L1: Role of PA in ED Flashcards
Largest PA specialties
#1 surgery #2 ER
Physicians to PA ratio in the ED
1:3
Top basket crash cart
Large gloves
Surgical cone mask
Defibrillator pads
Adult multi-function electrodes
Drawer 1 crash cart
Drugs
Drawer 2 crash cart
IV Solutions/Pediatric drugs
Drawer 3 crash cart
Adult intubation supplies
Drawer 4 crash cart
Peds intubation supplies
Drawer 5 crash cart
IV start supplies
Drawer 6 crash cart
IV supplies and tubing
Drawer 7 crash cart
Procedure trays
Bottom basket crash cart
Adult BVM+masks
Peds BVM+ #2, 3, 4 masks
5 in 1 connector and O2 tubing
Right side of crash cart
sharps container
Left side of crash cart
O2 tank + gauge
Adult + pediatric crash cart inventory list Anaphylaxis tx guide
Rear of crash cart
Clipboard: procedures sheet crash cart check off list pharmacy charge sheet code blue team sign in sheet code blue record sheets
3 supervision models for PAs in the ED
- PA see patients autonomously and consults PRN with supervising physician
- PA see patients, physician follows up with each patient as well (for billing purposes 85% → 100%)
- Physician sees all patients outside of PA scope and is available for second opinions
Top 10 reasons for ED visits
Abdominal pain Chest pain Fever Cough Headache SOB Back pain Pain Laceration Throat symptoms
Warning signs in history
Sudden onset, first episode Rapid, significant worsening of symptoms Altered level of consciousness or LOC Cardiopulmonary symptoms→ dyspnea, chest pain Extremes of age: newborns, elderly Immunocompromised Poor historian Frequent, recent ED visits Unvaccinated/under-vaccinated Patient signed off to you at end of shift
What might be a sign that a child is dehydrated?
Crying without tears
4 ED zones a PA might work in
Triage
Fast track
Intermediate care/acute care/high acuity care
Trauma
PAs in triage are helpful becauses
Reduce patients who left without being seen by 80%, wait times by 50%
Aid in compliance with “Emergency Medical Treatment and Labor Act” of 1986
Emergency Medical Treatment and Labor Act
Regulations for EDs providing medicare/medicaid services
Ensures all individuals access to emergency care, regardless of citizenship, legal status, or ability to pay
May transport patient only if needed
Requires Medical Screening Examination (MSE) by PA/NP/MD/DO
Medical Screening Examination
Determine if an emergent medical condition exists
PAs can perform MSE as long as written hospital policy specifies
Can ED PAs order transfers?
PAs can order transfers if: consult SP, SP co-signs order within time frame specified by hospital policy
Some hospital transfers mandate “Doc to Doc” interaction
Common chief complaints in fast track
Stable vital signs and minor illness Lacerations Minor bites/burns Abscesses or cellulitis Rashes Headaches, migraines (with pt history, not new onset?) Earaches, sore throats, cough, congestion Back pain Dysuria
Common chief complaints in Intermediate care/ acute care/ high acuity care
*more advanced illnesses or serious injury* Deformed extremities Age <3 months or Elderly Temperature > 103 F Abnormal vital signs O2 saturation <90% on room air Chest pain Difficulty breathing Neuro changes Abdominal pain/ pelvic pain Vaginal bleeding
Supervision model for Rural EDs and what PAs may do
May work alone with satellite physician supervision
May be only resource for healthcare in region
May cover ED alone without consultants available
Might not have skilled help for minor procedures
Stabilize + transfer critical patients to facility with higher level of care
Administrative role as lead PA in ED
Education, teaching and administrative functions pertaining to emergency medicine Scheduling Hiring and interview of new PAs Discuss PA issues at board meetings Can be partners in ED physician groups Leadership roles in clinical initiatives
PA in ED Teaching role
Teaching residents Precepting PA students “on-boarding” new PAs Research Lectures
Pre-hospital ground or air transport of patients
Care for patients at scene of call and during transport
Care for patients during transport from one facility to another
Care at events: concerts, sporting
Part of EMS team in rural areas where transport times to ED are longer
Military: transport to medical facilities in combat situations
Defenses a PA has against malpractice
ED note is the ONLY defense
What is the focus of a practitioner in the ED?
Think of the worst possible scenario and rule it out
How is the level of service for billing purposes supported?
ED note
What is meant by or included with “Disposition”
+/- exact diagnosis (not always possible/necessary)
Sick or not sick?
Where are they going?
Home with follow up vs admission + workup or monitoring?
Discharge, leaving against medical advice
To OR, to observation (24 hours non-cardiac chest pain or asthma)
Admit to med/surg, telemetry, or ICU
Transfer to skilled nursing facility or hospice
What should a procedure note include?
Name, DOB, Date/time Indication, Consent Description of procedure Estimated blood loss (EBL) Complications (if any)
What are the goals of informed consent?
Support patients to make a decision
give lots of information
offer guidance in weighing goals and possible outcomes
allow autonomous authorization→ patient consent or refusal
What are the exceptions to informed consent?
unconscious patient incapable of consenting imminent harm from non-treatment no surrogate available in timely way → make sure there is no evidence patient would refuse a specific tx
ADC VANDISMAL acronym for admission notes
Admit: floor, ICU, telemetry
Diagnosis: primary diagnosis at time of admission
Condition: stable vs unstable
Vitals: frequency, continuous pulse ox? when to call?
Allergies: foods and medications
Nursing: pressure dressings, neuro checks, etc
Diet: normal, low sodium, NPO?
IV fluids: maintenance, bolus
Specials: DVT prophylaxis
Meds: pre-hospital AND new medications
Activity: ad lib, fall risk, etc
Labs: CBC, CMP, q am
Leaving Against Medical advice note needs to address 3 broad areas:
Review: current medical condition, specific risks and benefits of treatments and alternatives, specific consequences of leaving
Assess mental capacity of patient: understands proposed tx, understands consequences, reasoning for refusal of tx/admission
Follow-up: advise when to seek medical attention, arrangement with social services, family members, etc.
Discharge note should include 5 components
Discharge diagnosis: cannot be a sign or symptom
Secondary diagnosis: regardless of when diagnosed
Discharge medications: all meds, doses, route, frequency
Discharge instructions: activity level, diet, wound care, return to ER
Follow-up: name of doctor, specialty, appointment location and time. Include timeframe if the patient is scheduling the appointment.
