"You can see the bone."

[NITRAS]

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Sometimes, late in my shift, I want to send a very basic community acquired pneumonia patient with minimal med history that I'm obs'ing from my ED in the tertiary care center I'm at and transfer him to a critical access hospital 2 hours away by med flight

Sort of relevant, but not really

Good chance they would send him back for "continuity of care". They saw a doctor in the general area that doesn't have privileges sometime in the past 5 years.

 

[RustedFox]

A decent amount of them don't have a supervising physician though! At least not on site and probably may not be sober at time of call.

This arrangement should be criminal.

 

[RustedFox]

The sound formally known as an onomatopoeia that was expressed when a cash register which was designed to use a mechanical bell was struck. This has been used lately as a pejorative to express exchange in monetary value, usually in an unscrupulous fashion. better?

Lol.

The father of my Goddaughter (and good buddy from residency) is a first-gen Chinese immigrant. One of the first jokes he ever told me was: "I'm going to name my son PingChing, because that's the sound that a Chinese cash-register would make."

 

[Zebra Hunter]

Why would you want to tell a patient that an NP or PA should've known what it is and shouldn't have sent you to the ER? We all can't know everything, and if they don't know at least they aren't just sending the patient home.

I certainly don't pretend to know everything, and I would hate it if an orthopaedic surgeon badmouthed me to a patient based on lack of knowledge or inappropriate care.

It is one thing to bad mouth someone for an unnecessary consult, it is another when not only are they unnecessarily consulting you, but they are also telling patients they will be receiving a certain unnecessary therapy. The former I can excuse, the latter is something that is inexcusable and they should be badmouthed for. The first thing I am telling someone with regard to a disease process I am not familiar with is, "I am not very familiar with this disease, as I don't see it often, so I am going to speak with the expert on this condition so that we can formulate a plan". It is certainly not "huh, I don't know what that is, but let me tell the patient I am admitting them for urgent surgery." Even when I am quite familiar with disease or injury, I make it a point to never make promises for other doctors. When I ask a patient to follow up with ortho, even if I know with 99% certainty that the patient will have surgery, I will tell them that "while surgery is the usual management for this, I will let the experts decide on what they believe is necessary as every case is different."

The problem is people don't think of ER physicians as experts in anything, and think we just magically have all the appropriate specialists just hanging out in the ER ready to evaluate patients. They think of ERs as a location rather than just another referral to a physician, which is really what it is. So we get mid-levels and PCPs that tell patients, "just go to the ER for IV antibiotics and so infectious disease can see you" or "go to the ER so plastic surgery can fix your laceration" or "go to the ER so ortho can fix your broken ankle/arm" rather than first discussing cases with us to make sure the patient is not getting false impressions on what will be done and what is necessary.

 

[Oligodinero]

A decent amount of them don't have a supervising physician though! At least not on site and probably may not be sober at time of call.

For PAs, this should absolutely never be the case. In all 50 states PAs must have SPs....and the SP must be able to be reached in emergencies if not on site.....or if the SP is on vacation then an alternate SP must be designated.
....now the NPs......yeah....we all know about their situation. Their lack of supervision is just a horrible injustice to their patients.

 

[thegenius]

Not even just lately. There was a Doonesbury strip back in the 80s that had a panel with a dermatologist cutting off a skin CA, and saying, "$500, cha-ching!"

An obscure reference to Doonesbury from about 35-40 years ago.

 

[thegenius]

I wonder if the PA read "epiploic appengiditis" really quickly and it sounded like "acute appendicitis"

If you read really fast, and are not paying attention, and maybe don't have an excellent command of English (or latin), I can see this mistake.




Still inexcusable.

 

[thegenius]

The problem is people don't think of ER physicians as experts in anything, and think we just magically have all the appropriate specialists just hanging out in the ER ready to evaluate patients. They think of ERs as a location rather than just another referral to a physician, which is really what it is. So we get mid-levels and PCPs that tell patients, "just go to the ER for IV antibiotics and so infectious disease can see you" or "go to the ER so plastic surgery can fix your laceration" or "go to the ER so ortho can fix your broken ankle/arm" rather than first discussing cases with us to make sure the patient is not getting false impressions on what will be done and what is necessary.

This needs to be copied and pasted on a postcard and sent to every single doctor in the United States, regardless of specialty.

 

[Apollyon]

An obscure reference to Doonesbury from about 35-40 years ago.

I have to be honest. I don't get this. If you are being sarcastic, I don't get it. I don't know if you are saying that Doonesbury is obscure, or just that the panel to which I refer is just as equally obscure as any other comic strip from the 80s. I mean, are you saying I should find it? Would that make it clearer? Or, is there something else?

All I'm saying is that it's not only a current thing.

 

[GeneralVeers]

The reality is that time is the big factor. Jenny doesn't want to spend the time either researching the problem, or calling us to ask our advice. It's quicker, and easier for her just to punt completely to the ER. She doesn't care about us, and doesn't care that the patient will get another big, inappropriate bill. She's just lazy, and under a time crunch from her absentee boss.

 

[thegenius]

I have to be honest. I don't get this. If you are being sarcastic, I don't get it. I don't know if you are saying that Doonesbury is obscure, or just that the panel to which I refer is just as equally obscure as any other comic strip from the 80s. I mean, are you saying I should find it? Would that make it clearer? Or, is there something else?

All I'm saying is that it's not only a current thing.

I don't know man.

The last time I thought of Doonesbury was when I read those comics in the 80s. So I would put that in the category of "obscure."

Perhaps for you, it's on the tip of your tongue, like the back of your hand, or like riding a bike.

Who knows?

 

[thegenius]

The reality is that time is the big factor. Jenny doesn't want to spend the time either researching the problem, or calling us to ask our advice. It's quicker, and easier for her just to punt completely to the ER. She doesn't care about us, and doesn't care that the patient will get another big, inappropriate bill. She's just lazy, and under a time crunch from her absentee boss.

Soon enough insurers and payors will find a way not to reimburse this crap. And we won't get paid and patients will get a huge bill.

Another unintended consequence of allowing non-doctors to play doctor.

 

[Apollyon]

I don't know man.

The last time I thought of Doonesbury was when I read those comics in the 80s. So I would put that in the category of "obscure."

Perhaps for you, it's on the tip of your tongue, like the back of your hand, or like riding a bike.

Who knows?

Good on ya. I'll take your "obscure", and raise you a "cryptic"!

 

[Fox800]

For PAs, this should absolutely never be the case. In all 50 states PAs must have SPs....and the SP must be able to be reached in emergencies if not on site.....or if the SP is on vacation then an alternate SP must be designated.
....now the NPs......yeah....we all know about their situation. Their lack of supervision is just a horrible injustice to their patients.

LOL, no. Not in North Dakota. PAs are now independent.

 

[Dr Mantis Toboggan]

The reality is that time is the big factor. Jenny doesn't want to spend the time either researching the problem, or calling us to ask our advice. It's quicker, and easier for her just to punt completely to the ER. She doesn't care about us, and doesn't care that the patient will get another big, inappropriate bill. She's just lazy, and under a time crunch from her absentee boss.

Yup, if you don’t know about it epiploic appendagitis is a 30 second search and read about on google situation

 

[southerndoc]

The issue at hand is that they send the patient AND set the expectation with the patient that "this is an emergency!" when really what they should do is call their supervising physician and act appropriately instead of blindly sending the patient and (ahem) continuing to act like a physician-equal.

I'm 10 years out. I'm pretty sure it was year 2 that I had an epiploic appendagitis. I didn't know what that was. Really; it had just never come up. You know what I did? I looked it up, read about it, learned quickly about it, and called my on-call surgeon to confirm my plan instead of reflexively admit "for them to figure it out", thereby pissing off IM, GS, and the patient.

Unfortunately, many urgent cares don't have access to a surgeon to discuss a case with. They do, however, have access to information on the condition. So I agree with you that they can look it up. Whether that warrants discussing their shortfalls with the patient is another story. I try not to ever say anything negative about another provider to a patient. Between my colleagues though, that's a different story. We all have to vent sometimes. Just don't vent to your patients. It will only backfire against you.

 

[Oligodinero]

LOL, no. Not in North Dakota. PAs are now independent.

Wow...that's news to me. Must be fairly recent....but since leaving the PA profession a couple years ago I haven't kept up with the PA world.

 

[Arodgeisfire]

Wow...that's news to me. Must be fairly recent....but since leaving the PA profession a couple years ago I haven't kept up with the PA world.

And they are pushing for more.

Almost all the new PAs I’ve worked with 100% believe the mantra that they learn everything medical students do but in a shorter time frame. Their attitudes and demeanor and overall smugness rivals the nps I’ve so joyously worked with

 

[RustedFox]

Unfortunately, many urgent cares don't have access to a surgeon to discuss a case with. They do, however, have access to information on the condition. So I agree with you that they can look it up. Whether that warrants discussing their shortfalls with the patient is another story. I try not to ever say anything negative about another provider to a patient. Between my colleagues though, that's a different story. We all have to vent sometimes. Just don't vent to your patients. It will only backfire against you.

They may not have GenSurg, but they damn well should have a SP.

 

[NYEMMED]

Unfortunately, many urgent cares don't have access to a surgeon to discuss a case with. They do, however, have access to information on the condition. So I agree with you that they can look it up. Whether that warrants discussing their shortfalls with the patient is another story. I try not to ever say anything negative about another provider to a patient. Between my colleagues though, that's a different story. We all have to vent sometimes. Just don't vent to your patients. It will only backfire against you.

I agree that I don’t down talk about other “providers” to patients.

They may not have a Surgeon to talk to but they should have google or uptodate, or they can call a SP.
I wouldn’t mind if they called me in the ED to ask if they need a emergent consult. Rather that then explain to a patient that they were sent in for me to basically do nothing...

 

[deleted480308]

Yup, if you don’t know about it epiploic appendagitis is a 30 second search and read about on google situation

I happened to have done just that because of this thread, you don’t even have to open up the search results to see a uniform “usually non-surgical” consensus

 

[Oligodinero]

And they are pushing for more.

Almost all the new PAs I’ve worked with 100% believe the mantra that they learn everything medical students do but in a shorter time frame. Their attitudes and demeanor and overall smugness rivals the nps I’ve so joyously worked with

Yeah that's terrible. They have absolutely no clue. I knew as a PA I had a broad, but superficial medical education....and I graduated with distinction and was in the 95% on my initial certification exam and all 3 of my recertification exams. Despite that, I had to do tons of reading as a PA just to begin to understand a lot of the more complex health problems I encountered. Even after that I didn't have a true in-depth understanding of the pathophysiology of what I encountered on a regular basis.....but the first 2 years of medical school opened my eyes.....it's kind of scary how much I didn't know as a PA, and humbling.

 

[MarsDominus]

And they are pushing for more.

Almost all the new PAs I’ve worked with 100% believe the mantra that they learn everything medical students do but in a shorter time frame. Their attitudes and demeanor and overall smugness rivals the nps I’ve so joyously worked with

Exactly this is why I find PAs more annoying. They think that PA school is equivalent if not better or harder than med schools. I know because I've had to work with a few smug PA students during my rotations.

 

[Fox800]

Exactly this is why I find PAs more annoying. They think that PA school is equivalent if not better or harder than med schools. I know because I've had to work with a few smug PA students during my rotations.

But they learn "everything" there is to learn in medical school, but in half the time! So, you see, it's so much tougher.

 

[deleted109597]

I really wish they would just call us and say something like "I think this patient might be sick and would appreciate your opinion" rather than lying about why they are sending the patient over, or relying on the patient to tell us everything.

I'd like the call, but i'm not offering any advice over the phone. You want to send them? Great, happy to see them. They may wait in the lobby, but we will take care of them thank you.
What I don't want is to sit on a witness stand while they paint me as downplaying an OBVIOUSLY BAD CONDITION that JENNY was TELLING ME ABOUT. Nope, don't wan't that. I feel for the patients, but I'm not taking the heat for some ***** not telling me the bad things.

 

[yeasports]

Dang, you are right; I forgot Doonesbury.

 

[NYEMMED]

But they learn "everything" there is to learn in medical school, but in half the time! So, you see, it's so much tougher.

There was one PA student who told me once the same line
"PA school is hard because we basically do all of medical school in 2 years..."

I was like oh really? Then why aren't you a physician?
"because I only went to school for 2 years not 4"

Right then, so half the education...

Then I had a Aspirin toxicity patient, We were talking about the Krebs cycle and how aspirin overdoses affect that.

Blank stare...

You do know of the Krebs cycle right? or at least how aspirin toxicity affects it?

blank stare...


Yup you did all of medical school in 2 years... Heres a book Kid...

 

[Boatswain2PA]

In fairness, I think few docs would be able to explain how asa tox effects the Krebs cycle without at least a refresher. And its not really necessary to have this deep understanding of it to recognize/identify asa tox and begin treatment.

 

[erdoc00]

In fairness, I think few docs would be able to explain how asa tox effects the Krebs cycle without at least a refresher. And its not really necessary to have this deep understanding of it to recognize/identify asa tox and begin treatment.

This highlights a major difference between physicians and "mid levels".

Physicians are supposed to be science-educated intellectuals and not technicians. It's why we are actual Doctors of medicine.

The term Doctor used to have intellectual and academic implications. Just like the SAT used to actually test aptitude. The trend with everything though seems to be dumbing everything down and turning these entities into participation trophies so that everyone can feel good about themselves. It's how we ended up with online nursing PhD programs.

 

[NYEMMED]

In fairness, I think few docs would be able to explain how asa tox effects the Krebs cycle without at least a refresher. And its not really necessary to have this deep understanding of it to recognize/identify asa tox and begin treatment.

In no way was it meant to be a knock to great PAs, I work with several I really trust. (and they know when they reach a limit in training)

It grinds my gears when (and its usually PA students and brand new PAs, who don't know how much they still do not know) that come out with the I just did med school in 2 years mentality. (but obviously they didn't)

 

[thegenius]

How smart do you have to be to learn all that material in half the time?!?! But wait, not smart enough to learn all that material and do it for 3x the pay?? Huh.

I think medical students would sign up for a med school in an instant if they could get their MD degree in 2 years and not 4.

Hmm...

If you could get it in 2 years, then you wouldn't be learning as much.

Hmm...

 

[Boatswain2PA]

In no way was it meant to be a knock to great PAs, I work with several I really trust.

No worries, I certainly didnt take it as a knock.

I think the greatest difference in Med/PA education isnt med school so much as it is the residency where you are exposed to much greater depth of everything related to the specialty.

 

[Lexdiamondz]

No worries, I certainly didnt take it as a knock.

I think the greatest difference in Med/PA education isnt med school so much as it is the residency where you are exposed to much greater depth of everything related to the specialty.

While residency is where you truly learn to be a physician, I would actually argue for generalist fields like EM, IM and FM the breadth and depth of basic science material learnt in medical school is pretty relevant. Do you need to remember every minute detail of Step 1? No. But there are plenty fundamental principles of physiology that I use every day that I was expected to know coming into residency - especially since this is a specialty where you deal with sick people with altered physiology.

 

[RustedFox]

There was one PA student who told me once the same line
"PA school is hard because we basically do all of medical school in 2 years..."

I was like oh really? Then why aren't you a physician?
"because I only went to school for 2 years not 4"

Right then, so half the education...

Then I had a Aspirin toxicity patient, We were talking about the Krebs cycle and how aspirin overdoses affect that.

Blank stare...

You do know of the Krebs cycle right? or at least how aspirin toxicity affects it?

blank stare...


Yup you did all of medical school in 2 years... Heres a book Kid...

I can see a situation where the PLP thought that the Krebs Cycle was a new piece of exercise equipment.

We had one like that. Loved obstacle course races, couldn't *science*.

 

[Boatswain2PA]

We had one like that. Loved obstacle course races, couldn't *science*.

A PA or a NP? PA school isnt med school, but there is lots of science in there (and required before you can get in).

 

[EMhawkeye]

A PA or a NP? PA school isnt med school, but there is lots of science in there (and required before you can get in).

Cursory yes.

 

[RustedFox]

A PA or a NP? PA school isnt med school, but there is lots of science in there (and required before you can get in).

In this case, it was a PA - who likely thought that "PA" stood for "Physical Activity", because all she would ever talk about is the next "Tough Mudder" or variant.

 

[Fox800]

My own run-in with Jenny last week:

Be me, working in a rural (but fairly high-functioning) non-trauma center ED in a small town that has some money.
Get a call from a nearby smaller town. Obviously a midlevel because the operator there is requesting I speak to the "provider".
Jenny: Hi there, I've got a 15 year old male that was thrown off an ATV. I did some x-rays and he has a fracture of the elbow...and there's a dislocation. My radiologist says it needs to be reduced with sedation but I don't feel comfortable doing that. I talked to my orthopedic surgeon and they said to put it in a splint and have them come to the clinic.

Me: So you have a 15 year old patient with a fracture-dislocation of the elbow?
Jenny: That's right
Me: And they were thrown from an ATV? How fast were they going?
Jenny: I'm not sure...
Me: It sounds like they need a trauma work-up. What other imaging did you do?
Jenny: An elbow x-ray.
Me: They probably need a chest x-ray, pelvis x-ray, a FAST exam, and perhaps CT imaging of the head and neck.
Jenny: ***Silence for a bit**...also they are having numbness of their pinky and ring fingers.
Me: So you're saying they now have ulnar nerve entrapment?
Jenny: I guess so.
Me: Yeah, we aren't a trauma center. It sounds like your patient has had a significant traumatic injury and now has an extremity with a neurologic deficit. I think they would be best-served at trauma center. I'm sorry but it would not be appropriate to transfer them here.
Jenny: OK
Me: (internally) WTF

 

[DrDuck2]

at a certain point in ones car

I was sent a greatest urgent care referral last night....

Urgent care referral form: Patient has a Baker’s cyst...

I actually called the urgent care and spoke with Jenny McJenerson...

She said: “well that what the ultrasound showed and I figured it would need a emergent ortho consult and surgery”

Sure, I’ll be happy to give your patient a referral to an outpatient Ortho, for a non-urgent finding....
Click ...

Sometimes I think you guys are making this up.... Day 1 of residency is next week, I guess I will see lol