Comments on: Physician assistants and nurse practitioners are staffing rural ERs full time http://www.kevinmd.com/blog/2009/01/physician-assistants-and-nurse.html Tue, 14 Feb 2012 17:18:00 +0000 hourly 1 By: Anonymoushttp://www.kevinmd.com/blog/2009/01/physician-assistants-and-nurse.html#comment-89284 Anonymous Sun, 18 Jan 2009 16:17:00 +0000 http://clients.emmense.com/kevinmd/2009/01/physician-assistants-and-nurse-practitioners-are-staffing-rural-ers-full-time.html#comment-89284 This is sort of an amalgam of some earlier comments, but ...<br/><br/>At our (urban) ED 80-90% of what comes in the door (excluding the stuff in the trauma bays) is BS related to either a lack of (access to) primary care or an entitlement attitude that you can get free and immediate care by calling 911 and getting a ride to our ED (because everyone knows we won't try to collect on a bill). Any NP/PA (or heck, good 4th year med student) can deal with these people.<br/><br/>That leaves the 10-20% which truly require intervention and admission. As someone pointed out, one issue is correctly identifying these people (I'm pretty sure that once they do, they could keep most folks alive for 30 minutes so an MD could see them).<br/><br/>The other issue is the MD staffing one. Sure you'd probably get better outcomes if you had an BC/BE ED MD on site 24/7, but if the choices are between closing an ED in a rural area or staffing with extenders and causing some excess of deaths compared to an MD staffed ED, I'm pretty sure the open ED actually saves lives vs the extra travel time (ie if you close the ED, the nearest ED isn't 30 minutes away, it is an hour). This is sort of an amalgam of some earlier comments, but …

At our (urban) ED 80-90% of what comes in the door (excluding the stuff in the trauma bays) is BS related to either a lack of (access to) primary care or an entitlement attitude that you can get free and immediate care by calling 911 and getting a ride to our ED (because everyone knows we won’t try to collect on a bill). Any NP/PA (or heck, good 4th year med student) can deal with these people.

That leaves the 10-20% which truly require intervention and admission. As someone pointed out, one issue is correctly identifying these people (I’m pretty sure that once they do, they could keep most folks alive for 30 minutes so an MD could see them).

The other issue is the MD staffing one. Sure you’d probably get better outcomes if you had an BC/BE ED MD on site 24/7, but if the choices are between closing an ED in a rural area or staffing with extenders and causing some excess of deaths compared to an MD staffed ED, I’m pretty sure the open ED actually saves lives vs the extra travel time (ie if you close the ED, the nearest ED isn’t 30 minutes away, it is an hour).

]]> By: Throckmortonhttp://www.kevinmd.com/blog/2009/01/physician-assistants-and-nurse.html#comment-89275 Throckmorton Sat, 17 Jan 2009 21:39:00 +0000 http://clients.emmense.com/kevinmd/2009/01/physician-assistants-and-nurse-practitioners-are-staffing-rural-ers-full-time.html#comment-89275 We have seen a significant increase in our transfer numbers from the outside ERs that are only staffed by PAs and NPS. My groups own experience is that the description of the patient more times than not is not accurate of what is really going on. This was shared at our last medical staff meeting. Because of EMTALA, our staff pretty much has to accept the patients but they are afraid to accept them because they really have no idea of what is going on with them, much less if they are stable. <br/><br/>These are some of the cases that were presented at our last staff meeting.<br/><br/>Patient diagnosed with severe renal colic witg stones and obstruction. Actually had a disecting aorta. (Was sent to urology)<br/><br/>Several severe pneumonias with shortness of breath. (They needed intubation and actually had cardogenic shock. Pneumonia was pulmonary edema)<br/><br/>Numerous cases of patients who needed to be intubated and stabilized prior to transfer who were not.<br/><br/>What really scares me is that at least these patients made it to the medical center. What about the patients that are sent home from the ER? We have seen a significant increase in our transfer numbers from the outside ERs that are only staffed by PAs and NPS. My groups own experience is that the description of the patient more times than not is not accurate of what is really going on. This was shared at our last medical staff meeting. Because of EMTALA, our staff pretty much has to accept the patients but they are afraid to accept them because they really have no idea of what is going on with them, much less if they are stable.

These are some of the cases that were presented at our last staff meeting.

Patient diagnosed with severe renal colic witg stones and obstruction. Actually had a disecting aorta. (Was sent to urology)

Several severe pneumonias with shortness of breath. (They needed intubation and actually had cardogenic shock. Pneumonia was pulmonary edema)

Numerous cases of patients who needed to be intubated and stabilized prior to transfer who were not.

What really scares me is that at least these patients made it to the medical center. What about the patients that are sent home from the ER?

]]> By: Anonymoushttp://www.kevinmd.com/blog/2009/01/physician-assistants-and-nurse.html#comment-89268 Anonymous Sat, 17 Jan 2009 06:12:00 +0000 http://clients.emmense.com/kevinmd/2009/01/physician-assistants-and-nurse-practitioners-are-staffing-rural-ers-full-time.html#comment-89268 Anon 8:13 you totally missed the point. Tre(o)y stated "I spent as many years in school and training as a family practice doc". Which is patently false. By the way, I am not an FP. Frankly given the constant abuse of this specialty it amazes me that anyone still goes into FP. The problem here is someone who thinks he is equal to an FP yet never went to med school or did a residency. I personally have no problems with PA/NP's when they act within their scope of practice. But I also don't think 6=11. Anon 8:13 you totally missed the point. Tre(o)y stated “I spent as many years in school and training as a family practice doc”. Which is patently false. By the way, I am not an FP. Frankly given the constant abuse of this specialty it amazes me that anyone still goes into FP. The problem here is someone who thinks he is equal to an FP yet never went to med school or did a residency. I personally have no problems with PA/NP’s when they act within their scope of practice. But I also don’t think 6=11.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2009/01/physician-assistants-and-nurse.html#comment-89262 Anonymous Sat, 17 Jan 2009 01:13:00 +0000 http://clients.emmense.com/kevinmd/2009/01/physician-assistants-and-nurse-practitioners-are-staffing-rural-ers-full-time.html#comment-89262 I am sooo special that 6 + me = 11 I am sooo special that 6 + me = 11

]]> By: Anonymoushttp://www.kevinmd.com/blog/2009/01/physician-assistants-and-nurse.html#comment-89261 Anonymous Sat, 17 Jan 2009 01:11:00 +0000 http://clients.emmense.com/kevinmd/2009/01/physician-assistants-and-nurse-practitioners-are-staffing-rural-ers-full-time.html#comment-89261 i have seen many excellent midlevel providers. this troy guy has the one thing that stands out to me in a bad midlevel- not knowing one's limits.<br/><br/>god help the zebra that walks into this guy's ED. i have seen many excellent midlevel providers. this troy guy has the one thing that stands out to me in a bad midlevel- not knowing one’s limits.

god help the zebra that walks into this guy’s ED.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2009/01/physician-assistants-and-nurse.html#comment-89259 Anonymous Sat, 17 Jan 2009 01:07:00 +0000 http://clients.emmense.com/kevinmd/2009/01/physician-assistants-and-nurse-practitioners-are-staffing-rural-ers-full-time.html#comment-89259 Trey-<br/><br/>As a board-certified Internist, i have NEVER seen a pericardiocentesis performed, except on the hit tv show ER! Do they teach that in NP school? Trey-

As a board-certified Internist, i have NEVER seen a pericardiocentesis performed, except on the hit tv show ER! Do they teach that in NP school?

]]> By: Anonymoushttp://www.kevinmd.com/blog/2009/01/physician-assistants-and-nurse.html#comment-89258 Anonymous Sat, 17 Jan 2009 01:00:00 +0000 http://clients.emmense.com/kevinmd/2009/01/physician-assistants-and-nurse-practitioners-are-staffing-rural-ers-full-time.html#comment-89258 two questions-<br/><br/>1. trey or troy?<br/>2. do you have your patients call you "doctor?" two questions-

1. trey or troy?
2. do you have your patients call you “doctor?”

]]> By: Anonymoushttp://www.kevinmd.com/blog/2009/01/physician-assistants-and-nurse.html#comment-89257 Anonymous Sat, 17 Jan 2009 00:29:00 +0000 http://clients.emmense.com/kevinmd/2009/01/physician-assistants-and-nurse-practitioners-are-staffing-rural-ers-full-time.html#comment-89257 "am not a midlevel I am not a nonphysician or extender. I spent as many years in school and training as a family practice doc"<br/><br/>So by saying that you are "not a nonphysician" therefore you are saying you ARE a physician. <br/>An FP spent 4 years in undergrad, 4years in med school, and 3 years in residency. You spent 4 years in undergrad (assuming you are a BSN) and two years in NP school. Out of curiousity how does 6=11? “am not a midlevel I am not a nonphysician or extender. I spent as many years in school and training as a family practice doc”

So by saying that you are “not a nonphysician” therefore you are saying you ARE a physician.
An FP spent 4 years in undergrad, 4years in med school, and 3 years in residency. You spent 4 years in undergrad (assuming you are a BSN) and two years in NP school. Out of curiousity how does 6=11?

]]> By: Treyhttp://www.kevinmd.com/blog/2009/01/physician-assistants-and-nurse.html#comment-89254 Trey Fri, 16 Jan 2009 20:08:00 +0000 http://clients.emmense.com/kevinmd/2009/01/physician-assistants-and-nurse-practitioners-are-staffing-rural-ers-full-time.html#comment-89254 I am one of those NPs caring for patients in the ED. I regularly diagnose ARF, CKD, CHF exac, AMI, PE, COPD exacerbation, PNU, RSV, acute abd -perforations, illeus, SBO, anaphylaxis... I can readily determine toxic from non-toxic. I intubate, place chest tubes perform pericardiocentesis, needle decompression of pneumothorax, lumbar puncture... <br/>I have seen surgeons, internists and family docs misdiagnose and miss stuff -plenty. I am not a midlevel I am not a nonphysician or extender. I spent as many years in school and training as a family practice doc. I am a board certified family practice NP and provide superior complex healthcare to those I serve.<br/><br/>Troy I am one of those NPs caring for patients in the ED. I regularly diagnose ARF, CKD, CHF exac, AMI, PE, COPD exacerbation, PNU, RSV, acute abd -perforations, illeus, SBO, anaphylaxis… I can readily determine toxic from non-toxic. I intubate, place chest tubes perform pericardiocentesis, needle decompression of pneumothorax, lumbar puncture…
I have seen surgeons, internists and family docs misdiagnose and miss stuff -plenty. I am not a midlevel I am not a nonphysician or extender. I spent as many years in school and training as a family practice doc. I am a board certified family practice NP and provide superior complex healthcare to those I serve.

Troy

]]> By: Anonymoushttp://www.kevinmd.com/blog/2009/01/physician-assistants-and-nurse.html#comment-89253 Anonymous Fri, 16 Jan 2009 19:08:00 +0000 http://clients.emmense.com/kevinmd/2009/01/physician-assistants-and-nurse-practitioners-are-staffing-rural-ers-full-time.html#comment-89253 First of all, NPs and PAs are not interchangeable. PAs get more medically oriented clinical and didactic training in diagnosis. PA clinical rotations average 2000 hours, NPs 800 hours. With the new trend toward "entry level masters NPS" (accepting someone with a non-nursing bachelor's degree for RN and NP training combined at the master's level and only two years long), NPs are being graduated with less experience and less clinical training than PAs, regardless of their antecedent careers. These programs are very popular and popping up all over.<br/><br/>Secondly, no one will know if this is problematic until you study the problem.....i.e., take these hospitals, a comparable rural hospital staffed with non BC/BP docs, and then a comparable hospital staffed with BC/BP docs, with even patient mix. There are hospitals in Michigan which fit each criterion and would make an excellent study. The proof will be in the pudding and not the opinion. First of all, NPs and PAs are not interchangeable. PAs get more medically oriented clinical and didactic training in diagnosis. PA clinical rotations average 2000 hours, NPs 800 hours. With the new trend toward “entry level masters NPS” (accepting someone with a non-nursing bachelor’s degree for RN and NP training combined at the master’s level and only two years long), NPs are being graduated with less experience and less clinical training than PAs, regardless of their antecedent careers. These programs are very popular and popping up all over.

Secondly, no one will know if this is problematic until you study the problem…..i.e., take these hospitals, a comparable rural hospital staffed with non BC/BP docs, and then a comparable hospital staffed with BC/BP docs, with even patient mix. There are hospitals in Michigan which fit each criterion and would make an excellent study. The proof will be in the pudding and not the opinion.

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