Jul 18, 2012
1,663
12
I am from the United States of America
Status
Pre-Medical
I've noticed recently a lot of posts about "clinical experience" and what constitutes as clinical experience, and what the pros and cons are of clinical employment. There've been a few scribe vs CNA vs PCA vs EMT discussions, and whether or not any of these jobs is really necessary, as well as some questioning of the motives of why people sought clinical employment in the first place, and whether or not such a job will "look good". At the root of many of these discussions seems to be a very fundamental confusion regarding the roles and responsibilities of these aforementioned jobs that.

As a PCA, I'm obviously biased in this argument. But, a few days ago, I thought of the bright idea to give a real-time synopsis of my day as an example of what a typical PCA does over the course of the day, and I chose today to be that day. I quickly realized that such a synopsis would be OUTRAGEOUSLY long, so I instead recorded a synopsis of the first 2 hrs of my shift today.

This is a LONG read (you've been warned), but maybe worthwhile for those who are on the fence about whether or not to pursue a clinical job, or those who are just confused as to what such a role entails. Either way, I hope it is helpful, interesting, and at least a little entertaining, so here it goes:

Some background: I work in the ED at a hospital in New England, and have been for 2.5+ years. It is both a trauma center and a tertiary care center, as well as an academic hospital. (Please don't try to guess which hospital this is, I won't respond to any speculations...). For the sake of HIPPA, all of the patient names I used are false, and the ages are approximations. Also, all medical information I've included is based solely on my own experience and perceived basic understanding of basic medical information I have learned on the job. I am not a doctor, and I do not claim to be, and all medical information I post should be taken as nothing more than the speculation of a premed.


8:00 I arrive at the hospital, and find my assignment. There are 3 "pods" that I may be assigned to work in each day...The one I am working in today is closed overnight, and begins taking patients at 800 - the beginning of my shift. The first patient (MR. Smith) has already arrived as I am putting my coat/bag in my locker. Mr. Smith is a transfer from an outside hospital (OSH). He presented to the OSH from rehab with altered mental status (AMS) from baseline and lethargy, and was found (via CT scan) to have bilateral subarachnoid hemorrhages. He was transferred to us for a neurosurgery consult and admission to the ICU.
When a patient as sick as this guy arrives right at the beginning of my shift, it's usually an ominous sign of an unusually busy day, so I get ready for the worst! On top of that, usually the pod is staffed by 2 PCAs, but I quickly realize there was a sick call, and I am the only one. Also, I am hungry because I did not eat breakfast, thirsty, and my nose is running because it is absurdly cold and windy outside.

8:05 Mr. Smith is moved from the EMS stretcher to a ED stretcher. He weighs almost 200 kilos. EMS gives report about his present illness, but knows little about his medical history. He has never been to our hospital before, so we also can't find much info about him. Given he came from a rehab, as well as the hunch of the ED staff, he probably has significant past neurological history. The patient presents intubated, on no sedation and minimally responsive, with a 20 gauge IV catheter in his hand for access and on some IV drip (I don't remember which one). The staff in the room are myself, 2 nurses, an EM resident and EM attending, as well as Neurology and Neurosurgery residents and a respiratory therapist.

Per my role as a PCA, I obtain his first set of vital signs, attach him to the cardiac monitor, and remove his clothing and excess blankets/sheets while listening to EMS give report to the NSGY and EM residents. Meanwhile, the respiratory therapist assesses the patient's ET tube, secures the ventilator and programs the vent settings based on the report. Nursing is working to establish better access.

8:10 After obtaining vital signs, I shoot off an EKG and get a finger stick as standard procedure for CVA patients and AMS patients. Simultaneously, NSGY is performing and verbalizing his neuro exam. The team decides the patient needs a CT-Angiogram (he did not receive one at the outside hospital, likely because they didn't want to wait for his kidney function labs to come back before transferring him - IV contrast is very toxic to the kidneys). A CTA requires an 18 gauge or better for access, so nursing works to place a larger bore IV in his arm while the respiratory therapist and myself place him on portable vent/portable monitor for transport to the CT scanner.

8:15 Nursing finally successfully places an 18 gauge in his forearm. Not an easy feat considering the patient's morbid obesity and likely significant medical history including diabetes and peripheral vascular disease (a hunch). We leave for the CT scanner. As usual, the NSGY resident (or maybe it was the neuro resident, I don't remember) tries to help by steering and pulling on the stretcher while I drive despite me asking him not to. I drive much better without someone pulling on the front of the stretcher. We crash into many side carts and chairs, and other ED staff and visitors try to escape our wake of destruction.

8:17ish We arrive at the scanner. Nursing, respiratory and I try to untangle all of the IV tubing, monitor cables and ventilator tubing before moving the patient onto the scanner. The staff present in the scanner are neuro, NSGY, 2 nurses, respiratory, myself and the CT tech. I end up having to roll the patient myself while neuro and NSGY furrow their brows and make important decisions amongst themselves and while the nurses try to catch up on documentation. The patient is very heavy. We place a board under him, and struggle to slide him on to the scanner. He barely fits. We flush the line to confirm it has not infiltrated, and the Tech preps the dye injection.

8:20 In the imaging room, the CT tech prepares the scanner. The patient is now bucking on the ET tube, and his pressure is 200/sys. Uh oh. The NSGY resident has decided to place an EVD (extra ventricular drain) into the patient's skull and then place a central line after reading the CTA and confirming god-knows-what (most NSGY stuff is way over my head) All I know is placing an EVD in the ED (a very uncontrolled environment) is usually a ****show, so I try to hide my grimace.

8:30 the CTA is done. I can tell there definitely significant blood in his subarachnoid space, but I don't know much else by looking at the scan. NSGY magically decides that the patient is a candidate for IR intervention. Duly Noted. On the way back to the room, NSGY asks me to grab him the EVD placement kit. I was already planning on that :).

8:33ish We arrive back to the ED bay. NSGY starts preparing for the placement. This is a pretty large-scale procedure compared to most ED procedures. It's entirely sterile, and the NSGY resident will drill into the patient's skull to place a bolt through which blood can be drained, and also (equally importantly) through which ICP (intracranial pressure) can be monitored. I grab the EVD kit, clippers to shave the patient's head, a pole to attach the pressure-monitoring transducer and pump channels for IV infusions. I also grab an arterial line (A-Line) placement kit. 2+ years in this job allows me to anticipate that this will be needed since an A-Line is used to monitor blood pressure more accurately and in real time, which is extremely important in CVA patients.

8:35 I return to the room with all of the equipment, and pat myself on the back when the EM resident asks for an A-Line kit. I tell her it's already in the room and hand the NSGY resident the clippers so he can shave the patient's head.

8:40 During the last 40 minutes when we were caring for Mr. Smith, 2 more patients had arrived in our pod, and the chief complaints (CC) are as follows: Ms. Jones, 25, has a hand injury status post (s/p) a fall on the ice and Mr. Dupree, 50 y/o, complains of "right sided pain". I am also responsible for caring for these patients, so I excuse myself from Mr. Smith's room for a moment. This isn't too big of a deal, since as a PCA, I really don't have much of a role in EVD placement. (I've seen at least 20 of them, so the observation value is pretty low by now as well, but it is a very cool procedure.) I ask the nurse who is taking care of these two patients what she needs from me. I come to find out that Mr. Dupree has a long history, including cardiomyopathy, two prior heart transplants, as well as renal insufficiency and hypothyroidism.

8:45 I meet Mr. Dupree first. He is a nice guy, and I crack some jokes about him changing into our hospital gown and how I was sure he'd rather be at the bruins game than the ED (he was wearing a bruins jersey). He needs an EKG given his history and CC, but fortunately, a PCA that works out at the front desk did one already. (Hospital policy requires that ED patients with certain complaints and risk factors receive EKGs within 10 minutes of arrival to screen for Myocardial Infarction). I put him on the cardiac monitor, give him a call bell, and tell him to call out if he needs anything.

8:50 I meet Ms. Jones, and take her to X-ray to get films of her hand. She is a sweet, spanish speaking girl (I know only minimal spanish). She tells me her story of what happened to her, and about how she broke her hand when she was a kid because a bully pushed her.

8:55 I throw on a cap and mask, and check in on Mr. Smith's room. NSGY is hard at work on the EVD placement, and in "the zone". the EM resident is struggling to place an A-Line (apparently this is exceptionally difficult on large patients with PVD), and nursing is working for more access so they can hang Keppra. Currently they are running propofol for sedation during the procedure, as well as Vancomycin which is one of the standard antibiotics required for such an invasive procedure as EVD placement. I ask if anyone needs anything. The nurse asks me for 4 60cc syringes and a filter so they can dilute and administer mannitol (which lowers ICP, I forget how but look it up if you're interested). The filter is required because Mannitol tends to crystallize.

8:57 I come back with the syringes. "Need anything else?" Nursing: "Ya, can you chart all of the vital signs we've taken so far?" We've been taking vital signs every 10ish minutes since he arrived, so I copy them off the monitor. His pulse has been stable, and his blood pressure has improved now to the 140s. I am pretty sure this is near the target blood pressure for CVA patients, so this is good news.

9:00 A new patient (Mrs. Leroy), 40y/o, complaining of 10/10 back pain. She needs help removing her coat and standing up from the wheel chair. I help her up and pretty much support her full body weight while I walk her to the stretcher. She states she doesn't need help changing into her gown. I come back with a pillow and a warm blanket after she changes. Meanwhile, Mr. Dupree needs an x-ray. His nurse is drawing labs, so I'll come back when she's done.

9:05 Hang out and catch up at the nursing station. The charge nurse comes by to check on us, and we thank him for giving us such a sick neuro patient at 800 in the morning. He doesn't seem remorseful. I introduce myself to the other EM resident since its the first time we've worked together, and I'm a damn friendly person.

9:10 I drink some water, pee, and sit down for the first time all shift. I discover that another PCA should be arriving at 1000, so there is light at the end of the tunnel.

9:15 Mr. Dupree is ready to go to x-ray. I remove him from the monitor, and push his stretcher over to the x-ray room. He is shirtless, sporting an obvious and large scar down the center of his chest, certainly from multiple heart surgeries and transplants. I ask him if he wants to put his gown back on and "show off our hospital's colors", and he says "not really".
I've gotta sympathize with patients like him - he is a big, lean guy and was probably extremely healthy till his heart finally tanked on him, and it was probably VERY sudden. His cardiomyopathy is genetic, so he only has bad genes to thank for all his health problems. He probably hates feeling sick and probably hates being a patient. I know if I were in his shoes, I'd feel the same way. He puts the gown on anyway, and I push him to x-ray.

9:20 Check back in on Mr. Smith. He is definitely the sickest patient I have right now, so I am pretty much constantly keeping my eye on that room, making sure everything is okay. I look specifically for neuro residents yelling and waving their hands around in fear, and listen for explosions (seriously) or carts being knocked over. I recall the story I heard about a sterile drape catching on fire while a NSGY resident cauterized a bleeder right after using an alcohol based prep.

9:25 the EVD placement is complete. Also, the A-Line has been placed and nursing got another IV, so everything is working out pretty well. Quite honestly, EVD placement and CTA all within 90 minutes of arrival is pretty good, so props to everyone involved. The NSGY resident wants to now place a central line. The Neuro attending apparently convinces him that IR is more important, the patient's vitals are more or less stable and the central line can wait till later. The EM resident starts giving pass off to the ICU team and IR team, and nursing calls report. Paperwork is beginning to be copied.

9:30 Mr. Dupree is back from x-ray. I put him back on the monitor, take his vital signs and give him a blanket (it gets pretty cold in the ED). I ask him how his x-ray went, and if it was everything he hoped and dreamed it would be.

9:35 New patient, Mr. Lovekill, arrives. He is 60 y/o, has a history of some type of cancer, which is in remission, and is complaining of palpitations. He needs an EKG (I judge this based on my excellent critical thinking skills). I help him get undressed, and obtain his EKG. His EKG shows Atrial fibrillation with Rapid Ventricular Response (RVR - which means rate of 100+) and a right bundle branch block (RBBB). His heart rate is actually in the 130s, and his pressure is in the high 90s, so I realize this patient is potentially going to be a bit of a problem. There are no old EKGs in our database, so I ask him if he has a cardiac history. He says he has a history of afib (well at least that's not new), so I'm a little more comforted. I set his blood pressures to cycle every 5 minutes since he is hypotensive, and show the attending the EKG. I make sure to tell her he is hypotensive, but that he does have a history of afib. She glances at it quick just as a spot check to make sure there is no ST-segment elevation (indicative of MI), and gives it back to me. I hand it to the resident.
I tell nursing what the EKG showed, and return to the patient with a pillow, a blanket, and a chair for his wife. They recognize me from the last time they were at the hospital, and remember where I grew up and where I went to undergrad from our past conversations. I feel bad for not recognizing them, but I don't think they take it personally. I let him know that he's likely going to have a chest x-ray and blood drawn/labs sent, and I tell them to call out if they need anything. The patient asks for a double scotch. I throw a code cart with a defibrillator in front of the room, 'just in case'.

9:45 Two more patients arrive - Mr. and Mrs. Daywalker. They both need their final rabies shots. Checking into the ED is apparently the most efficient way to get rabies shots. I'll check on them later. Mr. Smith is almost ready for transport.

9:55 Mr. Lovekill's pressure is tanking (80s) and everyone is wringing their hands. He is still mentating well and reporting no new symptoms, so it is comforting that he is tolerating the hypotension. The attending verbalizes words like "electrical cardioversion" and "diltiazem" which is making the patient visibly uneasy. His nurse starts looking for some extra access, 'just in case'.

10:00 My coworker arrives on a big white horse with a shiny sword. Help is finally here! She transports Mr. Smith to IR while I stay on the floor to take care of the other 5 patients and a few new ones. As things settle down slightly, I finally start some of my bread an butter work, such as QCing glucometers and stocking rooms. [The IR team ultimately (after 50 minutes of posturing, deliberating and measuring) that Mr. Smith is too big to safely fit on the IR table, so he ends up going to the unit instead.]

The End! That's the first 2 hours of my day today. Now, obviously, not every day do you end up with ICU patients at 800 sharp, and every day has rushes and lulls, but I think this is a pretty fair representation of a pretty normal day as an ED PCA. Let me know if you have any questions/comments/your own stories!
 
Last edited:

katiemaude

7+ Year Member
Apr 5, 2010
439
154
Status
Medical Student
Thank you for that detailed post. :)

I'm sure it will be interesting to a premed considering a nursing assistant position. It definitely shows how much you can experience in the position and absorb by actually participating in patient care, versus shadowing.

I have worked as a PCA (working on all kinds of floors, including ICUs and the ED) and I'm currently a tech in an operating room. It's been illuminating having a front row seat for various procedures and watching physicians from many different specialties in action. It also helped me confirm that medical school was the right path for me when there are so many fulfilling jobs in healthcare that I also could have pursued.
 
OP
G
Jul 18, 2012
1,663
12
I am from the United States of America
Status
Pre-Medical
Thank you for that detailed post. :)

I'm sure it will be interesting to a premed considering a nursing assistant position. It definitely shows how much you can experience in the position and absorb by actually participating in patient care, versus shadowing.

I have worked as a PCA (working on all kinds of floors, including ICUs and the ED) and I'm currently a tech in an operating room. It's been illuminating having a front row seat for various procedures and watching physicians from many different specialties in action. It also helped me confirm that medical school was the right path for me when there are so many fulfilling jobs in healthcare that I also could have pursued.
A lot of premeds think that clinical jobs will serve to make you "look good" to medical schools, but you and I both know that's really not what it's about :)