Dead Horse (midlevels)

[sum dude]

For all you that love the midlevels you work with (read: the extra money they make you), take a look at this.

https://www.aana.com/docs/default-source/marketing-aana-com-web-documents-(all)/crnas-we-are-the-answer.pdf?sfvrsn=b310d913_4

It is literally a guarantee this kind of nonsense statement will eventually be put out by whatever random society is representing NPs and PAs in the ED.

If I were an anesthesiologist the first thing I would be doing is putting every penny I earned for now into vanguard funds.

The second thing would be picking my jaw up off the floor that there are other specialties (mostly EM) that can look at the recent history and probably prevent the exact same extinction path currently happening to gas.

It’s like the black rhino jumping into the car with the dodo.

And before it gets brought up about the anesthesia scares in the 90s, there was NOTHING like this being put forward by nurses.

Work for or with? If it's with, then yeah, you have a problem, although CRNA vs NP vs PA are different animals

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[Birdstrike]

"I'm just as qualified as you and I'll gladly back that up by being 100% liable for my outcomes," is okay.

"I'm just as qualified as you, but I need you to take ultimate responsible for my outcomes," is not okay. That's so not cool, it's not even funny. It's a toxic landmine attitude.

I'm 100% fine with mid-levels having their lane as long as I'm not responsible for their outcomes. I could hire a PA or NP to work for me right now and probably be able to make more money and have more time off, but I want things done right, my way and by me, so I choose not to work with one currently. Unfortunately, in the ED, I did not have that freedom of choice.

 

[emergentmd]

Midlevels will never run an ED. It just will never happen. Even the Best ones that I have worked at can not take care of critical care patients. The avg ones would be lost taking care of fringe ER patients. The bad ones are hard pressed to care of anything but sore throat and ankle sprains.

I am very lucky that I have had a good 18 yrs in EM and paid well. Wish I saved more. Wished I didnt buy a huge house. But have enough where if everything goes to hell, I would just cut back and still live a very comfortable life.

When I started EM, there were very little Midlevel in the ER. My hospital was around 80 ppd, we had 4 EM doc shifts for about 40 hour coverage, saw 2pph with a mix of UC and EM patients. Some stressful moments but overall great environment. Lets say each doc gets $2500/shift, that is 10K/dy EM doc coverage.

Fast forward 15 years. our volume now is about 160 ppd. We should be at 8 EM doc shifts with 80 hr coverage or 20K/dy EM doc coverage. But we are not. We are at 6 doc and 54 hr EM doc coverage, and still make about 250/hr so about $13.5K/dy. 4 Midlevel coverage are about 40 hours at $60/hr = $2400/dy. So the CMG now makes 4K/dy in profit from this site.

To compare apples to apples from the EM doc work standpoint:
1. We need less EM docs. Instead of a 8 doc day, it is now a 6 doc day
2. We get to sign about 40% of charts that we never got to see for the same pay
3. We still see 2pph but now they are all work ups. The MLs sees all the UC patients so everything that comes back are work ups. I remember walking into the ER in my early days and saw 15 pts the 1st hour but wasn't bad as half were just 2 minute history and discharges. There is no way I would be able to see more than 8 pts my first hour b/c they are all workups.

Midlevels have not decreased pay but has mitigated any increase in pay we should have had. At my site, we would need 33% more EM docs and supply/demand would forced higher pay. They have made the job more difficult.

I think overall EM medicine is still a great field the way it stands right now. The problem for the future with MLs is the 6 doc to 4 ML ratio at my site could easily be changed to 4 doc and 6ML. This would make EM a pretty crappy job if pay is stagnant.

 

[Listen2Savage]

Midlevels will never run an ED. It just will never happen. Even the Best ones that I have worked at can not take care of critical care patients. The avg ones would be lost taking care of fringe ER patients. The bad ones are hard pressed to care of anything but sore throat and ankle sprains.

I am very lucky that I have had a good 18 yrs in EM and paid well. Wish I saved more. Wished I didnt buy a huge house. But have enough where if everything goes to hell, I would just cut back and still live a very comfortable life.

When I started EM, there were very little Midlevel in the ER. My hospital was around 80 ppd, we had 4 EM doc shifts for about 40 hour coverage, saw 2pph with a mix of UC and EM patients. Some stressful moments but overall great environment. Lets say each doc gets $2500/shift, that is 10K/dy EM doc coverage.

Fast forward 15 years. our volume now is about 160 ppd. We should be at 8 EM doc shifts with 80 hr coverage or 20K/dy EM doc coverage. But we are not. We are at 6 doc and 54 hr EM doc coverage, and still make about 250/hr so about $13.5K/dy. 4 Midlevel coverage are about 40 hours at $60/hr = $2400/dy. So the CMG now makes 4K/dy in profit from this site.

To compare apples to apples from the EM doc work standpoint:
1. We need less EM docs. Instead of a 8 doc day, it is now a 6 doc day
2. We get to sign about 40% of charts that we never got to see for the same pay
3. We still see 2pph but now they are all work ups. The MLs sees all the UC patients so everything that comes back are work ups. I remember walking into the ER in my early days and saw 15 pts the 1st hour but wasn't bad as half were just 2 minute history and discharges. There is no way I would be able to see more than 8 pts my first hour b/c they are all workups.

Midlevels have not decreased pay but has mitigated any increase in pay we should have had. At my site, we would need 33% more EM docs and supply/demand would forced higher pay. They have made the job more difficult.

I think overall EM medicine is still a great field the way it stands right now. The problem for the future with MLs is the 6 doc to 4 ML ratio at my site could easily be changed to 4 doc and 6ML. This would make EM a pretty crappy job if pay is stagnant.

Me applying this year

 

[Brigade4Radiant]

People decry residency expansion but the alternative is mid level expansion and supervision.

Even if you have super crappy HCA residencies they can’t join the market for three years and new grads become enlightened in the next 3-4 years on what they are worth

 

[MechEDoc]

Question for the masses! Have any of you worked in places with good crew resource management/patient care communication strategies with mid-level noctors?

My usual experience is that there is a hodgepodge collection of PAs and NPs who who have varying skill levels running around the department like little assassins. The challenge I have is that most the patient's are "co-managed" with an attending physician being loosely involved in their care. A not uncommon work flow is that I may sign up for a patient, see the patient, enter orders, find out that one of the mid-levels signed up for the patient 5-10 minutes later, did not engage in a conversation (e.g. I have also signed up for the patient, what are your thoughts regarding the patient's management and disposition?). The mid-level will then go on to usually enter a variety of nonsensical interventions and then discharge the patient without checking in.

While there is an element of no harm no foul, this appears to be highly sub-optimal and their documentation is usually pretty lousy and does not support the interventions made.

Anyone work at a place that has come up with a better solution? Or is everyone experiencing ongoing chaos throughout every shift?

 

[RustedFox]

We recently went to an "NP" for all admissions overnight.

The unspoken rule is: "Unless its an ICU-level admit, don't wake up the doc."

I have caught so many "mistakes" by them.

If my wife were sick, I wouldn't take her to my own hospital.

 

[MechEDoc]

We recently went to an "NP" for all admissions overnight.

The unspoken rule is: "Unless its an ICU-level admit, don't wake up the doc."

I have caught so many "mistakes" by them.

If my wife were sick, I wouldn't take her to my own hospital.

What's your liability like when you admit something pretty sick to a nurse (from a doctor), they mismanage it and there is a bad outcome before the next physician gets involved? I worry about this with every admission.

What do you do when you catch their mistakes? Make noise (and friends?) or keep your mouth shut and keep your friends?

 

[thegenius]

I specifically demanded an anesthesiologist for my kid’s surgery

Did you look like your avatar when you demanded for an anesthesiologist? LOL (check it out!)

 

[GonnaBeADoc2222]

What's your liability like when you admit something pretty sick to a nurse (from a doctor), they mismanage it and there is a bad outcome before the next physician gets involved? I worry about this with every admission.

What do you do when you catch their mistakes? Make noise (and friends?) or keep your mouth shut and keep your friends?

To my understanding it's zero. They have a supervising doc who is liable.

 

[deleted109597]

To my understanding it's zero. They have a supervising doc who is liable.

Hahahahahahahaha right. Just like everything else. Oh, you'll be named. And you'll be responsible for not having them "wake up the physician".

 

[MechEDoc]

Hahahahahahahaha right. Just like everything else. Oh, you'll be named. And you'll be responsible for not having them "wake up the physician".

This! I know of someone in litigation for a bad outcome under an NP's care that occurred weeks after the patient left the ER... Guess who carries a $1M/3M policy? Not the NP.

 

[Boatswain2PA]

Anyone work at a place that has come up with a better solution? Or is everyone experiencing ongoing chaos throughout every shift?

It works very well in my shop. 1 doc, 1-2 PAs, we all sit close together in fishbowl. I sign up for my patients, Docs sign up for theirs. We sit close enough that we can ask each other questions. Doc generally remains cognizant of what the PAs are doing through discussions, listening to nurse interactions, or reviewing charts/orders/results, etc.

Guess who carries a $1M/3M policy? Not the NP.

Then that's a failure of admin. I have always been required to maintain $1M/$3M for credentialing.

 

[MechEDoc]

It works very well in my shop. 1 doc, 1-2 PAs, we all sit close together in fishbowl. I sign up for my patients, Docs sign up for theirs. We sit close enough that we can ask each other questions. Doc generally remains cognizant of what the PAs are doing through discussions, listening to nurse interactions, or reviewing charts/orders/results, etc.


Then that's a failure of admin. I have always been required to maintain $1M/$3M for credentialing.

NP was outpatient. Didn't pursue a cardiac workup, doubled down on GERD. She wasn't under the hospital. Sounds like a pretty awesome idea if you ask me. People rob banks, not poor houses.

 

[RustedFox]

What's your liability like when you admit something pretty sick to a nurse (from a doctor), they mismanage it and there is a bad outcome before the next physician gets involved? I worry about this with every admission.

What do you do when you catch their mistakes? Make noise (and friends?) or keep your mouth shut and keep your friends?

I raise hell. Everyone from the NP to the on-shift admin to the house supervisor.

I seriously don't know how I'm going to sign this one chart.

Heat injury. Cr is like 3. Kid is 22. Landscaper.

K was 6.9

admitted from one MLP to the next MLP.

Kid got bicarb and insulin, but no glucose. Also got lactulose. Somehow. Not kayexelate. Lactulose.
Hypoglycemic event overnight.

I can't.

I seriously can't.

What was I doing when this happened? Stroke patient. Transferred out to our mothership for thrombectomy.


NOPE. NOPE. NOPE. NOPE.


I can't.

And I'm not a "team player" for raising hell.

 

[MechEDoc]

That's a pretty good misadventure, when are we going to start doing expert witness work?

Things I have seen:
1. mid-level starts patient on an SGLT2 inhibitor -> euglycemic DKA in DM II -> correct ED treatment -> admission to mid-level who restarts SGLT2 inhibitor and discharges.
2. Patient with behavioral abnormalities who is having delusionary parasitosis, mid-level keeps increasing amphetamines.
3. Using a slit lamp when not knowing how to and missing the obvious corneal foreign body.
4. Hand exam "normal" -> physician exam -> patient requires 8 sutures for full-thickness laceration.
5. Fight bite with open joint -> closed and discharged -> patient lost his finger when I saw him on bounce back.
6. Discharged every risk factor in the book patient with "heartburn", patient coded in his garage while walking into the house.

I could keep this up all night…

As for signing the chart you could write something like:

"I was not involved in the care of the patient, however I was in the department available for consultation and remain available throughout the statue of limitations for subpoenas, litigation, depositions, as well as a review by my medical board. Tearfully yours, RustedFox."

With respect to your patient that is seriously messed up. He would have done better sitting at home and pounding water. That would have lowered his potassium and treated his (likely) rhabdomyolysis and AKI. If he was really smart he would have had some very sugary drinks, the glucose bolus would have bumped up his insulin, leading to intracellular shift, and if he took a hyperosmolar solution like Gatoraide he may have gotten diarrhea leading to additional potassium secretion. Were they trying to kill him? Thankfully young people are pretty resilient.

 

[MechEDoc]

And I'm not a "team player" for raising hell.

This is why you need some form of effective CRM.

For instance, the nocturne could be required to check-in early in the evaluation due to multiple laboratory and vital sign abnormalities with a simple one-liner "RustedFox, I have a dehydrated 22-year-old male with hyperkalemia, an ECG with QRS of 130 ms as well as peaked T waves, a creatinine of 3, I am planning on doing X interventions with Y disposition. Is this okay?"

This mess is of our own making. Physicians have hired mid levels, misuse mid levels, and exploit mid levels, and exploit physicians.

If I were to push for this on the shifts I work I would be labeled "difficult".

 

[EMhawkeye]

My gift today admited to me by ER np.
70 yo f with previous hx of cva. Coming in for lethargy and ams. Afebrile. No white count. Cxr negative.

Asked if I wanted a chest ct to rule out pna. No head ct. previous hx of cirrhosis and no ammonia level. No drug screen ordered either.

 

[thegenius]

I raise hell. Everyone from the NP to the on-shift admin to the house supervisor.

I seriously don't know how I'm going to sign this one chart.

Heat injury. Cr is like 3. Kid is 22. Landscaper.

K was 6.9

admitted from one MLP to the next MLP.

Kid got bicarb and insulin, but no glucose. Also got lactulose. Somehow. Not kayexelate. Lactulose.
Hypoglycemic event overnight.

I can't.

I seriously can't.

What was I doing when this happened? Stroke patient. Transferred out to our mothership for thrombectomy.


NOPE. NOPE. NOPE. NOPE.


I can't.

And I'm not a "team player" for raising hell.

I hear all these things...i don’t understand how these are not brought up in review or remediation. Can’t you tell your boss “hey this NP almost killed someone, please for the life of me can i supervise him/her?”

I mean that was bad...

That pt was prob in the ED for 2-3 hours though...were you with the stroke patient the entire time?

We have NPs. There is one I don’t like but if anything he runs too many tests. The other ones are pretty good for the most part from what I can tell.

 

[thegenius]

That's a pretty good misadventure, when are we going to start doing expert witness work?

Things I have seen:
1. mid-level starts patient on an SGLT2 inhibitor -> euglycemic DKA in DM II -> correct ED treatment -> admission to mid-level who restarts SGLT2 inhibitor and discharges.
2. Patient with behavioral abnormalities who is having delusionary parasitosis, mid-level keeps increasing amphetamines.
3. Using a slit lamp when not knowing how to and missing the obvious corneal foreign body.
4. Hand exam "normal" -> physician exam -> patient requires 8 sutures for full-thickness laceration.
5. Fight bite with open joint -> closed and discharged -> patient lost his finger when I saw him on bounce back.
6. Discharged every risk factor in the book patient with "heartburn", patient coded in his garage while walking into the house.

I could keep this up all night…

As for signing the chart you could write something like:

"I was not involved in the care of the patient, however I was in the department available for consultation and remain available throughout the statue of limitations for subpoenas, litigation, depositions, as well as a review by my medical board. Tearfully yours, RustedFox."

With respect to your patient that is seriously messed up. He would have done better sitting at home and pounding water. That would have lowered his potassium and treated his (likely) rhabdomyolysis and AKI. If he was really smart he would have had some very sugary drinks, the glucose bolus would have bumped up his insulin, leading to intracellular shift, and if he took a hyperosmolar solution like Gatoraide he may have gotten diarrhea leading to additional potassium secretion. Were they trying to kill him? Thankfully young people are pretty resilient.

#2 made me laugh...
#3 is interesting...at my shop some of our PAs don’t even use the slit lamp because they admit they don’t know how to use it
#4 how in the world does that happen?

 

[MechEDoc]

#4 how in the world does that happen?

Re #4. You can get at most two of fast, good, or cheap at a time, we've got fast and cheap.

We've got two midlevels that I refer to in my mind as NP 007 and PA 007. The remainder I'm less worried about killing people. There was a little bit of blood on the hand, I cleaned it off and found a pretty nice laceration underneath it.

 

[206705]

Re #4. You can get at most two of fast, good, or cheap at a time, we've got fast and cheap.

We've got two midlevels that I refer to in my mind as NP 007 and PA 007. The remainder I'm less worried about killing people. There was a little bit of blood on the hand, I cleaned it off and found a pretty nice laceration underneath it.

Or as once put to me from an older, wiser man: "you can be lazy, stupid or arrogant, but never more than one of the three"