Atls & acls

[SLUser11]

I'm not saying you don't do these things, I'm just wondering what the attending physician is doing that's more important than the major trauma case that just rolled in?

Just to echo what emedpa said, there are plenty of ERs across the nation that are severely understaffed. While we resent the mid-levels "trying to steal our jobs" here in the big city, they are an integral part of rural care, and do good work for these underserved areas. It's these areas that are some of the main targets for ATLS.

you may not be aware of this but there are rural level 4 ed's all over the country that don't staff physicians at all. the entire e.d. staff is pa's with an available on call doc available for phone consults.
this is very common in vermont, maine, texas, georgia, montana, minnesota, alaska, hawaii, and other similar rural states.

Add Kansas to that list.

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[Apollyon]

you may not be aware of this but there are rural level 4 ed's all over the country that don't staff physicians at all. the entire e.d. staff is pa's with an available on call doc available for phone consults.
this is very common in vermont, maine, texas, georgia, montana, minnesota, alaska, hawaii, and other similar rural states.

Name one hospital in Hawai'i where it's PAs only. None on O'ahu, not at Kona or Hilo, not at Wilcox, not on Moloka'i, and not at Maui Memorial. I can't speak for Lana'i, there is another small hospital on Maui, and there is no hospital on Ni'ihau.

Could be Maui, the big island, Lana'i or Kaua'i. Even if it is, it's not "very common" here.

 

[deleted6669]

Name one hospital in Hawai'i where it's PAs only. None on O'ahu, not at Kona or Hilo, not at Wilcox, not on Moloka'i, and not at Maui Memorial. I can't speak for Lana'i, there is another small hospital on Maui, and there is no hospital on Ni'ihau.

Could be Maui, the big island, Lana'i or Kaua'i. Even if it is, it's not "very common" here.

I had a friend who worked there a few yrs ago. he's back in the states now. I will send him an email and post his response. I thought it was on the "backside" of oahu but could be wrong.

 

[dpmd]

ACS actually offers a course in rural trauma team development. It has this to say on the issue of extenders:

The basic premise of the course is the assumption that, in most situations, rural hospitals can provide three individuals to form the core of a trauma team consisting of a Team Leader (a physician or physician extender), Team Member One (a nurse), and Team Member Two (an additional individual who could be a nurse, aide, technician, pre-hospital provider, or clerk).

 

[deleted6669]

looks like a great course and it's one I would certainly take. it seems to get a course taught though that individual hospitals have to specifically schedule one and pay to bring faculty to their site. it's not a regularly given course like acls/atls/pals.
I would assume it follows atls guidelines and that they also will give a cert card to pa's as it acknowledges that pa's can be team leaders....doesn't that seem strange? I could be "rural atls" certified but not atls certified to use the same techniques.....I can run a trauma with minimal resources and 2 assistants only in the middle of nowhere but forget how to do it in a well staffed dept with ample resources?

 

[deleted6669]

Name one hospital in Hawai'i where it's PAs only.

http://www.wcchc.com/EmergencyCare.aspx

a friend of mine worked here 4 yrs ago. at that time pa's staffed the dept alone at night and docs were there during the day. don't know if that is still the case.

 

[Apollyon]

http://www.wcchc.com/EmergencyCare.aspx

a friend of mine worked here 4 yrs ago. at that time pa's staffed the dept alone at night and docs were there during the day. don't know if that is still the case.

Thanks. Sent you a PM. PM who was the PA.

 

[SocialistMD]

I would assume it follows atls guidelines and that they also will give a cert card to pa's as it acknowledges that pa's can be team leaders....doesn't that seem strange? I could be "rural atls" certified but not atls certified to use the same techniques.....I can run a trauma with minimal resources and 2 assistants only in the middle of nowhere but forget how to do it in a well staffed dept with ample resources?

Correct. The focus of the course is to make smaller hospitals recognize the patient who is going to need early transfer and not to waste time obtaining a rib series (or even a pan-CT scan) when the patient has an obvious open fracture and there is not an orthopedic surgeon at the hospital. From the pediatric side, we try to teach the paramedics not to stop at hospitals that do not have (pediatric) neurosurgeons when there is an obvious head injury (a problem we have in our region) that needs management.

It is a very interesting dynamic, as the instructors go to the small hospital and are on the home turf of the referrring hospitals. It is very eye-opening to see what those facilities actually are like and it gives us (the instructors) some insight as to why referring hospitals sometimes do the things they do that leave us scratching our heads.

 

[deleted6669]

Correct. The focus of the course is to make smaller hospitals recognize the patient who is going to need early transfer and not to waste time obtaining a rib series (or even a pan-CT scan) when the patient has an obvious open fracture and there is not an orthopedic surgeon at the hospital. From the pediatric side, we try to teach the paramedics not to stop at hospitals that do not have (pediatric) neurosurgeons when there is an obvious head injury (a problem we have in our region) that needs management.

It is a very interesting dynamic, as the instructors go to the small hospital and are on the home turf of the referrring hospitals. It is very eye-opening to see what those facilities actually are like and it gives us (the instructors) some insight as to why referring hospitals sometimes do the things they do that leave us scratching our heads.

do you know of any upcoming courses and can providers from other facilities attend?

 

[MattD]

at my rural job the doc will be treating one of the other unstable pts from the multi casualty incident while I have my own pts....it's not uncommon at this particular er to have several critical trauma pts at one time and with just 2 of us there we each manage our fair share.

That's certainly reasonable

you may not be aware of this but there are rural level 4 ed's all over the country that don't staff physicians at all. the entire e.d. staff is pa's with an available on call doc available for phone consults.
this is very common in vermont, maine, texas, georgia, montana, minnesota, alaska, hawaii, and other similar rural states.

I've never personally seen it, but I've certainly heard of such things. Do PAs have independent practice rights in these states, or if not, how is physician oversight attained? Periodic chart review by the off-site physician? Is there a physician in-house somewhere in the hospital who offers up his license? I'm curious how this works.

 

[deleted6669]

That's certainly reasonable



I've never personally seen it, but I've certainly heard of such things. Do PAs have independent practice rights in these states, or if not, how is physician oversight attained? Periodic chart review by the off-site physician? Is there a physician in-house somewhere in the hospital who offers up his license? I'm curious how this works.

there are no states with independent practice. pa's have their own license and dea but it is contingent on an association with a physician so we practice under our own license but can't ever work in a vacuum.
PA'S always practice with "supervision" (or in some states "sponsorship")but that doesn't mean an md must be on site. an on call md must always be available for phone consults and some review mechanism must be in place. in most states this means a % of charts must be reviewed. ca for example requires 5%, oregon requires 10%. in others such as nc regular meetings between the pa and doc are required.
I have friends who work in the aleutians 6 hrs by plane from their supervising physician of record. they have never met face to face and discuss cases only rarely although charts are reviewed as required by law.
at one of my jobs the only communication I ever have with my sp is by email. I work solo nights in an 11 bed dept and my charts are reviewed after the case. it is actually a fairly high degree of autonomy. I run the codes, traumas, mi's, cva's, etc and do all the procedures(intubation, cardioversion, etc)
obviously this is a small dept so for the sicker pts this means stabilization and transfer. generally the shifts are slow(12/night or so) but at times it can be quite busy. I saw 20 last night in 10 hrs which is brisk.

 

[JackADeli]

there are no states with independent practice. pa's have their own license and dea but it is contingent on an association with a physician so we practice under our own license but can't ever work in a vacuum.
PA'S always practice with "supervision" (or in some states "sponsorship")but that doesn't mean an md must be on site...

While I understand the healthcare provider shortage/sociel community needs, I think the "supervision" by phone is a wink and nod sham, particularly if we are talking about trauma staffing a small hospital with mid-levels and MD teleconferencing "supervision".

In light of this description, the ACS position of ~not being certified (i.e. "ACS doesn't call that a cert card") makes even more sense. Yes, maybe local communities allow ~independent PA practice (or telephone oversight). Thus, local ED staffed by PAs that lead the trauma team... But, it is still presumed that the PA is being supervised by an MD. To say on one hand they are running/leading the trauma then on the other hand say they are not independent because they are supervised then say the supervision is via telephone.... I wouldn't consider it certified either.

Further, if the state licensing requirements in general require physician ~"supervision", which is pretty much equivalent to what the trauma team leader does (i.e. supervise/oversee the team), then "I" couldn't deem it reasonable to declare someone certified in course designed to teach doctors to manage traumas. Especially, if their state licensing authority requires them to be supervised by a physician.

 

[SocialistMD]

do you know of any upcoming courses and can providers from other facilities attend?

It is regional and depends on when a group of instructors can get it scheduled. We are doing another one in August, but the course is usually confined to the providers (prehospital and in hospital) in the area. I'd talk to the tertiary hospital in your area and see if anyone there is teaching it and if you can set up a course for your hospital. That is kind of how we got into it. We are working on a pre-test and post-test to see if the course is going to change practices.

 

[MattD]

While I understand the healthcare provider shortage/sociel community needs, I think the "supervision" by phone is a wink and nod sham, particularly if we are talking about trauma staffing a small hospital with mid-levels and MD teleconferencing "supervision"...

But, it is still presumed that the PA is being supervised by an MD. To say on one hand they are running/leading the trauma then on the other hand say they are not independent because they are supervised then say the supervision is via telephone....

This was kind of my point. I don't know that there's any amount of money a hospital could pay me to convince me to allow my license to be utilized (and risked) in this way. It's not a dig on the PAs, who could be supremely qualified, it's simply that if I'm calling myself 'responsible' for the patient (which allowing the PA to treat the patient with my license as 'supervision' would render me), then I'm going to be the one making the decisions. To call myself responsible for a patient I never meet and only really know about 3 months later if that chart happens to pop up in my random chart review is absurd.

I know that I wasn't the one who wrote the legislation/guidelines regarding PA supervision, but I can't help but think that the intention of the supervision was meant to be for the protection of the INDIVIDUAL patient, ie. there is a physician around and on-site paying attention to what the PA is doing with each patient, who can step in and intervene if something is being missed. The interpretation that allows for having a physician off-site available for 'consult' and random chart review to be counted as supervision seems more like a safeguard for the PA's practice and license, and much less as a safeguard for the patients. I'm just picturing a courtroom scene with a PA trying to explain that he's not responsible for a bad outcome because he was being 'supervised' by a physician off-site, and the physician should take the blame. Somehow I think telling a patient's family that the PA was supervised because after the trauma a physician did an M&M style debrief with the PA wouldn't go over too well either. Again, I'm not trying to disparage anyone or their specialty, and like JAD mentions above I get the access to care issues, I just think there needs to be a bit more honesty in the whole deal. If a hospital has a trauma dept. run by PAs only, and an MD/DO type education is required as a prerequisite for ATLS certification, then I don't think the trauma dept has any business claiming to be staffed by ATLS certified teams, because even if you could somehow claim that ATLS trained PA + MD/DO = ATLS certified proveder, the physician isn't THERE.

All that said, I'm certainly glad the patients are being cared for by someone

 

[SocialistMD]

I don't know that there's any amount of money a hospital could pay me to convince me to allow my license to be utilized (and risked) in this way. It's not a dig on the PAs, who could be supremely qualified, it's simply that if I'm calling myself 'responsible' for the patient (which allowing the PA to treat the patient with my license as 'supervision' would render me), then I'm going to be the one making the decisions. To call myself responsible for a patient I never meet and only really know about 3 months later if that chart happens to pop up in my random chart review is absurd.

I know that I wasn't the one who wrote the legislation/guidelines regarding PA supervision, but I can't help but think that the intention of the supervision was meant to be for the protection of the INDIVIDUAL patient, ie. there is a physician around and on-site paying attention to what the PA is doing with each patient, who can step in and intervene if something is being missed. The interpretation that allows for having a physician off-site available for 'consult' and random chart review to be counted as supervision seems more like a safeguard for the PA's practice and license, and much less as a safeguard for the patients.

In the really-real world, PAs also cover step-down units with an ICU physician backup- many of these patients are not actually seen by the ICU physician unless the patient becomes unstable. Just because what you've seen in academic medicine makes you wary of PAs and how skilled they are at practicing medicine, the academic environment isn't how the majority of the world works and it isn't the bastion of safe and ideal practices that many people seem to think it is.

I don't know where this paranoia of cowboy PAs comes from, but every PA that I've worked with has been competent to exceptional, and all have known when they've reached their limits and when they need to call in for backup.

 

[JackADeli]

...every PA that I've worked with has been competent to exceptional, and all have known when they've reached their limits and when they need to call in for backup.

This has been my experience as well.

However, speaking to trauma and advanced trauma life support, I suspect 90+% of the time there will be no issue. Yet, IMHO/experience, trauma is an acute scenario that can change in seconds thus precluding ~"real" oversight by a physician through a phone call.