PAs intubating and doing central lines

[discongruent]

EM1 resident here, and not trying to ignite PA flame war here.

I noted on my community/rural ED rotation some of the PAs were doing intubations, doing central lines and running codes (in the ICU), with no direct physician supervision at night and priding themselves on doing so. I was not aware of PAs being able to do RSI without supervision, but please correct me if I am wrong here (I apologize for naivete). Could someone elaborate on the scope of PA practice in those particular scenarios?

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[Fox800]

EM1 resident here, and not trying to ignite PA flame war here.

I noted on my community/rural ED rotation some of the PAs were doing intubations, doing central lines and running codes (in the ICU), with no direct physician supervision at night and priding themselves on doing so. I was not aware of PAs being able to do RSI without supervision, but please correct me if I am wrong here (I apologize for naivete). Could someone elaborate on the scope of PA practice in those particular scenarios?

How rural are we talking? Shouldn't you be doing those as part of your resident education?

 

[deleted547339]

EM1 resident here, and not trying to ignite PA flame war here.

I noted on my community/rural ED rotation some of the PAs were doing intubations, doing central lines and running codes (in the ICU), with no direct physician supervision at night and priding themselves on doing so. I was not aware of PAs being able to do RSI without supervision, but please correct me if I am wrong here (I apologize for naivete). Could someone elaborate on the scope of PA practice in those particular scenarios?

I believe it's state dependent

 

[Rendar5]

If you are trained to do it, you can do it. Every hospital is different. I would personally have an issue with a PA putting in a central line in a non-Crash situation. That is simply because there is a 5% complication rate for that procedure, and I would not want to be held responsible for someone else's procedure. Intubation I have seen performed by respiratory techs, medics, and nurse Anesthetist . Nothing special about it in the ED. That said, if I'm responsible for the patient, I'm doing the tube.

 

[swamprat]

Yeah I feel procedures arent too difficult to learn. With that being said I will never have PAs doing those invasive procedures under my supervision.

 

[southerndoc]

We have PA's/NP's that do central lines, LP's, etc. One of them has done so many central lines that she is more proficient than most ER docs I know.

 

[exsanguination]

My personal thoughts on this matter lie with the "I'll never let a PA/NP do that under my watch" group.

Anesthesia lost their specialty this way! Ours is RIPE for the same. I know we like to say that "oh the risk is too much" and "the ED is different" but it's not. The BE/BC EM physician is the highest trained and most capable regarding ED management of all patients, but understand the only people who believe this is, well, BE/BC EM physicians.

The layman, businessman, NP/PA, consultants - they all don't care, it's the same to them.

I give EM another 10 years before we're all supervising 3-4 PAs much like anesthesia does now with their CRNAs

 

[Janders]

IMHO, CVLs are well within the scope of practice of PAs, if they are well-trained. I know plenty of ED/V-Surg/Gen-Surg PAs who were trained and have placed 100+ lines.

And let me tell you, in a busy ED with one MD and one PA and 20+ active patients, the ability to have your PA confidently place a CVL for 15-20minutes while you care for multiple other patients is helpful.

Proper training, proper supervision, etc.

I don't think handing off procedures like I&D, lac repair, or CVL placement is where you "lose" the ED to midlevels, if you believe that is how things are going to go. You want the MD seeing multiple critically ill people and thinking through the proper care, run of the mill CVL placement does not need the top-skill of a residency trained physician.

I think airway management is on a completely different level; it is more tightly related to the resuscitation/hemodynamics of the patient, much more likely to have skill-dependent user-errors, much more likely to need multiple attempts/techniques/rescue methods, and muhach harder to get hands-on training to learn to do in the community. So not only do I worry a bit about the technical aspects of placing the ETT, I worry about the pre-during-post-procedure medical management of the unstable airway patient. Much different than the act of placing a CVL.

YMMV

One thing to remember is that most of us were trained "on-the-job" during residency. As such, a PA could also, with thousands of hours of efforts, be on-the-job trained for most things we do. I am sure there are some out there with full airway training....

 

[canigetawhatwhat]

I enjoy putting in lines.

I will do them all!

-hov

 

[Rendar5]

I enjoy putting in lines.

I will do them all!

-hov

Please do my lines then.

 

[FLTDOC1]

EM1 resident here, and not trying to ignite PA flame war here.

I noted on my community/rural ED rotation some of the PAs were doing intubations, doing central lines and running codes (in the ICU), with no direct physician supervision at night and priding themselves on doing so. I was not aware of PAs being able to do RSI without supervision, but please correct me if I am wrong here (I apologize for naivete). Could someone elaborate on the scope of PA practice in those particular scenarios?

In some rural emergency departments -the PA/NP may be the sole practitioner ie no mDs in house

 

[Mad Jack]

The RTs from the fight team (we have an unusual RT/RN pair, both dual certified as paramedics, that are on our state air ambulance service) do many of the intubation in the ED at a certain state hospital. This is functional, as it allows them to maintain their skills between flights, because you don't want a guy who hasn't intubated in months trying to do so on a tin can in the sky.

The point being, scope of practice is variable depending on the needs of a location. A PA can do a lot in a rural spot, and it often makes sense to have them do more than less to prevent skill atrophy that could pose a problem in a crisis situation.

 

[goodoldalky]

They will occasionally do these procedures at my shop if they have met requirements for their credentialing card. They will never do an airway solo for the reasons mentioned above.

Overall I am against this. Patients who require central lines and intubation are critically ill and benefit from the expertise of an emergency physician. The sentiment that, "it's helpful for them to do this while you take care of 20 other patients" is common, and the same one cited at my 100k visit ED. But this is born out of chronic understaffing of the ED. If you cannot dedicate a physician for these types of patients because you are too busy, you need more doctors.

However, doctors are expensive, and CMG bean counters have found a way to get by with the least expense possible, and this method has become ubiquitous.

The day my family member shows up sick as **** needing intubation and a central line in the ED and a PA or NP walks in because the "doctor has 20 other patients" I'm not sure what my response will be.

For me I try to do all of these procedures personally when necessary for the reasons above. In my opinion, those who do not are doing a disservice to their patients. (Flame suit on.)

 

[cbrons]

Does this ever impact resident education and training?

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[goodoldalky]

Does this ever impact resident education and training?

Sent from my SM-N910P using SDN mobile

I would recommend not going to a program where this happens. Of course this would impact resident education. You need as many of these procedures as you can possibly get.

 

[emergentmd]

I enjoy putting in lines.

I will do them all!

-hov

If I could avoid all lines, LPs, lac repairs, chest tubes my life would be much better. Nothing special about doing procedures and this does not separate PAs from Mds. Its the decision making and breath of knowledge. With the advent of U/S central lines, a HS student could do it.

 

[Rendar5]

They will occasionally do these procedures at my shop if they have met requirements for their credentialing card. They will never do an airway solo for the reasons mentioned above.

Overall I am against this. Patients who require central lines and intubation are critically ill and benefit from the expertise of an emergency physician. The sentiment that, "it's helpful for them to do this while you take care of 20 other patients" is common, and the same one cited at my 100k visit ED. But this is born out of chronic understaffing of the ED. If you cannot dedicate a physician for these types of patients because you are too busy, you need more doctors.

However, doctors are expensive, and CMG bean counters have found a way to get by with the least expense possible, and this method has become ubiquitous.

The day my family member shows up sick as **** needing intubation and a central line in the ED and a PA or NP walks in because the "doctor has 20 other patients" I'm not sure what my response will be.

For me I try to do all of these procedures personally when necessary for the reasons above. In my opinion, those who do not are doing a disservice to their patients. (Flame suit on.)

What would your response be to the paramedic who needs to intubate in the field? Have doctors on ambulance rides?

 

[Doctor Bob]

You can teach someone how to do a procedure relatively quickly (as evidenced by the number of procedures IM residents need in order to get signed off on them at most institutions).
What takes forever is teaching someone what do to when a procedure goes wrong. And that only occurs by massive repetition, and understanding the downstream anatomy/physiology/pathology.

Otherwise healthy trauma patient needs a central line? Sure, whoever wants to can do it.
Otherwise healthy trauma patient needs a cordis for massive transfusion during ongoing CPR? I'm doing the line.
Cancer patient with 8 platelets needs a line? I'm doing it.
Cancer patient with 300 platelets needs a line? Doesn't matter to me who does it.

What I ask myself is: would I let the second year resident do this procedure? Somewhere around the 2nd/3rd year point in residency is when the didactic education from medschool finally tips the scales in favor of the resident over the midlevel. Before that point the midlevel's greater clinical exposure means more in terms of clinical acumen. But around year two their clinical judgement balances out and then the book knowledge the doc can bring to bear becomes more important.

 

[littlejuan]

You guys are ignoring that this is an EM1 resident posting about PA doing all the procedures that he should be doing. It's all well and good for PAs to do these procedures but not at the expense of a resident's education.

 

[goodoldalky]

What would your response be to the paramedic who needs to intubate in the field? Have doctors on ambulance rides?

Are there no doctors in the ED?

 

[goodoldalky]

If I could avoid all lines, LPs, lac repairs, chest tubes my life would be much better. Nothing special about doing procedures and this does not separate PAs from Mds. Its the decision making and breath of knowledge. With the advent of U/S central lines, a HS student could do it.

Let's not compare lac repairs to intubations and chest tubes.

 

[Angry Birds]

If I could avoid all lines, LPs, lac repairs, chest tubes my life would be much better. Nothing special about doing procedures

I agree. But, I think the fear is real that we could be replaced in the future if we cede these procedures.

 

[Fox800]

Let's not compare lac repairs to intubations and chest tubes.

Yeah that seemed pretty lame.

 

[ffighter23]

I am a long time follower of EM on SDN and also a practicing PA and I think I may be of help in giving a realistic explanation here of PAs in EM and why *some* do procedures.

(1) Are all PAs in EM credentialed to intubate, do central lines, LPs, run codes, etc? Absolutely not. I know 100 PAs in EM and only about 10-12 that do these. So about 10%. Of those that do them, many learned outside of their PA education: example-- I learned to intubate as a paramedic, did anesthesia rotation as a paramedic, I worked for many years as a flight paramedic with frequent RSI being performed. It was a skill learned over the course of 5-7 years. Many PAs that I know who are credentialed were either medics or RTs. Does that mean I can manage a difficult airway? Probably, but obviously a lot goes into patient care outside of the intubation and managing a crashing patient is another skill that has to be learned. An average PA does not have this skill. I think the same goes for things like central lines-- a PA may have worked for an interventional radiologist for 5 years before transitioning to EM and done 500 central lines and 150 myelograms. Would it be a problem for him to do lines and LPs in the ER now? Of course not. But managing the medical complexity is likely beyond his scope (and pay grade, I might add). Most PAs that do these on a regular basis work very rural. As in-- 24 hour shifts and they are only healthcare provider for 100 miles.

(2) On another note, procedural skills and management of complex patients should ABSOLUTELY go through an EM physician if possible. All lowly PAs understand this and it's the reason why I boot everything over to the doc whenever possible because they are making 3-5x the amount of money as I do (most EM PAs make $55-65/hr). Level 1's and 2's are picked up by docs only in my ER but we all know those pesky 3's and 4's can be triaged wrong and I get stuck with a STEMI, epiglottitis, or even a subdural hematoma in fast track (all things that have happened to me in the past two months). It happens more often than I like. There is no reason I should take on that kind of liability. On average, this happens about 2 times a month to me at my community ED. If anything docs should be teaching their PAs to recognize the things that need to be immediately sent over to them.

(3) Lastly, over the past 10 years there have been many PA residencies/fellowships start up in EM. There are about 20 or so that I know about. They range in length from 12-24 months. These fellowships basically put the PAs in the same boat as the PGY-1/2's and they attend didactic and procedure/sim labs and work all off service and EM rotations as the physician EM residents. These exist at Albany/Einstein Philly/Yale/Brown/Johns Hopkins/UCSF-Fresno/Cook County and some others. These quasi residencies/fellowships are 100% voluntary for PAs and only admit 1-2 PAs each class to join the PGY1 EM residents. So maybe 20-40 PAs every year are learning to do procedures and work up complex patients in an academic environment. Many go on to work at these institutions or go rural and use their skills in underserved areas. These PAs admitted are usually prior medics/RTs or have some kind of experience before hand and are very committed to working with high acuity patients in EM. So basically, these PAs aren't just walking off the street and bragging that they can do complex procedures. They are actually being trained and supervised to do so. Their training usually doesn't end after the 1-2 years of residency and they continue to be trained at that institution.

So this begs the question: Should PAs be trained at the residency level in EM or is this going to be a CRNA moment in the EM profession? I have thoughts on this, but I'll reserve them because I just wanted to give my perspective from inside EM as a PA.

 

[Fox800]

So this begs the question: Should PAs be trained at the residency level in EM or is this going to be a CRNA moment in the EM profession? I have thoughts on this, but I'll reserve them because I just wanted to give my perspective from inside EM as a PA.

Can you clarify this statement? You aren't going to get PAs "trained at the residency level in EM" after a PA fellowship. There's a reason medical school + EM residency is a minimum of seven years, with residency being 50-80 hours a week.

 

[alpinism]

If I could avoid all lines, LPs, lac repairs, chest tubes my life would be much better. Nothing special about doing procedures and this does not separate PAs from Mds. Its the decision making and breath of knowledge. With the advent of U/S central lines, a HS student could do it.

You can. Its called doing an internal medicine residency.

 

[Boatswain2PA]

EM1 resident here, and not trying to ignite PA flame war here.

I noted on my community/rural ED rotation some of the PAs were doing intubations, doing central lines and running codes (in the ICU), with no direct physician supervision at night and priding themselves on doing so. I was not aware of PAs being able to do RSI without supervision, but please correct me if I am wrong here (I apologize for naivete). Could someone elaborate on the scope of PA practice in those particular scenarios?

PAs practice medicine. With some restrictions state to state (some states I can't sign death certificates, can't order durable medical equipment, etc), we practice medicine the same way Physicians do. To do intubations, CVLs, etc we have to be credentialed to do those things....just like Physicians do.

We just have to work for a Physician who allows us to do them.

I believe it's state dependent

I don't know of any state that prevents PAs from intubating, CVLs, etc. Most state dependent requirements are administrative.

.....What I ask myself is: would I let the second year resident do this procedure? Somewhere around the 2nd/3rd year point in residency is when the didactic education from medschool finally tips the scales in favor of the resident over the midlevel. Before that point the midlevel's greater clinical exposure means more in terms of clinical acumen. But around year two their clinical judgement balances out and then the book knowledge the doc can bring to bear becomes more important.

I've often heard this to be true and then wondered why. If an EMP is 20 years out of residency, the majority of what they know and do is not what they learned in their residency, but rather what they have learned in practice, CME, etc. The same thing with an EM PA.

So why is a 20 year EM PA still at the same level as an R2?

I think your right about the "clinical judgement", but let me flesh that idea out a little more.

Med school teaches you to be a resident. And then residency teaches you to become a fully independent practitioner. You're it. Nobody else is going to come back you up. You're an EMP and can't get the airway...then nobody's going to get it. Nobody is there to say "you should draw the lactate", or "let's go ahead and do the LP." I've read people on these boards say they finally "got good"at intubation when there wasn't a senior resident looking over their shoulder and pushing them out of the way after their 2nd failed attempt. They HAD to get it!

Meanwhile, PA school teaches to practice medicine, but always with Physician oversight....with training wheels.

That's a huge mental difference.

But if you go to rural America there aren't many training wheels in the ED. In my primary gigs I work for good FPs, but I practice better EM than they do. POCUS? Yeah, they can figgure out what way the baby is laying, but finding the left kidney during a FAST? Nope, I better do that. Running codes? I did 2 my last shift, with ROSC on both, with good neurological outcome with one of them.

No training wheels in that ED.

 

[exsanguination]

Can you clarify this statement? You aren't going to get PAs "trained at the residency level in EM" after a PA fellowship. There's a reason medical school + EM residency is a minimum of seven years, with residency being 50-80 hours a week.

But that's the point, the PA "residency' which he describes is the exact same as the PGY1-2 curriculum. There is no difference. So in essence, aside from the (largely clinically worthless) tome of knowledge we learned in medical school, the PA is getting the same training as the MD/DO.

Yet another example of how we are screwing ourselves in the long run in order to fix short term chronic understaffing issues and increase throughput of patients cheaply.

 

[Janders]

The day my family member shows up sick as **** needing intubation and a central line in the ED and a PA or NP walks in because the "doctor has 20 other patients" I'm not sure what my response will be.

So, again, I don't cede airway to my PAs. Now a couple have show interest in learning, and I like teaching, so if they want to stand next to me an learn line an intern/2nd year resident that is fine. But I'll be there.

CVLs are different. As an above poster mentioned, if there is a trauma arrest and we need the best person dropping a blind cordis, that is ME. But if between the PA and I there are 15 active patients, and 2 code strokes, a STEMI and a SNF-Septicon all arrive by ambulance within 5 minutes... and one of our 15 patients needs a CVL for a touch of levophed as their MAP is 60 after 3L NS IVF bolus... Should I go drop the line and let the PA see the 4 sick new arrivals? Should the PA drop the the line and I go see the 4 new arrivals? Should we defer the line and I'll see 3 and the PA sees 1 and then we do the line?

Even with good staffing surges happen. Not every PA I've worked with is good-to-go with CVL, but some ARE and IMHO its a completely valid procedure for them to be doing.

 

[fahimaz7]

If I'll let a MS3 put one in in the ICU we should let a trained PA do it. It's not a hard procedure using ultrasound unless it's on a whale of a patient.

 

[Mad Jack]

They will occasionally do these procedures at my shop if they have met requirements for their credentialing card. They will never do an airway solo for the reasons mentioned above.

Overall I am against this. Patients who require central lines and intubation are critically ill and benefit from the expertise of an emergency physician. The sentiment that, "it's helpful for them to do this while you take care of 20 other patients" is common, and the same one cited at my 100k visit ED. But this is born out of chronic understaffing of the ED. If you cannot dedicate a physician for these types of patients because you are too busy, you need more doctors.

However, doctors are expensive, and CMG bean counters have found a way to get by with the least expense possible, and this method has become ubiquitous.

The day my family member shows up sick as **** needing intubation and a central line in the ED and a PA or NP walks in because the "doctor has 20 other patients" I'm not sure what my response will be.

For me I try to do all of these procedures personally when necessary for the reasons above. In my opinion, those who do not are doing a disservice to their patients. (Flame suit on.)

Odd- most of the places I've heard of having this sort of thing aren't high-volume, but rather extremely low volume, the sorts of places that are so out of the way they can't attract or afford EM physician coverage at all, let alone 24/7, but they're too far out for transporting people to the nearest well-staffed ED to be practical in many cases. Shocking that a high-volume ED with EM physician coverage would allow this.

 

[southerndoc]

Odd- most of the places I've heard of having this sort of thing aren't high-volume, but rather extremely low volume, the sorts of places that are so out of the way they can't attract or afford EM physician coverage at all, let alone 24/7, but they're too far out for transporting people to the nearest well-staffed ED to be practical in many cases. Shocking that a high-volume ED with EM physician coverage would allow this.

The PA's/NP's that do central lines/lumbar punctures at my ER are doing so in a 150,000 volume ER with very high acuity.

 

[goodoldalky]

But if between the PA and I there are 15 active patients, and 2 code strokes, a STEMI and a SNF-Septicon all arrive by ambulance within 5 minutes... and one of our 15 patients needs a CVL for a touch of levophed as their MAP is 60 after 3L NS IVF bolus... Should I go drop the line and let the PA see the 4 sick new arrivals? Should the PA drop the the line and I go see the 4 new arrivals? Should we defer the line and I'll see 3 and the PA sees 1 and then we do the line?

In this case I think the correct answer would be to start peripheral norepi, activate the Cath lab, hang tpax2, fire off your sepsis order set on the septic UTI who is of course full code, then go put the line in the first guy. The PA meanwhile can maintain flow, DC the Uris ankle pains do two pelvics and sew up a lac. Having them put the CVL in unsupervised leaves flow hanging, all those menial tasks undone, etc..

Listen, I get it. You can come up with a most horrendous scenario where you are unavailable. In reality we are talking about PAs and NPs doing these procedures while the MD does some other non critical care activity, which some times is sitting on his or her duff, just my observation.

And if this is a more than once a year scenario, the problem is you need more doctors. The above happens to me occasionally and the problem is not our PAs and NPs or what they do or do not do, it's that we don't have enough physicians. Many reasons for that.

 

[deleted497653]

At my EM residency training hospital, there were Acute care nurse practitioners intubating and putting in central and art lines. There was two ICU teams and one was staffed by NPs and PAs and they did all the procedures on their patients. In the ED also, they intubated their patients if they had picked up the chart.

As far as midlevels taking over EM, this is just not possible at this time and maybe not for another 20 years. Not enough PAs and NPs are working in the ED (or even wanting to work in the ED) to make this even close to feasible. The midlevel takeover in Anesthesia was easier because because a big portion of work is nursing-like e.g. starting IVs and pushing meds, monitoring vitals, urine, giving blood etc. EM is just too broad compared to anesthesia. Most PAs/ NPs don't want this responsibility. There is way too much info to master.

Also, there is a higher ratio of CRNAs to anesthesiologists compared to ED doctors to ED PAs/NPs . You can't hire a bunch of PAs/NPs to be supervised if you don't have enough applicants to start with. So I say it will not happen.

I would train a PA to do a central line if they had interest and would let a PA do a central line on me if they were trained (and I needed a central line). At some point, you have to accept that medicine is changing. You can't fight that PAs are coming along that can do the same procedures that an MD does. It's shocking at first, but when you think of it, it's just a procedure. And yes, they should be paid the same to do a procedure as an MD (if they do the procedure).

Not saying PAs are as smart/educated as MDs, just that they can do the same procedures.

 

[swamprat]

At my EM residency training hospital, there were Acute care nurse practitioners intubating and putting in central and art lines. There was two ICU teams and one was staffed by NPs and PAs and they did all the procedures on their patients. In the ED also, they intubated their patients if they had picked up the chart.

As far as midlevels taking over EM, this is just not possible at this time and maybe not for another 20 years. Not enough PAs and NPs are working in the ED (or even wanting to work in the ED) to make this even close to feasible. The midlevel takeover in Anesthesia was easier because because a big portion of work is nursing-like e.g. starting IVs and pushing meds, monitoring vitals, urine, giving blood etc. EM is just too broad compared to anesthesia. Most PAs/ NPs don't want this responsibility. There is way too much info to master.

Also, there is a higher ratio of CRNAs to anesthesiologists compared to ED doctors to ED PAs/NPs . You can't hire a bunch of PAs/NPs to be supervised if you don't have enough applicants to start with. So I say it will not happen.

I would train a PA to do a central line if they had interest and would let a PA do a central line on me if they were trained (and I needed a central line). At some point, you have to accept that medicine is changing. You can't fight that PAs are coming along that can do the same procedures that an MD does. It's shocking at first, but when you think of it, it's just a procedure. And yes, they should be paid the same to do a procedure as an MD (if they do the procedure).

Not saying PAs are as smart/educated as MDs, just that they can do the same procedures.

I couldn't care less about them doing the procedure per se, its the decision of when to do the procedure I have an issue with. If the decision is made by the MD whatever. A PA or NP making decisions like this undermines our field as well as patient care.

 

[alpinism]

I couldn't care less about them doing the procedure per se, its the decision of when to do the procedure I have an issue with. If the decision is made by the MD whatever. A PA or NP making decisions like this undermines our field as well as patient care.

Exactly.

As many people in this thread seem to be forgetting, its not necessarily the procedure that's the hard part, but deciding when to do the procedure and on which patients.

 

[deleted497653]

You may have an issue with it personally but eventually the need for providers, cost effectiveness, and safety will dictate "who" will do the procedure and on "which patients''. As in anesthesiology, the argument the MDs initially had was that the difficult cases would go to the MD while the midlevels had the easier cases like colonoscopies, the "easy" cases; nowadays, CRNAs will do even some of the "hard" cases. They claim the "same" outcomes for patients.

If a PA can safely do procedures, why would you have a problem with them doing it?

While your preference may be to withhold procedures (your choice), other MDs may not care that a PA is doing a difficult intubation (A PA with previous experience). Just my opinion.

 

[Rendar5]

You may have an issue with it personally but eventually the need for providers, cost effectiveness, and safety will dictate "who" will do the procedure and on "which patients''. As in anesthesiology, the argument the MDs initially had was that the difficult cases would go to the MD while the midlevels had the easier cases like colonoscopies, the "easy" cases; nowadays, CRNAs will do even some of the "hard" cases. They claim the "same" outcomes for patients.

If a PA can safely do procedures, why would you have a problem with them doing it?

While your preference may be to withhold procedures (your choice), other MDs may not care that a PA is doing a difficult intubation (A PA with previous experience). Just my opinion.

while I have no problems with a mid-level provider doing intubations, same with respiratory text, and paramedics, I will have to disagree when it comes to difficult cases. Whenever you have a difficult intubation, it needs to go to the most experienced provider. That Will always be an M.D., before PA, within the same field. When I have had difficult intubation's that I as an emergency medicine doctor request assistance for, it's anyone from anesthesia . The nurse provider for them will sometimes do it, but for what they in their field would consider a difficult intubation I have seen them defer straight to the anesthesiologist. Which is what they should be doing. (The 750 pound man that was obtunded from a probable stroke that I had to deal with at three in the morning)

 

[deleted497653]

if the airway has been predetermined to be difficult, obviously it should go to the doc (unless it's on the field and there is no doctor, so the most highly skilled person would have to do it, or just bag 'em, until someone more skilled arrives etc). It really depends on the situation who ends up doing it. If it's a code and the PAs arrive first with no MD in sight, then why not let them attempt. And they would be most experienced in that situation if they know how to intubate. Technically, that could be a risky airway.

However, the general discussion here was concerning training of ED midlevels to do procedures traditionally reserved for the MD/DO. Some docs are for it and others against it or picky on the circumstances.

 

[emergentmd]

Ahhhhh..... My point is doing procedures is nothing magical and I could teach almost anyone to do a chest tube, lumbar puncture, intubate.

Where I am special is I can Intubate a crashing patient, put in all my orders, diagnose the pt, stabilize the pt, call in the admission in less than 5 minutes while discharging 2 other pts, seeing two new pts all at once in 15 minutes. I do that all the time.

I can teach anyone to do each one of those and they would do a good job in 30 minutes. But I am special b/c I can care for 3 crashing pts and do a good job even if they all came in at once.

That is why a PA will never take over my job. They would kill 2 out of 3 crashing pts who came in all at once. I could care for all 3 just as well if they came in an hr apart.

 

[maxxor]

Ahhhhh..... My point is doing procedures is nothing magical and I could teach almost anyone to do a chest tube, lumbar puncture, intubate.

Where I am special is I can Intubate a crashing patient, put in all my orders, diagnose the pt, stabilize the pt, call in the admission in less than 5 minutes while discharging 2 other pts, seeing two new pts all at once in 15 minutes. I do that all the time.

I can teach anyone to do each one of those and they would do a good job in 30 minutes. But I am special b/c I can care for 3 crashing pts and do a good job even if they all came in at once.

That is why a PA will never take over my job. They would kill 2 out of 3 crashing pts who came in all at once. I could care for all 3 just as well if they came in an hr apart.

Doesn't matter when bean counters see they can hire 3 PAs for 1 of you. It happened to anesthesia; please don't let it happen to ER.

 

[emergentmd]

Doesn't matter when bean counters see they can hire 3 PAs for 1 of you. It happened to anesthesia; please don't let it happen to ER.

PAs/NPs will be more prevalent but will never take over my job. All of my jobs now have PAs or the like and the good ones are helpful and the bad ones just make my job more difficult.

Throw a mix of this into any ED and it would be chaos. Trust me, EM trained docs will all have great opportunities for the next 10 yrs. Who knows what will happen after that.

 

[maxxor]

PAs/NPs will be more prevalent but will never take over my job. All of my jobs now have PAs or the like and the good ones are helpful and the bad ones just make my job more difficult.

Throw a mix of this into any ED and it would be chaos. Trust me, EM trained docs will all have great opportunities for the next 10 yrs. Who knows what will happen after that.

Sounds a lot like this (from 2002!)
http://forums.studentdoctor.net/threads/need-for-anesthesiologists.47191/#post-447511

Specifically
"I'm not that worried about CRNAs. I'm sure some will call me stupid or ignorant, but my experience is that they are just not as valuable to the hospital, surgeon, surgicenter, patient, etc... as an anesthesiologist. I'm sure there are lots of reasons for this, but to oversimplify it just looks really bad if a hospital doesn't have anesthesiologists. Most people who will tell you otherwise aren't in surgery or anesthesia (unless they're CRNAs) and don't know about all they crazy things that happen to sick patients who need surgery. As medical care gets increasingly complex, the need for anesthesiologists will only continue to increase."

 

[exsanguination]

What a great find maxxor, and it's exactly parallel with the flawed thinking I hear from EM physicians.

It doesn't matter though because the boat has already sailed, the train has left the station, and we are rocketing full-speed towards a management model as I alluded to earlier in the thread.

The writing on the wall is LOUD AND CLEAR!!!!

 

[GeneralVeers]

I hate central lines. They are time consuming and just no fun. I would be happy to have a PA do all of them for me. Airway is no problem. Most of the time can RSI in 5 minutes or less if my nursing staff is on the ball.

 

[emergentmd]

I hate central lines. They are time consuming and just no fun. I would be happy to have a PA do all of them for me. Airway is no problem. Most of the time can RSI in 5 minutes or less if my nursing staff is on the ball.

I give or atleast try to give up all of my Lacs/abscesses to PAs/NPs. I would be happier if I never did that. The same goes to central lines, LPs, and fracture reductions. My time is definitely more valuable doing other "doctorly duties." than spending 30 min for a complicated lac, or stinky abscess.

 

[Cinematographer]

Lol even with CRNAs anesthesiologists are still banking. The person who wrote that comment in 2002 might still agree with what he said 15 years ago.

 

[thedoctor8706]

What would your response be to the paramedic who needs to intubate in the field? Have doctors on ambulance rides?

There was a recent study published in Annals of Internal Medicine that compared BLS crews vs ACLS crews (who could intubate, cardiovert, etc) in regards to mortality benefit. The study population was Medicaid and Medicare beneficiaries in urban areas. In the subgroups of trauma, stroke, and respiratory distress, BLS groups had a statistically higher mortality benefit. Only sub-group who benefited from ACLS were primary cardiac event patients.

This seems to support the idea that the goal should be to "scoop & go" instead of fooling around at the scene trying to intubate. Obviously this was a very select patient group, but I found the results interesting.


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[link2swim06]

There was a recent study published in Annals of Internal Medicine that compared BLS crews vs ACLS crews (who could intubate, cardiovert, etc) in regards to mortality benefit. The study population was Medicaid and Medicare beneficiaries in urban areas. In the subgroups of trauma, stroke, and respiratory distress, BLS groups had a statistically higher mortality benefit. Only sub-group who benefited from ACLS were primary cardiac event patients.

This seems to support the idea that the goal should be to "scoop & go" instead of fooling around at the scene trying to intubate. Obviously this was a very select patient group, but I found the results interesting.


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Some medics do enough tubes to be good at it.

If you are only tubing once every 12 months you probably aren't going to be great at it. Probably not so good to tube the goose and ventilate the stomach for 20 minutes. EMS systems are so varied in training, acuity, and transport times that it is going to be very "system dependent" on what is best for patients.

 

[Psai]

There was a recent study published in Annals of Internal Medicine that compared BLS crews vs ACLS crews (who could intubate, cardiovert, etc) in regards to mortality benefit. The study population was Medicaid and Medicare beneficiaries in urban areas. In the subgroups of trauma, stroke, and respiratory distress, BLS groups had a statistically higher mortality benefit. Only sub-group who benefited from ACLS were primary cardiac event patients.

This seems to support the idea that the goal should be to "scoop & go" instead of fooling around at the scene trying to intubate. Obviously this was a very select patient group, but I found the results interesting.


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The only skill a paramedic needs is to be able to hit the gas pedal.