PAs running their own ERs?

[devildoc2]

I ran into an ER doc the other day, and he said that in rural areas, its common to find an emergency room that is RUN by a PA with PAs and NPs working the unit with no MD present. An ER MD checks 10% of their charts, HOWEVER, the chart review is done over the internet and happens AFTER THE PATIENTS ARE TREATED AND RELEASED! The ER MD never sets foot in the facility, she monitors everything via internet.

My questions:

1) do laws allow PAs to run ERs in cities too? Or just rural areas?

2) Can PAs hire MDs to work under them? Does the PA dictate medical care to the MD or what?

3) How are the roles of PAs restricted in urban EDs? If all the MDs are busy with other patients and a massive GSW comes into the ER, does the PA have the right to run it the whole way, including intubation, chest tube, all on his own? Or is he REQUIRED to go get an MD to be present with him while this is going on?

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[docB]

I've run across urgent cares run by midlevels but not real ERs. I don't know how that would work.

 

[Vukken99]

I ran across an ad from a PA magazine...

The ad was from a hospital in Texas like 45 min from Dallas area...city of Bowles...

The ad talked about only PA staffed ER.....

I wonder what is the point of ER guys monopolizing ER work against other doctors if the trendy is even undertrained PAs are doing ER on their own without an MD.

Our profession needs to open their eyes....

And that is not a telemedicine ...what that ER doc is doing by reviewing the chart on line....That is not considered supervision......

What a smart group of physicians we are...limit other physicians but allow PAs...

 

[Sessamoid]

And that is not a telemedicine ...what that ER doc is doing by reviewing the chart on line....That is not considered supervision......

It is considered supervision, but would be wholly inadequate by urban ED standards. The problem very small rural EDs face is that the patient volume is so low that hospitals find it impossible to recruit even family docs, much less EM residency trained physicians to staff their EDs. After all, low patient volume == low reimbursement. If their ED sees perhaps 20 patients in a day, even the lowest paid specialties will turn up their nose at that job.

In Texas (as in most states) a physician can delegate to a PA whatever duties he deems appropriate. Legally, the kicker is that if you get sued for something the PA did, if you haven't seen the patient yourself then you're standing on very thin ice. I'm not familiar with any PA run EDs, but PA and NP-only staffed urgent care clinics are common in rural areas. I'm not crazy about the idea of a PA alone in the ED but I'm also not willing to personally work for 50 dollars an hour ensure that their ED has a residency-trained doc.

Rural hospitals are often probably seeing just the opposite in census trends that the rest of us in metro areas are. The vast majority of the EDs in the country are seeing dramatically increasing volume. Rural areas are rapidly becoming depopulated in many parts of the country, with corresponding decreases or stasis in patient volumes. I don't see that demographic trend changing in our lifetimes.

 

[Vukken99]

I think ER is too hyped up honestly....

I have seen ER resident unable to recognize diffuse T-wave inversion as a sign of acute MI...a senior resident who is like making 330k a year now practicing what I called substandard medicine really...

Other thing...they shake when they have to put a chest tube...Once I became surgery resident chest tubes were like nothing....

Sure they intubate but if the airway is difficult then they still call anesthesia....

I fail to see the need to actually have ER residencies just trying to monopolize ER work.....

Family Physicians with one year of ER training can do that job easily....
And, Many ER pioneers were non ER trained anyhow....

It is money issue I think more than anything else....pure politics..

I am glad I am not in ER anymore..

 

[Sessamoid]

I think ER is too hyped up honestly....

I have seen ER resident unable to recognize diffuse T-wave inversion as a sign of acute MI...a senior resident who is like making 330k a year now practicing what I called substandard medicine really...

Other thing...they shake when they have to put a chest tube...Once I became surgery resident chest tubes were like nothing....

Sure they intubate but if the airway is difficult then they still call anesthesia....

I fail to see the need to actually have ER residencies just trying to monopolize ER work.....

Family Physicians with one year of ER training can do that job easily....
And, Many ER pioneers were non ER trained anyhow....

It is money issue I think more than anything else....pure politics..

I am glad I am not in ER anymore..

Do you have to practice to troll like this, or does it come naturally?

Damn, my ignore list is getting longer and longer.

 

[flighterdoc]

Our profession needs to open their eyes....

And that is not a telemedicine ...what that ER doc is doing by reviewing the chart on line....That is not considered supervision......

What a smart group of physicians we are...limit other physicians but allow PAs...

Exactly. The reason this is happening is because of the AMA and the LCME. There needs to be MORE medical school seats, to allow MORE physicians in the US. And, physicians will have to accept making less money or living in less desireable locations (out in the country).

The solution is NOT to limit midlevels first. They're the only medical care that a lot of folks can get.

 

[Bandit]

I work in just this setting as a PA. There are many PA run ERs with MD collaboration by phone only. Trust me, you must be very experienced for these job, but the scope of practice for a PA is ANYTHING allowed by the collaborating physician.

Physicans need not be directly supervising or even on premise.

I know many PAs that are full partners in practice and some ebven started the practice and hired an MD. This is not uncommon. Of course medical guidlines and open discussion must be tolerated. The best possibly medical judgement from who ebver it came from

 

[ERMudPhud]

I think ER is too hyped up honestly....

Other thing...they shake when they have to put a chest tube...Once I became surgery resident chest tubes were like nothing....

I've always thought chest tubes were one of the easier procedures we do. Not nearly the finesse involved in intubations, lines or even LP's. At my current hospital I put them in and the surgeons may not see the patient until the next morning. That doesn't prevent some of them from trying to bill for my procedure though.

Sure they intubate but if the airway is difficult then they still call anesthesia....

My group rarely calls anesthesia but one of the last times they were called (a while ago) was an object lesson in how even the experts can make mistakes. A colleague sees a patient a few days postop from some sort of EENT procedure for difficulty breathing. He looks in the mouth and sees a giant tense blood bulla obscuring the airway, soft palate, and much of the hard palate. He said it looked like the patient had stuffed a waterballoon in his mouth. Its midafternoon, the patient is in no distress yet so he talks to anesthesia and EENT and thinks that the plan is to take the patient to the OR do a fiber optic intubation and then find the source of the bleeding. Somehow instead two anesthesiologists come to the ED and RSI the patient. As soon as they stick in the laryngoscope the bulla explodes. My friend walks into a room with the patient and the anesthesiologists covered in blood. Now the patient is paralyzed, they can't see to tube him and there is too much bleeding in his mouth to bag him so he gets cric'd by the ED doc before going to the OR. Another colleague got called to the OR to help with a code the other day!

And, Many ER pioneers were non ER trained anyhow....

The same could be said for pioneers in any field. That is what it means to be a pioneer.

Anybody else think vukken might be the illegitimate love child of Macgyver and Kinetic? He hates midlevels, expert witnesses, and EM. Plus he is no longer with his original residency. So, vukken did you inherit enough balls from Kinetic to explain the circumstances under which you left your residency. The only thing that makes me doubt this hypothesis is that he sounds like an FMG with only a passing acquaintance with English when he writes and we know Macgyver would never having anything to do with bringing another FMG into America.

For the OP. I've seen rural ER's staffed this way but usually in places so remote and with such low volume that they couldn't get an MD to go there.

 

[ERMudPhud]

Other thing...they shake when they have to put a chest tube...Once I became surgery resident chest tubes were like nothing....

Wasn't there a troll a while back whose trademark was the extreme use of multiple periods and a complete lack of full sentences?

 

[Vukken99]

I resigned because I was not being trained...
Plus I used to feel very angry on Surgeon bashing...

Residents who don't know squat were bashing surgeons..
I was like have some respect will yah..

They asked me to stay but I had left...

they had something against ex-surgery residents....
I had a research which would have changed the protocol for pancreatitis diagnosis and management backed by a multi-international biotech company but I had to leave.

the program director became mad that I wanted to leave...I told him I wasnot being trained...I didnot want a senior resident who could not recognize acute MI to supervise me...what is wrong with that....Then he could not say anything. Plus I asked why non ER trained guys are doing shifts here and teaching Residents if your philosophy is only ER trained guys type of attitude.
It did not make any sense to me.

I am even afraid that guy graduated and who knows is he is getting into some malpractice..poor patients....

the worst yet to come, the program director punched a patient in front of me...he said patient was assaulting him and I saw patient just touched his arm to get attention. he called the security on this patient poor patient...

What a role model he was....

It was a real nightmare...some ER guys are out there in space....

I am happy about the decision I made I was able to return to General Surgery very fast since they offered me a position before I took ER...

I am sorry guys ER is pure BS.........
ER is full of Wannabe George Clooney....If you want to be a star go to hollywood not ER..

What a laugh that is

Yup ER residents I call them WBCs= Wannabe George Clooney hahahahaha.

 

[devildoc2]

So whats the role of PAs in urban EDs?

How many ER docs and how many PAs does a busy urban ED unit have?

What distinguishes the PAs scope of practice from the ER docs? Do they ahve constant supervision? Or is it like the rural areas where they basically have full autonomy, and an ER doc checks 10% of their charts 2 weeks AFTER the patient is treated and released?

 

[Vukken99]

if only 10% of charts of PA charts are being audited then pretty much
you are assuming that 90% which is like majority of this practice is assumed to be autonomous practice...

Sure, just to by pass the law, they got some ER doc on paper...

But, the rationale is pretty much they are independent...

I am going to post that ad on PA magazine which claims to have only PAs in their ER and they are only 45 minutes from Dallas.

I think it is pretty ridiculous....

ER trained people say"oh you are not ER trained so you can't work here"
they are saying this to other specialist..then again they are allowing some autonomouc PA run ER to flourish....

they are really smart indeed....those Wannabe George Clooneys

 

[Sessamoid]

So whats the role of PAs in urban EDs?

How many ER docs and how many PAs does a busy urban ED unit have?

What distinguishes the PAs scope of practice from the ER docs? Do they ahve constant supervision? Or is it like the rural areas where they basically have full autonomy, and an ER doc checks 10% of their charts 2 weeks AFTER the patient is treated and released?

In urban and suburban EDs, PAs never practice alone. The ratio varies by hospitals, and many groups don't like using them at all. At my previous group we had one mid level who saw most of the peds and gyn problems (as a couple of the senior partners absolutely hated seeing those cases) and one midlevel who worked on the graveyard shift as we were single covered for physicians at night.

The peds/ob NP mostly just saw a bunch of cases then brought over the charts to sign. She had a very clear idea of what her limits are and consistently called us over to evaluate patients whenever anything unusual came up, if she anticipated needing CT for potential appendicities, etc.

As has already been noted, scope of practice is basically whatever the EP decides to delegate. The PAs I've worked with usually don't seen comfortable with highly complicated medical cases.

 

[Vukken99]

even a grammar school student would know that 45 minutes from a major city is more like suburb than rural....

Don;t be ridiculous ER people are a joke...really.....

But I do admit I know two ER physicians who are pioneers who got their priorities straight: one of them even helped to pass a legislation to limit the independently run urgent care facilities by PA or NPs....

 

[ERMudPhud]

Where I work we have between 0 and 2 PA's on at a time while having 1-4 docs on depending on the time of day. The PA's tend to focus on minor trauma and minor complaints like earaches, sore throats, etc... They can be a huge benefit because if I am gloved up sewing a complicated lac it completely takes me away from the rest of the ED during that time or else I waste a lot of time gloving and degloving whenever I get pulled away to another case. Trauma alerts always get turned over to the physician even if it was a walkin from an MVA 20 hours ago. All EKGs and films get read by the physician as they are done. The PA's discuss all but the simplest cases with us prior to discharge. Our PA's generally have a great deal of experience before working for us. One is still in the reserves as a special forces medic. A few have gone on to medical school. As far as procedures go they do lac repairs, LP's, arthrocentesis, and some simple ortho. They don't do sedation or intubation without us at the bedside. They don't do lines. They generally don't see critically ill patients but will step up to the plate quite capably if necesarry. I remember once coming out of one trauma room after intubating a patient to find the charge nurse who had been sent to get me. She led me back to another room where the special forces medic was calmly bagging a GCS=3,apnic head trauma patient who been brought in by friends. He was also directing the nursing staff to put in peripheral lines and maintain inline stabillization. For us the decision to use PAs is primarily one of efficiency. Having them sew lacs frees us to see other patients and our overnight shifts aren't usually busy enough to warrant two docs.

 

[Vukken99]

silly kids.....

I still think ER is pure joke anyhow...
How difficult is to clear a C-spine X-ray huh????

I am in favor of that FP oriented ER fellowship in Tennesse...

In NYC area hospital, many ER just hire FPs without any ER training to staff their ER..but they have to have all life support courses under their belt...

PLus Er is no brainer really:
they order cardiac panel, abdominal panel it is all panel and lke gunner of all work ups.....

Plus the vitals...the vitals that is all about in ER vitals....
Tachy??? what is the BP please......oh hypotensive huh run some fluids...

Pure Joke no offense...
Pure monopoly...

 

[spyderdoc]

Anyone have any objections to me deleting mr v99's posts? I think this thread will still be interesting without them?
Mark

 

[DrQuinn]

Already done. The troll has been slain by the mighty Neo.

Q, DO

 

[spyderdoc]

Already done. The troll has been slain by the mighty Neo.

Q, DO

I just had a deja vu "No Lieutenant, your men are already dead..." moment...Thanks Neo!

 

[beanbean]

This thread is very "pre-allo" for the EM forum. The threads here are usually fun, non-insulting, yet always informative. Unlike, some other forums on SDN which follow the "Jerry Springer Show method of arguing your point". The closest thing we usually have to trolls in the EM forum are some of our patients.

Yet here we have a thread started by DevilDoc who is known in the Allopathic forum as the guy who was almost kicked out of his top 10 school after almost failing MS1 (because he was working 40 hrs/wk on research) only to be saved by making a crazy deal with his committee to graduate in the top 10 of his class. Alas, he then posted that he was failing MS2 and hated medicine so much he wanted to quit school. Truly bizarre threads.

Enter Vukken99.... who in his unique style..... feels the need to tell us all how useless EDs are.....He has now been banned.

Where did this soap opera come from?

 

[DrQuinn]

Where did this soap opera come from?

From the bowels of the ED waiting room.

Q, DO

 

[DrQuinn]

I just had a deja vu "No Lieutenant, your men are already dead..." moment...Thanks Neo!

"The other life is lived in computers, where you go by the hacker alias "Neo" and are guilty of virtually every computer crime we have a law for. One of these lives has a future, and one of them does not."

Q, DO

 

[ERMudPhud]

Was he just banned for the stuff he posted here? I think we need to get a thicker skin. It's not liking he wasn't saying the same stuff we've all heard before and will continue to hear in our careers. Its been said before by posters more obnoxious then him plus although he had a bit of a fringe perspective he seemed to make some worthwile contributions in other threads. See his post on DO friendly surgery programs or his post pointing out that general surgeons could do hand fellowships. (I wasn't aware of that and I've worked with lots of hand surgeons and I have a brother doing the ortho/hand route)

 

[devildoc2]

Where I work we have between 0 and 2 PA's on at a time while having 1-4 docs on depending on the time of day......
our overnight shifts aren't usually busy enough to warrant two docs.

Does this mean that before the introduction of PAs, that your ER would have had MORE ER docs to cover everything?

PAs seem to have at least a partial effect on hiring of ER docs.

Instead of a new ER doc getting 10 job offers, he only gets 6. Not enough for him to feel the heat of not having a job, but enough to make a noticeable difference in career opportunities.

 

[DrQuinn]

Was he just banned for the stuff he posted here? I think we need to get a thicker skin. It's not liking he wasn't saying the same stuff we've all heard before and will continue to hear in our careers. Its been said before by posters more obnoxious then him plus although he had a bit of a fringe perspective he seemed to make some worthwile contributions in other threads. See his post on DO friendly surgery programs or his post pointing out that general surgeons could do hand fellowships. (I wasn't aware of that and I've worked with lots of hand surgeons and I have a brother doing the ortho/hand route)

It actually wasn't this thread that got him banned, it was another thread in either General residency or Family Practice, where he personally insulted several SDN members.

I actually enjoy a troll or two here in the EM forums, but basically he was out of control at severla other threads.

Q, DO

 

[SoldierDO]

Well, to all this is my first post in this forum.

I could not resist writing since I am not sure why Vukken was banned!

His comments seemed somewhat abrasive, but I really enjoyed his comments.

He sounded like someone who is dealing with lots of issues in our healthcare in dismay.

Lack of tolerance is sign of dictatorship..Iraq all over again!

 

[ERMudPhud]

dictatorship..Iraq!

Careful, too many periods and you'll give yourself away....

 

[Sessamoid]

Careful, too many periods and you'll give yourself away....

Check the IP address?

 

[Sessamoid]

Does this mean that before the introduction of PAs, that your ER would have had MORE ER docs to cover everything?

PAs seem to have at least a partial effect on hiring of ER docs.

Instead of a new ER doc getting 10 job offers, he only gets 6. Not enough for him to feel the heat of not having a job, but enough to make a noticeable difference in career opportunities.

You could make the same arguments about PAs assisting during surgery when in the old days they would have called in another surgeon to assist.

More often what you see is PAs filling in where it wouldn't make financial sense ot have another physician on hand. At the trauma center where I worked before, we had enough lacerations and minor trauma to keep the PA busy doing almost nothing but suturing much of the time. Very routine and dull work which it didn't make sense to hire another residency trained physician for.

Where I am now, the PA allows us to see more patients enough that the hospital becomes a more competitive place to work. It probably makes it easier to recruit quality physicians than without. Before our group started here, the hospital was single coverage without physician extenders, and there was often a long wait to get in to the ED. It wasn't cost effective to hire another physician, but when the ED got surges in volume the wait times exploded. Hiring a PA was a win-win situation. Patients get seen in a more timely fashion, the physician doesn't get stressed out when it's overly busy, and eveybody's happier since the patients don't start the visit angry at the wait times.

 

[ERMudPhud]

Check the IP address?

Can we do that ourselves? Or only the moderators? Ah for the old days of usenet when it was easy to trace the headers.


On a side note: if you read the thread that got Vukken banned, its easy to find in the FP forum, you'll see that despite his surgical training he appears to be running some sort of urgent care clinic. He mentions being in solo practice and seeing everything from acute coronary syndromes to minor trauma -not your typical general surgery practice. No wonder he's threatened by midlevels and angry at the EM monopoly.


Also, I never could find the mythical suburban Dallas hospital employing only PA's in it ED. A search on mapquest and texas.com for Bowle, Bowles, Bowl, or even Bowels only found Bowles creek. I am not sure it is even a town but it is >150 miles from Dallas (not a 45 minute drive even in Texas) and the nearest hospital is 40 miles away. I did find a Bowie Texas about 80 miles from Dallas(possibly a 45 minute drive in Tx) but their hospital appears to staff MD's. As EMEDPA has shown there are PA run ED's in rural areas but the ad he posted appeared to be for a very rural ED in which the PA's were working single coverage for less than half what a suburban ED doc makes. No wonder they can't recruit ED docs. For that matter I have visited village health clinics in Alaska staffed by EMT's. The more remote you are the less training you need to be the only health care game in town.

 

[Sessamoid]

Can we do that ourselves? Or only the moderators? Ah for the old days of usenet when it was easy to trace the headers.

At least moderators, if not admins. I do miss the usenet. It's become such a morass of spam and crap for a long time now.

 

[SDN]

Same user. Banned per our troll policy.

 

[DrQuinn]

Also, I never could find the mythical suburban Dallas hospital employing only PA's in it ED. A search on mapquest and texas.com for Bowle, Bowles, Bowl, or even Bowels only found Bowles creek. I am not sure it is even a town but it is >150 miles from Dallas (not a 45 minute drive even in Texas) and the nearest hospital is 40 miles away. I did find a Bowie Texas about 80 miles from Dallas(possibly a 45 minute drive in Tx) but their hospital appears to staff MD's. As EMEDPA has shown there are PA run ED's in rural areas but the ad he posted appeared to be for a very rural ED in which the PA's were working single coverage for less than half what a suburban ED doc makes. No wonder they can't recruit ED docs. For that matter I have visited village health clinics in Alaska staffed by EMT's. The more remote you are the less training you need to be the only health care game in town.

Man, I can't wait to be an attending where I have the time to do that sort of internet snooping.

Q, DO

 

[Freeeedom!]

We had the exact OPPOSITE happen in our city ED's...stopped hiring PA's, refuse to hire NP's (bad experiences) and hire moonlighting EM residents and FP attendings instead. It speeds things up and we have more confidence in their abilities.

 

[ERMudPhud]

Man, I can't wait to be an attending where I have the time to do that sort of internet snooping.

Q, DO

Quinn >2000 posts
ERMudPhud >100 posts

 

[j-snake]

I just got caught up with the whole Vukken 99 (SoldierDO) drama.

Hilarious

 

[DrQuinn]

Quinn >2000 posts
ERMudPhud >100 posts

Quinn = 2.00 posts per day
ERMudPhud = 0.69 posts per day.

Ok, ok, I'll let you win this one.

Q, DO