Ther description says it all.  There's a difference of being in a hospital with your preceptor somewhere in house. This does not sound like an actual rotation. 

Rounding and doing a note is not "functioning as a kinda PA".  It's the making of diagnoses and ordering therapies that makes one a PA.  

There is nothing wrong with sending students in for rounding without direct supervision.   

[iconic]

I used to round on patients in nursing home then the preceptor would come by lunchtime to round on them; no one saw anything wrong with that practice