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

[Lexdiamondz]

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.

Dude, a CRNA intubates more in six months than most EM residents do in their entire residencies, and more in 2 weeks than most FPs do in their entire careers. VL, bougies, etc are only truly useful in the hands of an experienced provider and even though CRNAs intubate healthy elective cases, by sheer volume they will probably be more technically proficient at the physical skill of intubating than many ER docs, and definitely more skilled than any FM doc, rural or not.

Just because rural EDs dont have much backup doesn't mean their docs are technically more proficient. In fact, oftentimes they're less proficient because their critical care volume is much lower and their primary training (FM) didn't adequately prepare them for those types of presentations. Not knocking these docs - they do what they can with less than ideal resources - but the reality is they aren't the optimal folks to be providing this type of care in these settings.

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[MedicineZ0Z]

Dude, a CRNA intubates more in six months than most EM residents do in their entire residencies, and more in 2 weeks than most FPs do in their entire careers. VL, bougies, etc are only truly useful in the hands of an experienced provider and even though CRNAs intubate healthy elective cases, by sheer volume they will probably be more technically proficient at the physical skill of intubating than many ER docs, and definitely more skilled than any FM doc, rural or not.

Just because rural EDs dont have much backup doesn't mean their docs are technically more proficient. In fact, oftentimes they're less proficient because their critical care volume is much lower and their primary training (FM) didn't adequately prepare them for those types of presentations. Not knocking these docs - they do what they can with less than ideal resources - but the reality is they aren't the optimal folks to be providing this type of care in these settings.

You're comparing urban CRNAs to rural. Theres an enormous difference in volume of tubes between the two.
We are discussing rural settings here fyi.
And yes the younger or middleaged ones may be suboptimal but it's still magnitudes ahead of your best of the best advanced mid super providers or whatever you want to call them.

 

[VA Hopeful Dr]

You're comparing urban CRNAs to rural. Theres an enormous difference in volume of tubes between the two.
We are discussing rural settings here fyi.
And yes the younger or middleaged ones may be suboptimal but it's still magnitudes ahead of your best of the best advanced mid super providers or whatever you want to call them.

Not necessarily. There are a fair number of midlevels who work in the ED that I'd trust above most FPs (including myself).

There's likely way more that I wouldn't (like the NP my kid saw 4 weeks ago who wanted to flu swab her post-infectious ileus, but I digress), but to make a blanket statement like you did is ignorant and frequently wrong.

 

[Rekt]

Not necessarily. There are a fair number of midlevels who work in the ED that I'd trust above most FPs (including myself).

There's likely way more that I wouldn't (like the NP my kid saw 4 weeks ago who wanted to flu swab her post-infectious ileus, but I digress), but to make a blanket statement like you did is ignorant and frequently wrong.

There it is

 

[Lexdiamondz]

You're comparing urban CRNAs to rural. Theres an enormous difference in volume of tubes between the two.
We are discussing rural settings here fyi.
And yes the younger or middleaged ones may be suboptimal but it's still magnitudes ahead of your best of the best advanced mid super providers or whatever you want to call them.

Regardless, it's pretty silly to argue that any FP would be better than a CRNA at intubations when the latter does it literally every day. I admire your pride in your chosen field, but you're just wrong.

 

[VA Hopeful Dr]

There it is

?

 

[Apollyon]

?

I don't know the guy's angle yet, but what he posts is often contentious or incendiary.

 

[VA Hopeful Dr]

I don't know the guy's angle yet, but what he posts is often contentious or incendiary.

I'm pretty sure I know, but I want to make sure before I respond.

 

[deleted109597]

Presence of CT Scanner=/= well equipped.

 

[GonnaBeADoc2222]

Dude, a CRNA intubates more in six months than most EM residents do in their entire residencies, and more in 2 weeks than most FPs do in their entire careers. VL, bougies, etc are only truly useful in the hands of an experienced provider and even though CRNAs intubate healthy elective cases, by sheer volume they will probably be more technically proficient at the physical skill of intubating than many ER docs, and definitely more skilled than any FM doc, rural or not.

Just because rural EDs dont have much backup doesn't mean their docs are technically more proficient. In fact, oftentimes they're less proficient because their critical care volume is much lower and their primary training (FM) didn't adequately prepare them for those types of presentations. Not knocking these docs - they do what they can with less than ideal resources - but the reality is they aren't the optimal folks to be providing this type of care in these settings.

Please do not compare my intubation skills to that of a crna.

 

[TooMuchResearch]

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.

You not having heard of it doesn't make it untrue.

I think I got all those negatives right.

 

[RoyBasch]

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.

That sounds like a reasonable system. It seems as if any patient in your shop who needs a major procedure always has staff physician involvement.

 

[Darth Doc]

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.

Procedure skills are very different than diagnostic skills. As a PA to MD, I've experienced that difference.

 

[southerndoc]

That sounds like a reasonable system. It seems as if any patient in your shop who needs a major procedure always has staff physician involvement.

No, they're definitely not doing central lines, LP's, or chest tubes without physician involvement. Only one of our NP's is credentialed to do chest tubes, but 2 are credentialed for LP's and central lines. As I mentioned previously, our residents don't work a lot of nights. I think they get around 3-4 night shifts/month (not counting late shifts til 2a). So it's helpful to have an APP in the main ED to help with lac repairs and even to do a CVL or LP (particularly LP, I hate them) when it's down to 2 docs plus 1 peds doc covering the ER from 3a-7a.

Our APP's are pretty good. As I said before, those that don't do well don't last.

As our residency grows to all 3 classes, I'm sure there will always be a night resident who will be given the first opportunity for procedures. They already get first opportunity when they're here. Even when I'm working and don't have a resident, I still give first opportunity to any resident that is in the ER (even off-service rotators) before doing it myself or giving it to one of our NP's.

The APP's staff our fast track area independently. If they have questions, they come get us. We rarely have misses from them. They're really good about coming to get us when they have questions, someone is complicated, etc. There's really no reason why every simple laceration, influenza, or ankle sprain needs to be seen by a physician. Every chest pain, shortness of breath, etc. does. It's our policy that ESI level 3 and above must also be seen by a physician. ESI levels 4 and 5 can be independently managed by the APP.

 

[MedicineZ0Z]

Regardless, it's pretty silly to argue that any FP would be better than a CRNA at intubations when the latter does it literally every day. I admire your pride in your chosen field, but you're just wrong.

You're changing the context and moving goal posts. You're also unfamiliar with the people who cover those places. The rural FPs have typically done years and years in nearby community settings. They're often drive-ins from those areas to cover the rural ER. Years/decades of intubating in the ER puts you ahead of many CRNAs who are new to the field and do the healthiest patients only and/or rely on video.

 

[Lexdiamondz]

You're changing the context and moving goal posts. You're also unfamiliar with the people who cover those places. The rural FPs have typically done years and years in nearby community settings. They're often drive-ins from those areas to cover the rural ER. Years/decades of intubating in the ER puts you ahead of many CRNAs who are new to the field and do the healthiest patients only and/or rely on video.

Most of these places are so low volume that they aren't getting more than a handful of intubations a year, if that. I don't know what dreamland you're living in dude.

By all mean though keep fighting the good fight against midlevel creep.

 

[Stephanopolous]

There are hospitals here in NM that have the set up where NP's are running the ICU's at night, solo.

 

[MedicineZ0Z]

Most of these places are so low volume that they aren't getting more than a handful of intubations a year, if that. I don't know what dreamland you're living in dude.

By all mean though keep fighting the good fight against midlevel creep.

You missed the point. These guys worked and still do work in much busier community settings. The procedural experience over years or decades is already there. They simply drive out to rural areas to do 24 or 48 hour coverage. *Some* of them also live there and aren't what I described, which is less common and depends on where it is.

There are hospitals here in NM that have the set up where NP's are running the ICU's at night, solo.

That's most states now...

 

[wholeheartedly]

No, they're definitely not doing central lines, LP's, or chest tubes without physician involvement. Only one of our NP's is credentialed to do chest tubes, but 2 are credentialed for LP's and central lines. As I mentioned previously, our residents don't work a lot of nights. I think they get around 3-4 night shifts/month (not counting late shifts til 2a). So it's helpful to have an APP in the main ED to help with lac repairs and even to do a CVL or LP (particularly LP, I hate them) when it's down to 2 docs plus 1 peds doc covering the ER from 3a-7a.

Our APP's are pretty good. As I said before, those that don't do well don't last.

As our residency grows to all 3 classes, I'm sure there will always be a night resident who will be given the first opportunity for procedures. They already get first opportunity when they're here. Even when I'm working and don't have a resident, I still give first opportunity to any resident that is in the ER (even off-service rotators) before doing it myself or giving it to one of our NP's.

The APP's staff our fast track area independently. If they have questions, they come get us. We rarely have misses from them. They're really good about coming to get us when they have questions, someone is complicated, etc. There's really no reason why every simple laceration, influenza, or ankle sprain needs to be seen by a physician. Every chest pain, shortness of breath, etc. does. It's our policy that ESI level 3 and above must also be seen by a physician. ESI levels 4 and 5 can be independently managed by the APP.

Our fast track folks do stuff like order a strep, influenz, and RSV on every little kid who comes in with a fever cough and sore throat. The docs never do this. They might not be "hurting" anyone, but it's still not good medicine.

You missed the point. These guys worked and still do work in much busier community settings. The procedural experience over years or decades is already there. They simply drive out to rural areas to do 24 or 48 hour coverage. *Some* of them also live there and aren't what I described, which is less common and depends on where it is.

You're generalizing your region and own experience to a wider area than might be applicable . The FPs who staff ours are pretty young, new docs, and only one works another location where they regularly intubate people. They've intubated 3 people at my facility in the last year. One was done by the flight crew this morning that came to pick up the patient for transfer. They had to cric a guy a few weeks ago. Little scary.

And for folks asking about how you can just staff an ED with a midlevel at night with physician at home backup, our policy technically states we need a doc or midlevel available to get to the ED in 30 minutes and RNs can start stuff while they wait for the doc to arrive. In reality we have a midlevel in house for thr ED at night and a physician available somewhere nearby (housing next door) for phone or in person backup.

 

[MedicineZ0Z]

Our fast track folks do stuff like order a strep, influenz, and RSV on every little kid who comes in with a fever cough and sore throat. The docs never do this. They might not be "hurting" anyone, but it's still not good medicine.



You're generalizing your region and own experience to a wider area than might be applicable . The FPs who staff ours are pretty young, new docs, and only one works another location where they regularly intubate people. They've intubated 3 people at my facility in the last year. One was done by the flight crew this morning that came to pick up the patient for transfer. They had to cric a guy a few weeks ago. Little scary.

And for folks asking about how you can just staff an ED with a midlevel at night with physician at home backup, our policy technically states we need a doc or midlevel available to get to the ED in 30 minutes and RNs can start stuff while they wait for the doc to arrive. In reality we have a midlevel in house for thr ED at night and a physician available somewhere nearby (housing next door) for phone or in person backup.

I'm going off from numerous examples ive seen and heard, definitely not just my personal rotation experiences.

If they are doing a cric is it because of lack of airway experience or because of necessity?

And it's still very silly to not staff an ED with a real doctor. Doesnt matter who or what that midlevel is.

 

[Lexdiamondz]

I'm going off from numerous examples ive seen and heard, definitely not just my personal rotation experiences.

If they are doing a cric is it because of lack of airway experience or because of necessity?

And it's still very silly to not staff an ED with a real doctor. Doesnt matter who or what that midlevel is.

Dude you’re an MS4 on the wrong side of every discussion on this forum that you’ve inserted yourself into. You make claims based on little/no experience in the face of residents and attendings who actually do the job on a daily basis, and almost never actually contribute anything of substance to any discussion.

 

[Stephanopolous]

That's most states now...
[/QUOTE]

Sorry I was trying to respond to an earlier post where they were unsure if it was only PA's or NP's as well that are found in these situations.

 

[TooMuchResearch]

You're changing the context and moving goal posts. You're also unfamiliar with the people who cover those places. The rural FPs have typically done years and years in nearby community settings. They're often drive-ins from those areas to cover the rural ER. Years/decades of intubating in the ER puts you ahead of many CRNAs who are new to the field and do the healthiest patients only and/or rely on video.

Nope, the rural FPs we displaced had only rural experience.

 

[CCM-MD]

Dude you’re an MS4 on the wrong side of every discussion on this forum that you’ve inserted yourself into. You make claims based on little/no experience in the face of residents and attendings who actually do the job on a daily basis, and almost never actually contribute anything of substance to any discussion.

Glad someone said it.

 

[alpinism]

Most of these places shouldn't even have a emergency department let alone a midlevel or physician.

 

[deleted109597]

Most of these places shouldn't even have a emergency department let alone a midlevel or physician.

I'm not sure I follow.
They deserve something. Otherwise all they get is a 18 week community college medic trying to save their life during the 3 hour drive to the closest hospital. Now, should those hospitals have inpatient beds, or be doing elective surgeries? No. But that doesn't mean there shouldn't be critical access emergency departments.

 

[alpinism]

I'm not sure I follow.
They deserve something. Otherwise all they get is a 18 week community college medic trying to save their life during the 3 hour drive to the closest hospital. Now, should those hospitals have inpatient beds, or be doing elective surgeries? No. But that doesn't mean there shouldn't be critical access emergency departments.

Personally think these hospitals should have at least 10K visits to operate an emergency department.

I'd argue in favor of the Australian system with flight docs and helicopters for sick patients.

 

[southerndoc]

Personally think these hospitals should have at least 10K visits to operate an emergency department.

I'd argue in favor of the Australian system with flight docs and helicopters for sick patients.

That's not cost effective.

 

[TooMuchResearch]

Personally think these hospitals should have at least 10K visits to operate an emergency department.

I'd argue in favor of the Australian system with flight docs and helicopters for sick patients.

Why?
We cover 2 hospitals with under 10k, another with 10-12k.
I'm in one right now.
They do elective and depending on the complexity some urgent surgeries.
We have heme/onc.
I can get patients specialty follow-up locally (city specialists see patients in the hospital adjacent clinic).
Why shouldn't these patients have access to emergency medical care?

 

[deleted109597]

Hospitals with 10K visits (unless surgical specialty hospitals) should NOT be doing elective surgeries. The data is clear that you have to have volume to make it good. This is why centers of excellence in everything else always have minimum numbers. There aren't any lap chole centers of excellence that I'm aware of, but there are lap chole centers of death.

 

[Apollyon]

Hospitals with 10K visits (unless surgical specialty hospitals) should NOT be doing elective surgeries.

Are you talking ED volume, or total patient visits now?

 

[deleted109597]

Are you talking ED volume, or total patient visits now?

ED volume. Because 10000 visits becomes anywhere between 1-2000 inpatients. 3-6 per day. Not enough volume for profiency in surgery. Unless it's a surgical specialty hospital where they schedule most surgeries separate, and the ED only exists due to state law. Many of those have plenty of surgical volume, but nobody ever finds the ER because the hospital isn't advertising it as such.

 

[Apollyon]

ED volume. Because 10000 visits becomes anywhere between 1-2000 inpatients. 3-6 per day. Not enough volume for profiency in surgery. Unless it's a surgical specialty hospital where they schedule most surgeries separate, and the ED only exists due to state law. Many of those have plenty of surgical volume, but nobody ever finds the ER because the hospital isn't advertising it as such.

I think that you are thinking of just where you are, possibly. Our surgical and ortho are quite busy, and virtually all of theirs is outpatient. The hospital visits greatly outnumber the ED visits. Or, are you stating that most general surgical issues that go to the OR come from the ED?

 

[deleted109597]

I think that you are thinking of just where you are, possibly. Our surgical and ortho are quite busy, and virtually all of theirs is outpatient. The hospital visits greatly outnumber the ED visits. Or, are you stating that most general surgical issues that go to the OR come from the ED?

In rural places, yes. I'm not talking inner city here. >2/3rd of admissions come through the ED. Typically surgeries are at a similar clip unless the hospital has a robust day surgery program. Most rural shops do not.

 

[Apollyon]

In rural places, yes. I'm not talking inner city here.

I'm rural, and, where I am, it is just not so.

 

[TooMuchResearch]

I think that you are thinking of just where you are, possibly. Our surgical and ortho are quite busy, and virtually all of theirs is outpatient. The hospital visits greatly outnumber the ED visits. Or, are you stating that most general surgical issues that go to the OR come from the ED?

Our rural places keep the ORs pretty busy most days. Gen surg, Ortho, Ophtho, ENT, etc. Even for the urgent/emergent stuff from us, they're good at asking us to ship to the tertiary center if they seem too sick for a smaller facility.

 

[southerndoc]

ED volume. Because 10000 visits becomes anywhere between 1-2000 inpatients. 3-6 per day. Not enough volume for profiency in surgery. Unless it's a surgical specialty hospital where they schedule most surgeries separate, and the ED only exists due to state law. Many of those have plenty of surgical volume, but nobody ever finds the ER because the hospital isn't advertising it as such.

Don't forget to include elective surgeries performed at the hospital.

 

[Apollyon]

Don't forget to include elective surgeries performed at the hospital.

That's what I said in post #83.

 

[deleted109597]

That's what I said in post #83.

And I did in post #84.
However, many physicians are deluded about what "busy" surgery programs means. There's a litany of quality data on this. Below a certain volume, it's just not safe.
Hospital volume and patient outcomes after cholecystectomy in Scotland: retrospective, national population based study
Surgical Volumes | Patient Safety & Quality at Johns Hopkins Medicine
Relationship between Patient Safety and Hospital Surgical Volume
Relationship between surgeon volume and outcomes: a systematic review of systematic reviews
So, just saying "we do a lot" may not mean a whole hell of a lot when it comes to actual outcomes. None of us operates. Few of us are in the OR for any reason (intubation training, codes, etc). So it's conjecture and surgeons we know.

 

[alpinism]

Why?
We cover 2 hospitals with under 10k, another with 10-12k.
I'm in one right now.
They do elective and depending on the complexity some urgent surgeries.
We have heme/onc.
I can get patients specialty follow-up locally (city specialists see patients in the hospital adjacent clinic).
Why shouldn't these patients have access to emergency medical care?

Because the number of true emergencies is so low that it doesn't make sense to have a 24/7 ER staffed with board certified physicians.

For example your typical 5,000 pt critical access hospital with a 1% ICU admission rate is only seeing about 4 ICU level patients per month.

Many of these places can go weeks between seeing a true life or death emergency and most patients would survive the extra 30 min ambulance ride without any complications. Now there should definitely be exceptions for places like Alaska where the closest hospital is hundreds of miles away by plane but most places in the United States are a short drive away from multiple hospitals.

 

[deleted109597]

Many of these places can go weeks between seeing a true life or death emergency and most patients would survive the extra 30 min ambulance ride without any complications. Now there should definitely be exceptions for places like Alaska where the closest hospital is hundreds of miles away by plane but most places in the United States are a short drive away from multiple hospitals.

You must have never been out west. I can't get a patient to a hospital via EMS in 30 minutes from my critical access freestanding. I can with a helicopter. Montana, Utah, the Dakotas, all have similar distance issues.

 

[gutonc]

You must have never been out west. I can't get a patient to a hospital via EMS in 30 minutes from my critical access freestanding. I can with a helicopter. Montana, Utah, the Dakotas, all have similar distance issues.

Oregon, Washington, large chunks of Northern California, Nevada, Idaho, etc, etc, etc. 2-6 hours by diesel, 30-90 minutes with kerosene.

 

[wholeheartedly]

My critical access is about 5 k volume. We're about 110 miles from the nearest non-critical access hospitals.

 

[alpinism]

Yeah I meant places like Alaska, Washington, Oregon, etc..

I'll stand by my previous comment for everywhere else in the states.

 

[Apollyon]

Yeah I meant places like Alaska, Washington, Oregon, etc..

I'll stand by my previous comment for everywhere else in the states.

Pennsylvania, for one more. In fact, that's where I am, right now - 100 miles from anything, in the middle of the Allegheny National Forest.

 

[southerndoc]

Pennsylvania, for one more. In fact, that's where I am, right now - 100 miles from anything, in the middle of the Allegheny National Forest.

Are you doing locums now?

 

[Apollyon]

Are you doing locums now?

No, this is my regular gig.

 

[southerndoc]

Thought you were in SC.

 

[gutonc]

Yeah I meant places like Alaska, Washington, Oregon, etc..

I'll stand by my previous comment for everywhere else in the states.

Big chunks of the Midwest, Plains, AZ, NM, CO, TX....

Keep digging man. It's a bigger country that you seem to think it is.

Also, just for fun, I was looking up populations of these various areas. Washington, Oregon and Idaho combined have a population about the same as all of New England (~14.5 - 15M based on 2018 estimates).

Your exceptions are starting to prove the rule.

 

[deleted109597]

Yeah I meant places like Alaska, Washington, Oregon, etc..

I'll stand by my previous comment for everywhere else in the states.

Yeah, for the record, more places in the US are >30 miles from a hospital than <30 miles. Populations not so much, but ~100 million is concentrated in very few major cities. The Texas Medical Center, where there are 21 hospitals in 2 miles, its the outlier here, not the rural hospitals.