1 Role of the PA in EM Flashcards
About ____% of all PAs work in Emergency Medicine
13%
2nd largest specialty after surgical subspecialties
And 19% of newly certified PAs practice in urgent care or ED
Advantages of ED PAs
Cost effective
Efficient
Reduce wait times
Increase patient satisfaction
Provide care in underserved areas
What items are in the top basket of the crash cart?
Large gloves Surgical cone mask Defibrillator pads Adult multi-function electrodes Peds Multi-function electrodes
What items are in the bottom basket of the crash cart?
Adult BVM with adult masks
Peds BVM with #2, 3, 4 masks
5in1 connector and O2 tubing
What hangs off the right side of the crash cart?
Sharps container
What hangs off the left side of the crash cart?
O2 tank and gauge
Adult and Peds crash cart inventory list
Anaphylaxis treatment guide
What will you find on the back of the crash cart?
Clipboard with: • Procedures sheet • Crash cart check off list • Pharmacy charge sheet • Code blue team sign in sheet • Code blue record sheets
Backboard
What will you find in the first drawer of the crash cart?
ADULT DRUGS
Amiodarone Atropine Calcium chloride Dextrose Dopamine Epi Lidocaine Sodium bicarbonate Sodium chloride Sterile water Vasopressin Povidone-iodine swabstick Alcohol swabs Blank labels
What will you find in Drawer 2 of the crash cart?
IV SOLUTIONS AND PEDS DRUGS
Peds: Atropine Sodium bicarb Saline flush syringes Sodium chloride
IV:
Sodium chloride 0.9% 100 ml
Dextrose 5% 250 ml
Sodium chloride 0.9% 1000ml
What will you find in Drawer 3 of the crash cart?
ADULT INTUBATION SUPPLIES
Macintosh #3, #4
Miller #3
14 Fr styles
What will you find in Drawer 4 of the crash cart?
PEDS INTUBATION SUPPLIES
Miller #0-2, Macintosh #2
Peds 8 Fr
Neonatal 6 Fr
What will you find in Drawer 5 of the crash cart?
IV START SUPPLIES
What will you find in Drawer 6 of the crash cart
IV SUPPLIES AND TUBING
What will you find in Drawer 7 of the crash cart?
PROCEDURE TRAYS
Surgeon’s gloves Sensi care latex free gloves Sutures Cut down packs Crico pack**
What are the three most common supervision models utilized for PAs in the ED?
PA sees patients fairly autonomously and consults PRN with the supervising physician
PA sees patients, physician follows up with each patient as well
Physician sees all patients outside of PA scope and available for second opinions
What are the different parameters that determine a PA’s scope of practice in the ED?
State laws and regulations
Facility/institution policies
Experience/expertise of the PA
Supervising physician delegation
Commonly performed procedures for ED PAs
Wound exploration and de ride meant Simple/multiple layer laceration repair Incision and drainage of abscess Removal of RB from (ENT or soft tissue) Arthrocentesis Lumbar puncture Slit lamp exam Emergency ultrasonography Nail trephination/removal Closed reduction of fractures and dislocations
Advanced procedures that PAs may or may not perform in the ED
Rapid Sequence intubation Cricothyrotomy Needle thoracentesis Chest tube thoracotomy Central/arterial line placement Procedural sedation Provide medical direction for EMS
Top 10 reasons for ED visits
Abdominal pain Chest pain Fever Cough HA SOB Back pain Pain (other) Laceration Throat symptoms
What are some examples of RED FLAGS in a patient’s history?
Sudden onset of Sx (esp if fist episode) Rapid, significant worsening of Sx Altered level of consciousness or loss of consciousness CV/Pulm Sx (dyspnea, CP) Extremes of age Immunocompromised Poor historian Frequent, recent ER visits Unvaccinated or under-vaccinated Patient signed off to you at the end of shift****
_________ is an extremely important first impression
General appearance
Are they uncomfortable? What is their level of social interaction Hydration status Lethargy Diaphoresis Skin changes (pallor, jaudice)
How can you tell a peds pt is dehydrated?
Crying but with minimal tear production
How to be mindful in the ED
Listen carefully, even if you feel “time crunched”
Don’t act rushed (patients can tell…)
How to be thoughtful in the ED?
Speak slowly, avoid medical jargon
Utilize translator if needed (even if they have a family member - might not be a reliable translator)
What are some ways to be sensitive to patients in the ED?
Focus on the patient
Offer to tie the patient’s gown
Share normal findings immediately
If there is an abnormal finding, let the patient know if it is not a concern at the time (REASSURANCE!)
How to be gentle in the ED
Examine non-tender areas first
Warn patient prior to examining painful area
How to be thorough in the ED
Check skin
Check for pain above and below a joint injury
How to be efficient in the ED
Not all patients need a full exam
Base exams on your differential diagnoses
What things do you need to re-evaluate regularly in the ED?
Review vitals
Appearance
Pain level
Response to interventions
What things do you need to make sure you “wrap up” before discharge?
Recheck vitals prior to discharge (don’t trust others to do it for you)
CLEAR DISCHARGE INSTRUCTIONS
Ask if the patient has questions before they leave
PAs in triage reduce patients who leave without being seen by _____ and patient wait times by _____.
80%
50%
PAs aid in compliance with ….
EMTALA (Emergency Medical Treatment and Labor Act)
What is EMTALA?
Ensures all individuals access to emergency care, regardless of citizenship, legal status, or ability to pay
May transport patient to another facility only if needed
Requires medical screening exam (MSE), which must be done by a PA/NP/Physician (not RN) to determine if an emergent medical condition exists
PAs may perform ______ for EMTALA as long as written hospital policy specifies
Medical Screening Exams (MSEs)
In which cases may PAs initiate hospital transfers under EMTALA?
PA must consult SP first
SP must co-sign the order within the timeframe specified by hospital policy
Some hospital transfers mandate “Doc to Doc” interaction
Who goes to the “fast track”?
Patients with stable vital signs and minor illnesses
Examples: Lacerations Minor bites/burns Abscesses and cellulitis Rashes HA (Hx of migraines or similar prior HA) Earaches, sore throats, cough, and congestion Back pain Dysuria (if simple, no fever)
Examples of PAs working in pre-hospital settings
Care for patients at scene of EMS calls and during transport to ED
Care for patients during transport from one facility to another
Care for people at events (concerts, sporting, etc)
Part of EMS team in rural areas (where transport times longer)
Military (transport to medical facilities in combat situations)
What is your only defense against malpractice when working in the ED?
Your very detailed ED note - must be thorough and complete
Think of the worst possible scenario and document how you ruled it out
Reflects credibility and competency
Components of the ED note
Identifiers - Name, DOB
DOS, time/mode of arrival, time of triage or exam room, time examined
CC, Pertinent Hx, Vitals, Pertinent PE
Orders (labs/imaging) and Results
Dx
Disposition (where are they going), time of disposition
Discharge instructions if applicable
Exact _______ is not always possible/necessary, but appropriate __________ is key
Diagnosis - Disposition
Is the patient sick or not sick?
Are they stable enough to go home with close f/u?
Do they need to be admitted for further work up/monitoring
Disposition examples
Discharge
Leaving against medical advice (AMA)
To OR
Admit to Observation (typically 24h, non-cardiac CP, asthma)
Admit to Med/Surg, Telemetry, ICU
Transfer (skilled nursing facility, hospice)
You can always ask for a _______, whether you are admitting the patient or not
Consult
With admission - Inpatient IMED/Hospitalist
For specialty - Cardio, Pulm, ID, Surg, Anethesiology, ENT, Opto, Neuro
Goals of informed consent
Support patients to make their own decision
Give info - more than we think we need to give
Make info understandable
Offer guidance in weighing goals and possible outcomes
Allow autonomous authorization (patient may consent or refuse)
Exceptions to informed consent
Unconscious patient
Incapable of consenting
Imminent harm from non-treatment
No surrogate available
What questions do you need to ask yourself to justify an emergency exception to informed consent
Will failure to treat quickly result in serious harm to the patient?
Would most capable and reasonable people want treatment for this type of injury?
Is the patient unable to participate in care decisions?
Can patient preferences be related in a timely way from a surrogate?
Is there any evidence that the patient would refuse this specific treatment?
Components of the procedure note
Patient name and DOB
Date/time of procedure
Indication
Consent
Description of procedure
Estimated Blood Loss (EBL)
Complications (if any)
What is ADC VANDISMAL?
Acronym for the components of an admission note Admit to Dx Condition Vitals Allergies (food and meds) Nursing Diet IVF or I/Os Specials (ie DVT prophylaxis) Meds Activity Labs
What are the different components of the discharge note
Discharge Dx
(Secondary Dx, incl all active medical problems)
Discharge meds
Discharge instructions, include ED precautions
Follow-up
Leaving against medical advice is most common in…
Young patients
Men
Drug/EtOH Hx
No insurance/low income
What should review with a patient who insists on leaving AMA?
Current medical condition
Specific risks and benefits of proposed treatment and alternatives
Specific potential consequences of leaving AMA
DOCUMENT REASON!
In addition to reviewing and documenting risks with the patient, what else do you need to do for patients leaving AMA?
Assess mental capacity of the patient - do they understand proposed treatment, consequences of refusal, reasoning for refusal
Follow up - advise patient when to seek medical attention, arrange with social services, family members to follow up
