ED Procedures: MD vs PA/NP

[navrdd]

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I know there have been a lot of threads about ED procedures but none answered my question. For those practicing in the community, do PA/NP's do a lot of the simpler procedures (lacerations, I&Ds, reductions, etc.)? I personally love those quick gratifying procedures and wouldn't want anyone taking them. Are you forced by large patient loads to hand off these procedures?

 

[emergentmd]

Our PA/NPs can do all minor procedures. Lacs, digital blocks, I&D, nail removal, etc. They do not do ortho reduction. You may love minor procedures but after a few years, you are happy not to spend time pushing out puss, taking out smelly toenails, suturing up drunks.

 

[swamprat]

In before that "PA guy" talks about how he does anything and everything a doc does and they pull charts from the same rack.

So with that said it probably depends on where you work too.. if you work academics you probably won't be getting first crack at many procedures due to residents.

 

[Arcan57]

There a certain satisfaction to a well done I&D or a lip lac that closes just so. That satisfaction is quickly washed away by the tide of charts that build up while performing the procedure.

 

[napster]

At my shop, the PAs are trying to get credentialed to perform LPs, central lines. Apparently, this is supposed to relieve the MD of time intensive procedures so ED flow is preserved. I wholeheartedly disagree - just keep the PAs plowing through Level 4 and 5s while I am doing the procedure (which would take much less time of course). Let the PAs do PA stuff and MDs do MD stuff!
Fortunately, it will take years before any of them will have sufficient "proctored" cases to be credentialed.

 

[navrdd]

Thanks for the replies, it is a little disheartening to hear. I'm sure I'll get bored of these procedures at some point, but they are also part of what attracted me to EM in the first place.

 

[la gringa]

if you work single coverage, all procedures are yours.... whether you like it, or have the time, or not!

 

[Rendar5]

They do all minor procedures, I have one PA/NP that did central lines and intubations at her old shop There is nothing particularly special about most procedures that an MD/DO can somehow do them better than everyone else. I'm there for the complex critical thinking in the grand scheme of things. Hell, even the RT's at my shop intubate routinely on the floor (not the ED, they're not needed for that there).

Dont' feel disheartened, though. at night when fast track is closed, I can suture and I&D as much as I want. And midlevels won't touch a reduction any time of day with a 20 foot pole.

 

[deleted206819]

I'm not sure that everyone realizes this but once the mid-levels become more adept at the procedures that are the domains of MDs/DOs there is nothing to stop them from moving up the chain to assume the care of sick and more acutely ill patients. It's scope of practice creep that might ultimately affect our positions within healthcare. Look at the independently licensed and practicing NPs/PAs in some states -- they are able to open primary care offices and diagnose patients without oversight. Do you think that this won't happen in the ED?

 

[Rendar5]

Except our procedures are not purely in our domain

 

[deleted206819]

Except our procedures are not purely in our domain

But they are if these procedures occur in the ED. I would not allow a PA or NP to autonomously perform LPs, intubations, or anything else in my ED regardless of their experience as it increases my risk and liability.

 

[Rendar5]

no they're not purely our domain, no more than intubation and procedural sedation and propofol is purely the domain of an anaesthesiologist

 

[Boatswain2PA]

I'm not sure that everyone realizes this but once the mid-levels become more adept at the procedures that are the domains of MDs/DOs there is nothing to stop them from moving up the chain to assume the care of sick and more acutely ill patients. It's scope of practice creep that might ultimately affect our positions within healthcare. Look at the independently licensed and practicing NPs/PAs in some states -- they are able to open primary care offices and diagnose patients without oversight. Do you think that this won't happen in the ED?

There is not a single state where PAs are independently licensed or are able to independently practice. PAs are, by definition, dependent upon physician supervision. We work for you. Nurse practitioners, however, do not legally require physician "supervision", and in many states do not even have to have physician "collaboration". In these states, a NP (even a new grad who just finished their "500 hour clinical year") can practice "advanced nursing" without any type of physician oversight.

I work single coverage in a rural ED. If it comes in the door, I take care of it to the best of my ability. One of my most important tools is calling my "attending" for advice, or sometimes (rarely) calling him/her in for help.

 

[Boatswain2PA]

Sorry...double post.

 

[deleted6669]

really depends where you work and the skill and experience of the PAs you work with. some places Pas just suture and do I+Ds and only work in fast track. at places with more experienced PAs you will see folks doing a full range of skills to include intubation, centeral lines, paracentesis, u/s, procedural sedation, etc and working in main.

 

[SeekerOfTheTree]

First it started with call centers, then it moved to design and build, now critical thinking...all done offshore for cheaper. Reminds me of the 90s. Similar mentality. Cost savings an increase efficiency.

When you can pay them half price to do the same job we do won't it be more cost effective to hire less and less MDs and let more PAs and NPs run resuscitation and trauma because procedurally they are equivalent since it takes nothing special to do these procedures. The hospital bills the same rate but pays them less.

You can compartmentalized every aspect of medicine and have someone else do it to increase your efficiency but you must remember at some point your role as a physician will become insignificant because you allow it.

Example. Train a person to just read chest X-rays and determine pneumonia or not. If any question send it to a senior radiologist. Would make it easy for radiologist but they don't so this at most places...why? GI should have NPs and PAs do colonoscopy and endoscopy but most places I have been to they don't. Why? Most internal medicine fellowship trained doctors would never have to even see a hospital if they had this mentality to have everyone else do their procedures.

When a patient walks in and we don't know what is going on and we order a full panel, it's hard for me to convince people I am thinking critically. When a critically ill patient walks in and I place lines and tube him, my staff respects me for identifying and intervening because
I am involved in that critical intervention process with critical thinking behind it.

We are physicians not managers. Let's protect our profession and act like it before we are left wondering what happened to our specialty.

 

[Rendar5]

You do realize there is a surplus of em jobs right?

 

[deleted206819]

What difference does it make if there are a surplus of EM jobs throughout the country? I agree with SeekerofTheTree in that if we allow more and more of our duties and responsibilities to be "outsourced" to mid-levels then in the next decade or so we will be looking at the demise of our specialty and medicine. Look at the internal medicine folks and the independence of NPs, anesthesiologists and CRNAs. Do we want to be managing a cadre of mid-levels down the line?

 

[Rendar5]

Since i like earning money, yes i prefer hiring midlevels to non EM docs.

 

[deleted206819]

Non-EM trained physicians do not belong in the ED. I'm not begrudging anyone for earning more money but be cognizant of the fact that mid-levels such as NPs are becoming more independent and while PAs may work for physicians today that might not be so in the future.

 

[KnuxNole]

If you had to pick between a Non-EM trained physician and a PA/NP, which one would you choose? 😛

 

[RustedFox]

If you had to pick between a Non-EM trained physician and a PA/NP, which one would you choose? 😛

The one that carries their own liability.

 

[MSmentor018]

What difference does it make if there are a surplus of EM jobs throughout the country? I agree with SeekerofTheTree in that if we allow more and more of our duties and responsibilities to be "outsourced" to mid-levels then in the next decade or so we will be looking at the demise of our specialty and medicine. Look at the internal medicine folks and the independence of NPs, anesthesiologists and CRNAs. Do we want to be managing a cadre of mid-levels down the line?

i agree, if we end up outsourcing we're going to end up out of a job.....at least the surplus of one. anesthesia is a great example. first the rise of the crna's to "Be like doctors and deliver cost effective care" then anesthesia invented the AA to combat the rise but now they've supersaturated the market. once a 12 bed OR that required 12 physicians can now be run with 5.

 

[SeekerOfTheTree]

The idea of "let me ***** out my specialty so I can make as much money as possible" has been done for short term gain with long term regret. Enough examples have been provide above. Please leave the specialty with some strength so when I practice I can call myself an EM physician rather than a triage doctor.

I also understand there is a surplus of jobs so should we fill all those with NPs and PAs? It's easier to replace non-EM trained physicians with EM trained physicians versus replace a mid level with a physician. It's not seen as being cost effective.

 

[namethatsmell]

Money talks. If we ever divorce ourselves from ffs, the argument that most np/pa's are "cost saving" as independent practitioners will likely go out the window. In my experience (admittedly only ~4 short years) most mid levels order more tests and consult more...unfortunately under the current payment system that's a silent boon for hospitals. They get to pay less and collect more.

I've met a few ex-military types of PAs/nps who have been in the biz for 30 years and are great--they want to see higher acuity pts by working in a small, remote hospital that *truly* can't recruit docs...I'm okay with that. Otherwise that's what medial school and residency is for.

Also, RTs intubating?? How common is this?

 

[RustedFox]

Also, RTs intubating?? How common is this?

Everywhere man. Paramedics can tube; why can't RTs?

 

[Rendar5]

not too familiar with unemployed anaesthesiologists, honestly. nor am I too familiar with how I end up being a triage doctor by allowing myself to deal with the high risk cases and directly manage a midlevel's care. I also find it strange that someone would want a non-em trained physician over an em-trained physician assistant. Have you seen how most non-em trained doctors are nowadays when it comes to our patients? someone who trained 20-30 years ago usually manages to do great, someone trained nowadays just leaves me shaking my head how they underperform someone they have more schooling than (with a few rare exceptions). Yes, I'd rather be overseeing someone who knows what they're doing than working with someone who slows down my department and leaves me picking up their flack. If that means they primarily take care of fast track stuff and call me in for difficult reductions, so be it. If it means on overnights when there's not enough patient load to warrant a fast-track that they can do a procedure that would take me out of commission for 30 minutes, great. Trust me, I'm still directing everything.

I have yet to see a high-acuity or a risky case on a PA's chart that they didn't personally ask me to review with them. If they had, it would've gone to my director and I would've spoken with them, and their job would be at risk. If you want to see 3.5-4 pt's/hour, please feel free to get rid of midlevels and only use EM-trained doctors in your ED's.

 

[Rendar5]

Everywhere man. Paramedics can tube; why can't RTs?

never had an RT tube at my academic hospital. seen them occasionally at my community rotation in residency. They routinely do it at my hospital, and have in-house anaesthesia or myself rescue them rarely. honestly they're quite skilled at it. If I'm rescuing it, you can be sure that it's a difficult intubation (why my bougie goes with me to all in-house codes).

 

[namethatsmell]

Everywhere man. Paramedics can tube; why can't RTs?

I get teaching a Medic to intubate since the premise is that a pt would need plastic out of range from the hospital and higher level care...although the trend in EMS seems to have medics tubing less and placing more king-type airways.

I've probably worked at ~10 different hospitals and RTs tubed at 0. And it made sense to me since a physician (ED or CC or anesthesia) was always in house. I guess I just haven't been around as much yet.

Are RTs doing RSI? Are they learning to cric?

 

[Rendar5]

No rsi or cric at my current job for rt. Just sedation.

 

[Arcan57]

First it started with call centers, then it moved to design and build, now critical thinking...all done offshore for cheaper. Reminds me of the 90s. Similar mentality. Cost savings an increase efficiency.

When you can pay them half price to do the same job we do won't it be more cost effective to hire less and less MDs and let more PAs and NPs run resuscitation and trauma because procedurally they are equivalent since it takes nothing special to do these procedures. The hospital bills the same rate but pays them less.

You can compartmentalized every aspect of medicine and have someone else do it to increase your efficiency but you must remember at some point your role as a physician will become insignificant because you allow it.

Example. Train a person to just read chest X-rays and determine pneumonia or not. If any question send it to a senior radiologist. Would make it easy for radiologist but they don't so this at most places...why? GI should have NPs and PAs do colonoscopy and endoscopy but most places I have been to they don't. Why? Most internal medicine fellowship trained doctors would never have to even see a hospital if they had this mentality to have everyone else do their procedures.

When a patient walks in and we don't know what is going on and we order a full panel, it's hard for me to convince people I am thinking critically. When a critically ill patient walks in and I place lines and tube him, my staff respects me for identifying and intervening because
I am involved in that critical intervention process with critical thinking behind it.

We are physicians not managers. Let's protect our profession and act like it before we are left wondering what happened to our specialty.

For most EPs, being a physician involves managing providers with less training (residents, NPs, PAs, etc.). The main issue with losing ground to midlevels is not in them existing or what we let them do. It's whether our supervision has value. If we're the guy in Office Space that's in charge of interfacing between the engineers and the customers, then we are going to eventually lose our jobs. If we are a rubber stamp for the midlevels we're supervising, then we'll eventually be replaced. If a midlevel being supervised by an MD has more efficient work-ups with fewer adverse events then their unsupervised colleague, we get to stick around.

 

[Boatswain2PA]

Non-EM trained physicians do not belong in the ED. I'm not begrudging anyone for earning more money but be cognizant of the fact that mid-levels such as NPs are becoming more independent and while PAs may work for physicians today that might not be so in the future.

Traxus - Outside of major metropolitan areas, very few EDs have strictly EM trained docs working there. There simply aren't enough EM docs out there to cover every shift in every hospital, and there never will be.

I do hope that, as the EM field progresses, there will be EM trained docs in every tertiary center, and thus making their expertise available to every patient in the catchment area. I am always incredibly appreciative when I can call the tertiary hospital ED and talk to the ER doc before I ship someone their way.

For what it's worth, I second what Arcan says. Your mid-levels should work FOR you. They should be a tool for YOU to use to improve your patient care and numbers. You guys/gals are smart enough to run the ED, you should be smart enough to manage your well-trained staff.