How does an NP solo-staff a well equipped ER?

[MedicineZ0Z]

This is the case I'm referencing, where an NP staffing an ER led to a patient's due to gross incompetence.

ER Patient Death Due To Incompetent NP

Here's what I'm genuinely confused about...

- well equipped ER given that they have a CT, this isn't a rural ER in the boonies - it's like 25 mins from Oklahoma city!
- an ER doc who is at home is the "supervising physician" , how is a board certified ER doc taking responsibility for this??
- NP is covering nights, when there would be literally no back up

Why doesn't the ER bring in a non-ED physician to staff the ED at 90% of the ED doc's pay? You get someone who is dozens of times more competent and save a lot of money.
Also, how are ERs like this even in existence? An ER solo-coverage by a family NP, what if someone came in coding? Polytrauma? Giant pneumo?

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[thegenius]

Really sad.

Obviously this small ER was rolling the dice that nothing scary would come in during the wee hours in the night. Not sure how else you could justify staffing it with a non ER trained health care provider.

I hope a copy of this trial is sent to every single hospital in the nation that has an ER, so this kind of thing doesn't happen again.

 

[southerndoc]

We have some awesome NP's and PA's that do central lines, chest tubes, etc. Keep in mind that most hospitals don't have ICU's staffed by intensivists 24/7. Many have NP's and PA's that staff those units, and frequently they are empowered to start central lines, LP's, intubate, etc. One of the NP's we grabbed from critical care used to intubate at another hospital.

 

[cyanide12345678]

It's ridiculous how legally a hospital could keep an ER open with just a NP staffing. That should be illegal -_-

Edit: Are we sure this was an emergency department and not an urgent Care? Some urgent cares have CT scanners as well.

X-RAYS & CT SCAN AT OUR URGENT CARE

 

[southerndoc]

It's ridiculous how legally a hospital could keep an ER open with just a NP staffing. That should be illegal -_-

Edit: Are we sure this was an emergency department and not an urgent Care? Some urgent cares have CT scanners as well.

X-RAYS & CT SCAN AT OUR URGENT CARE

It was a critical access hospital at the time of the event leading to this litigation (2015).

At the time of the incident:

• Acute Licensed Beds: 48
• Co-workers: 120
• Acute Inpatient Discharges: 449
• Surgeries (Inpatient and Outpatient): 541
• Emergency Visits: 8,337
• Outpatient Visits: 14,488
• Traditional Charity Care: $1.2 million
• Unreimbursed Medicaid: $175,000

 

[thegenius]

We have some awesome NP's and PA's that do central lines, chest tubes, etc. Keep in mind that most hospitals don't have ICU's staffed by intensivists 24/7. Many have NP's and PA's that staff those units, and frequently they are empowered to start central lines, LP's, intubate, etc. One of the NP's we grabbed from critical care used to intubate at another hospital.

Our hospital has no ICU doc on at night. If anything needs to be done they call the ER doc. ICU patients tend to be critically stable, not crashing.

 

[southerndoc]

Our hospital has no ICU doc on at night. If anything needs to be done they call the ER doc. ICU patients tend to be critically stable, not crashing.

ER docs responding to hospitalized patients is ripe for the picking. There has been tons of successful litigation against ER providers who become "hospitalists" because hospitals aren't staffed at night.

Critically stable, not crashing has not been my experience in both residency and having good friends in the ICU who talk about patients crashing. Remember, intensivists aren't dealing just with their ICU patients, but they frequently must admit and resuscitate admitted patients on the floor who crash. Patients in the ICU crash as well. To say they don't is pretty naive.

 

[GonnaBeADoc2222]

The only thing that matters to these people (admin) is money. Seriously, that's all. Loss of human life, monetary losses from litigation, etc. is all built into the calculus. If the left side of the equation (PROFIT) is > than the right side of the equation (loss of human life + expected malpractice losses) then it's all good to them.

This EM doc who is "supervising" from home is an absolute ***** and quite frankly a traitor to all of us for accepting this arrangement and 100% deserves the litigation that's undoubtedly coming their way.

 

[MedicineZ0Z]

We have some awesome NP's and PA's that do central lines, chest tubes, etc. Keep in mind that most hospitals don't have ICU's staffed by intensivists 24/7. Many have NP's and PA's that staff those units, and frequently they are empowered to start central lines, LP's, intubate, etc. One of the NP's we grabbed from critical care used to intubate at another hospital.

Why are midlevels doing these procedures at all? The US is like the only country that allows that.

 

[d2305]

It's just the US and Canada with PAs, I'm not sure about NPs.

 

[Fox800]

They could staff it with physicians, but it's all about that $$$$$.

Somehow the CAH's up here in the Midwest manage to find the coin to staff physicians in the ED 24/7. They might not be EM-boarded, but still 1000x better than an NP.

 

[Rekt]

We have some awesome NP's and PA's that do central lines, chest tubes, etc. Keep in mind that most hospitals don't have ICU's staffed by intensivists 24/7. Many have NP's and PA's that staff those units, and frequently they are empowered to start central lines, LP's, intubate, etc. One of the NP's we grabbed from critical care used to intubate at another hospital.

Disgusting. Obviously trained by you guys as well. Aren't you Wellstar as well? What a shame to your residents.

 

[southerndoc]

Residents always get priority for procedures. All of our PGY-1's have already gotten their numbers for 3 years worth of residency. At 160,000 patients/year with an average ESI of 2.85, there are a ton of procedures available.

For clarification, these NP's and PA's were certified prior to start of our residency. Our APP's primarily staff an ambulatory care unit (fast track), perform screening, and assist attendings in simple procedures (I&D's, lac repairs, etc.) on patients not seen by a resident. We still have so many patients that the majority of patients are seen without a resident. In 2 years when we have a full complement of residents, things may be different. On overnights when there is an APP, they usually average about 0.5 pph. Unlike when I was a resident, our residents don't work 50% of their shifts as overnight shifts.

APP's do not respond to medical alerts, trauma alerts, etc. Those are all given to the residents. Even if the attending doesn't have a resident assigned to him or her, we usually give procedures to the residents.

So no, APP's definitely do not steal procedures from the residents or compete with them. That's far from the case.

 

[Brigade4Radiant]

ER docs responding to hospitalized patients is ripe for the picking. There has been tons of successful litigation against ER providers who become "hospitalists" because hospitals aren't staffed at night.

Critically stable, not crashing has not been my experience in both residency and having good friends in the ICU who talk about patients crashing. Remember, intensivists aren't dealing just with their ICU patients, but they frequently must admit and resuscitate admitted patients on the floor who crash. Patients in the ICU crash as well. To say they don't is pretty naive.

That doesn’t mean you are off the hook. Did you admit a patient where there is no known doctor to incubate? You can still be sued it not like once they are upstairs you are covered.

Also hospital bylaws you can be fired and have that reported to the National provider data base.

Also it depends on the state Southern states it’s much harder to litigate saving a patients life vs northern.

Similar to if your PA messes up a central line it is all of you on the hook but not the CMG.

 

[southerndoc]

Correct, you supervise the APP and are responsible for their actions always.

 

[RustedFox]

Don't get me started.
I'm scheduling my deposition for the lawsuit where I never saw the patient, but the PA did (and subsequently staffed it with another physician) tomorrow. I'm "on the hook".

Here's how it should work.
Want to take care of patients? Go to doctor school.
Want to help to take care of patients? Go to PA school, and do what you're told.
NPs shouldn't exist. Go to PA school, and prepare to do what you're told.


Took sign out from NP tonight.
Wheezy toddler.
"I ordered a CXR, flu swabs, RSV swab, nebs. He has croup."

I see the patient.
Not a cough anywhere.
No croup. No "bark". No nothing.
Bronchiolitis.

I ordered the Orapred, cancelled all labs and nebs.
Discharged.

They don't even know the difference.

Can't stand it.
They shouldn't practice anywhere.

Want a good story? Ask me about the NP that saw me (I have ulcerative colitis) in clinic, without then-knowing that I was a physician.
That's a GOOD one.

 

[southerndoc]

Luckily our APP's are good. Those that aren't don't survive here. For the record, when I said that we have APP's that do central lines and chest tubes, I should point out that it's n=2. We have 2 of them. I don't want to give the impression that we have 15 APP's running around doing every line in the department. I think 3 are credentialed for LP's.

 

[GonnaBeADoc2222]

Correct, you supervise the APP and are responsible for their actions always.

There's nothing "advanced" about them. Nor do they "assist" me. I'd rather send them home and just see all the patients myself.

 

[qwerty89]

This is the case I'm referencing, where an NP staffing an ER led to a patient's due to gross incompetence.

ER Patient Death Due To Incompetent NP
who transitioned from firefighting to nursing.
Here's what I'm genuinely confused about...

- well equipped ER given that they have a CT, this isn't a rural ER in the boonies - it's like 25 mins from Oklahoma city!
- an ER doc who is at home is the "supervising physician" , how is a board certified ER doc taking responsibility for this??
- NP is covering nights, when there would be literally no back up

Why doesn't the ER bring in a non-ED physician to staff the ED at 90% of the ED doc's pay? You get someone who is dozens of times more competent and save a lot of money.
Also, how are ERs like this even in existence? An ER solo-coverage by a family NP, what if someone came in coding? Polytrauma? Giant pneumo?

Unbound caring: Former firefighter transfers skills to nursing. Antoinette Thompson-Ducasse, a nurse practitioner at Mercy Hospital in El Reno, was previously a firefighter. (Photo by Brent Fuchs) Care isn’t bound by careers, said Antoinette Thompson-Ducasse, who transitioned from firefighting to nursing.

Scroll down for the headline. Its behind a paywall unfortunately.

 

[miacomet]

Don't get me started.
I'm scheduling my deposition for the lawsuit where I never saw the patient, but the PA did (and subsequently staffed it with another physician) tomorrow. I'm "on the hook".

Here's how it should work.
Want to take care of patients? Go to doctor school.
Want to help to take care of patients? Go to PA school, and do what you're told.
NPs shouldn't exist. Go to PA school, and prepare to do what you're told.


Took sign out from NP tonight.
Wheezy toddler.
"I ordered a CXR, flu swabs, RSV swab, nebs. He has croup."

I see the patient.
Not a cough anywhere.
No croup. No "bark". No nothing.
Bronchiolitis.

I ordered the Orapred, cancelled all labs and nebs.
Discharged.

They don't even know the difference.

Can't stand it.
They shouldn't practice anywhere.

Want a good story? Ask me about the NP that saw me (I have ulcerative colitis) in clinic, without then-knowing that I was a physician.
That's a GOOD one.

Orapred for bronchiolitis? Is there some new evidence? Our quaternary care peds hospital does not do this.

 

[RustedFox]

Orapred for bronchiolitis? Is there some new evidence? Our quaternary care peds hospital does not do this.

Not to my knowledge. Give a wheezy tot steroids, watch them get better in an hour or so.
I didn't need to watch them get better.

 

[Fox800]

Orapred for bronchiolitis? Is there some new evidence? Our quaternary care peds hospital does not do this.

No, there is not. Nothing really helps except suctioning and respiratory support if they're sick as s*&t.

 

[RoyBasch]

We have some awesome NP's and PA's that do central lines, chest tubes, etc. Keep in mind that most hospitals don't have ICU's staffed by intensivists 24/7. Many have NP's and PA's that staff those units, and frequently they are empowered to start central lines, LP's, intubate, etc. One of the NP's we grabbed from critical care used to intubate at another hospital.

Although there are some mid levels who I know are competent to physically perform these procedures (I happen to work with some), I would argue the most challenging part of the procedure is deciding which patients they are indicated and which patients they are contraindicated.

They are not extremely complicated procedures technically, a central line ain't a whipple. The issue is they are very invasive and their complications are potentially severe and life ending--particularly if unrecognized. Thus I believe it requires physician level knowledge to know which patients should be subjected to these procedures and their attendant risks.

I have made the decision that a central line is indicated in a patient and then had a PA actually do the procedure. I think that is acceptable. I think a PA deciding the procedure is indicated and performing it without physician involvement is sub-optimal.

 

[Birdstrike]

This is the case I'm referencing, where an NP staffing an ER led to a patient's due to gross incompetence.

ER Patient Death Due To Incompetent NP

Here's what I'm genuinely confused about...

- well equipped ER given that they have a CT, this isn't a rural ER in the boonies - it's like 25 mins from Oklahoma city!
- an ER doc who is at home is the "supervising physician" , how is a board certified ER doc taking responsibility for this??
- NP is covering nights, when there would be literally no back up

Why doesn't the ER bring in a non-ED physician to staff the ED at 90% of the ED doc's pay? You get someone who is dozens of times more competent and save a lot of money.
Also, how are ERs like this even in existence? An ER solo-coverage by a family NP, what if someone came in coding? Polytrauma? Giant pneumo?

Money.

Look no further than the desire by those staffing an ED to save (and therefore pocket more) money. If those in charge spend the necessary money to bring a competent person in to staff your ED, lives get saved. If they don't, people die. Even the method in which an employee is terminated for incompetence comes down to money. You can immediately fire a person on the spot, for cause. But sometimes it's cheaper to let the 30 day out-clause expire, because it saves dollars that otherwise might have been spent to bring someone competent in more quickly. It might also avoid potential lost dollars spent defending against a feared wrongful termination lawsuit.

When greed battles ethics and wins, bad things happen.

 

[evilbooyaa]

I think the worst thing is, as said immediately above, that an NP who was deemed incompetent enough to FIRE for that incompetency was allowed to 'finish his/her shifts', especially as a solo provider. The supervising physician is a ******* for agreeing to supervise 'from home'. The hospital staff are idiots for allowing money to be more important than patient care. I'd go after the hospital if I was the family.

 

[RustedFox]

No, there is not. Nothing really helps except suctioning and respiratory support if they're sick as s*&t.

The idea is more "if you think the child has croup (which he doesnt)... then why are you sending flu swabs?"

 

[thegenius]

ER docs responding to hospitalized patients is ripe for the picking. There has been tons of successful litigation against ER providers who become "hospitalists" because hospitals aren't staffed at night.

Critically stable, not crashing has not been my experience in both residency and having good friends in the ICU who talk about patients crashing. Remember, intensivists aren't dealing just with their ICU patients, but they frequently must admit and resuscitate admitted patients on the floor who crash. Patients in the ICU crash as well. To say they don't is pretty naive.

Can you give examples of successful litigation?

And I'm not naive...I wrote "ICU patients tend to be critically stable." Critical patients can die at any moment, I'm aware of that.

 

[southerndoc]

Although there are some mid levels who I know are competent to physically perform these procedures (I happen to work with some), I would argue the most challenging part of the procedure is deciding which patients they are indicated and which patients they are contraindicated.

They are not extremely complicated procedures technically, a central line ain't a whipple. The issue is they are very invasive and their complications are potentially severe and life ending--particularly if unrecognized. Thus I believe it requires physician level knowledge to know which patients should be subjected to these procedures and their attendant risks.

I have made the decision that a central line is indicated in a patient and then had a PA actually do the procedure. I think that is acceptable. I think a PA deciding the procedure is indicated and performing it without physician involvement is sub-optimal.

All patients seen by an APP in the main area of the ER must be seen by an attending as well. Only fast track type patients can be managed by the APP independently. Never seen one of those get an LP or a central line, and if they needed one, they would be moved to the main area of the ED.

 

[southerndoc]

Can you give examples of successful litigation?

And I'm not naive...I wrote "ICU patients tend to be critically stable." Critical patients can die at any moment, I'm aware of that.

Yes, give me a few days when I'm off and I'll pull them up. One recent case an ED doc was successfully sued for managing a boarding patient's DKA.

 

[cyanide12345678]

They could staff it with physicians, but it's all about that $$$$$.

Somehow the CAH's up here in the Midwest manage to find the coin to staff physicians in the ED 24/7. They might not be EM-boarded, but still 1000x better than an NP.

I moonlight at a place with 3-4k volume. Even that place is staffed with 24 hours of physician coverage. Half of them are EM boarded even. While the hourly isn't impressive, it comes to about 3-400 per patient seen.

There should be legislation against NP/PAs running ERs solo. You never know what can come through those doors.

 

[CajunMedic]

It's ridiculous how legally a hospital could keep an ER open with just a NP staffing. That should be illegal -_-

Welcome to Mississippi. I can name 2, maybe 3 ED’s off the top of my head, that if they had to hire physicians, they couldn’t keep the doors open. Single coverage NP’s 24/7. One has a retired plastic surgeon occasionally.

At one time, there was a state requirement that NP’s had to have X number of hours of additional training at one of the larger hospitals before covering a Critical Access ED.

One told me: “we won’t hire you to work just the ER, you’ll have to have clinic and cover inpatient too”

 

[cyanide12345678]

Acep and AAEM trying to fight this? Or does acep just agree to lower cost by having NPs run solo?

 

[MedicineZ0Z]

Welcome to Mississippi. I can name 2, maybe 3 ED’s off the top of my head, that if they had to hire physicians, they couldn’t keep the doors open. Single coverage NP’s 24/7. One has a retired plastic surgeon occasionally.

At one time, there was a state requirement that NP’s had to have X number of hours of additional training at one of the larger hospitals before covering a Critical Access ED.

One told me: “we won’t hire you to work just the ER, you’ll have to have clinic and cover inpatient too”

I'm curious, what do these people do whenthey get a very difficult airway on a crashing patient? If you havent done at least 100 or more tubes you have 0 chance of getting those.
And realistically these people have such little procedural exp I wouldnt be surprised if they cant even manage an easy airway.

 

[MedicineZ0Z]

Don't get me started.
I'm scheduling my deposition for the lawsuit where I never saw the patient, but the PA did (and subsequently staffed it with another physician) tomorrow. I'm "on the hook".

Here's how it should work.
Want to take care of patients? Go to doctor school.
Want to help to take care of patients? Go to PA school, and do what you're told.
NPs shouldn't exist. Go to PA school, and prepare to do what you're told.


Took sign out from NP tonight.
Wheezy toddler.
"I ordered a CXR, flu swabs, RSV swab, nebs. He has croup."

I see the patient.
Not a cough anywhere.
No croup. No "bark". No nothing.
Bronchiolitis.

I ordered the Orapred, cancelled all labs and nebs.
Discharged.

They don't even know the difference.

Can't stand it.
They shouldn't practice anywhere.

Want a good story? Ask me about the NP that saw me (I have ulcerative colitis) in clinic, without then-knowing that I was a physician.
That's a GOOD one.

Pleaseee tell us

 

[Hamhock]

All patients seen by an APP in the main area of the ER must be seen by an attending as well. Only fast track type patients can be managed by the APP independently. Never seen one of those get an LP or a central line, and if they needed one, they would be moved to the main area of the ED.

I appreciate your "corporate" perspective in many threads; especially those related to department management and hospital hierarchy.

However, it really seems like you are frequently supporting the idea that midlevels without supervision are adequate in the ED -- even if restricted to fast track. Is this to make more money even though a doc would be better in that situation?

This sense I have nears an irritation with the use of the term APP. NP/PA, nurse practitioner, physician assistant, midlevel .
The advanced practice provider is the physician.

HH

 

[southerndoc]

Pleaseee tell us

Please don't! Only communicate with your attorney until the case reaches a settlement, judgement, or is dropped. Posting, emailing, or discussing cases with anyone is required to be disclosed.

 

[TooMuchResearch]

I'm curious, what do these people do whenthey get a very difficult airway on a crashing patient? If you havent done at least 100 or more tubes you have 0 chance of getting those.
And realistically these people have such little procedural exp I wouldnt be surprised if they cant even manage an easy airway.

They call a rural medic crew who may have more experience or they call a CRNA.

 

[southerndoc]

I appreciate your "corporate" perspective in many threads; especially those related to department management and hospital hierarchy.

However, it really seems like you are frequently supporting the idea that midlevels without supervision are adequate in the ED -- even if restricted to fast track. Is this to make more money even though a doc would be better in that situation?

This sense I have nears an irritation with the use of the term APP. NP/PA, nurse practitioner, physician assistant, midlevel .
The advanced practice provider is the physician.

HH

I'm not corporate. I'm an associate medical director. I do support APP's practicing independently in fast track type situations or in remote ER's where it is impossible to get a physician to staff it. Definitely don't want to sacrifice my own job security to be replaced by an APP.

 

[WilcoWorld]

I think the worst thing is, as said immediately above, that an NP who was deemed incompetent enough to FIRE for that incompetency was allowed to 'finish his/her shifts', especially as a solo provider. The supervising physician is a ******* for agreeing to supervise 'from home'. The hospital staff are idiots for allowing money to be more important than patient care. I'd go after the hospital if I was the family.

I also see this as the biggest issue in this case - They'd already decided the NP was incompetent. The hospital deserves to pay out the wazoo for allowing someone they knew was incompetent to continue to practice AND to do so unsupervised!

 

[Apollyon]

Posting, emailing, or discussing cases with anyone is required to be disclosed.

Except with your doctor (you as the patient), your clergy person, or your spouse.

 

[CajunMedic]

I'm curious, what do these people do whenthey get a very difficult airway on a crashing patient? If you havent done at least 100 or more tubes you have 0 chance of getting those.
And realistically these people have such little procedural exp I wouldnt be surprised if they cant even manage an easy airway.

They call a rural medic crew who may have more experience or they call a CRNA.

@TooMuchResearch hit the nail on the head. I've been on the crew called in to get the airway or vascular access and then the inevitable transfer up the road or to the helicopter. These places have no CRNA backup

 

[MedicineZ0Z]

They call a rural medic crew who may have more experience or they call a CRNA.

If it's a truly difficult airway, the medic won't have a big chance either. CRNA yes but some of these places don't even have ORs so there wouldn't be one. I've read and heard of stories of midlevels in these places not having a clue how to intubate and basically having someone beg for others to drive in.

I'm not corporate. I'm an associate medical director. I do support APP's practicing independently in fast track type situations or in remote ER's where it is impossible to get a physician to staff it. Definitely don't want to sacrifice my own job security to be replaced by an APP.

Offer more money to the closest family doctors, they will staff it. But right, you despise the idea of a family doctor working in an ER but are okay with midlevels?

@TooMuchResearch hit the nail on the head. I've been on the crew called in to get the airway or vascular access and then the inevitable transfer up the road or to the helicopter. These places have no CRNA backup

Guessing on what would appear to be bread and butter type cases?

 

[Rekt]

I'm not corporate. I'm an associate medical director. I do support APP's practicing independently in fast track type situations or in remote ER's where it is impossible to get a physician to staff it. Definitely don't want to sacrifice my own job security to be replaced by an APP.

Give them an inch...

Also, what's the point of an NPP seeing 0.5pph? That seems very useless of them.

 

[southerndoc]

Except with your doctor (you as the patient), your clergy person, or your spouse.

Why would you discuss it with the patient who is suing you? Spouse, yes. Clergy, not sure of. Never thought of that one. Does that mean you can speak to a private counselor or psychiatrist about your case and it be protected with HIPAA? Not sure that has ever been tried before, but I would think that HIPAA would hold up and prevent disclosure. The same may apply to clergy.

 

[VA Hopeful Dr]

Why would you discuss it with the patient who is suing you? Spouse, yes. Clergy, not sure of. Never thought of that one. Does that mean you can speak to a private counselor or psychiatrist about your case and it be protected with HIPAA? Not sure that has ever been tried before, but I would think that HIPAA would hold up and prevent disclosure. The same may apply to clergy.

He's saying you can talk to your doctor if you are in the role of patient

 

[Apollyon]

Why would you discuss it with the patient who is suing you? Spouse, yes. Clergy, not sure of. Never thought of that one. Does that mean you can speak to a private counselor or psychiatrist about your case and it be protected with HIPAA? Not sure that has ever been tried before, but I would think that HIPAA would hold up and prevent disclosure. The same may apply to clergy.

No, if YOU are the patient.

And confidentiality applies to the psychiatrist, but I don't know about the counselor/psychologist. The only exception is the Tarasoff exception.

As for the clergy, I actually only know of the Catholic, and it has to be under the rubric of confession. That seal exists even after your death (if the priest is still alive).

 

[TooMuchResearch]

If it's a truly difficult airway, the medic won't have a big chance either. CRNA yes but some of these places don't even have ORs so there wouldn't be one. I've read and heard of stories of midlevels in these places not having a clue how to intubate and basically having someone beg for others to drive in.

Offer more money to the closest family doctors, they will staff it. But right, you despise the idea of a family doctor working in an ER but are okay with midlevels?




Guessing on what would appear to be bread and butter type cases?

Yes, that's how it works. And at some of the places I work now, there used to be FP docs who called in a CRNA for every intubation and apparently many patients in respiratory distress.

 

[MedicineZ0Z]

Yes, that's how it works. And at some of the places I work now, there used to be FP docs who called in a CRNA for every intubation and apparently many patients in respiratory distress.

Never heard of that before (for every?? intubation). I've heard of CRNA back up when the ER doc (FP staffed) fails a couple attempts. And lets be real if they aren't getting it with the glidescope/c mac, the CRNA who intubates super healthy elective cases a couple times a week probably isn't either.
Also heard of plenty of places with 0 back up. I rotated at one with a decent volume (30-40 pts a day) that was solely FP staffed with no back up at all.
Also, all of the rural ERs in Canada are FP staffed and anesthesia back up isn't even a thing at community hospitals (let alone rural) except for the rare event.

 

[jw3600]

My god. Stop using the term APPs. It’s propaganda.

 

[Fox800]

My god. Stop using the term APPs. It’s propaganda.

There's nothing advanced about them. Advanced compared to what?