- Email: [email protected]
1980 Scientific Assembly Rolls into Las Vegas
sponsibility v a r i e s widely a n d m a y include d r a i n a g e of c u t a n e o u s abscesses, r e p a i r of facial l a c e r a t i o n s , or proper e v a l u a t i o n and t r e a t m e n t of o p h t h a l m i c f o r e i g n b o d i e s . T h e emphasis of the t r a i n i n g is to provide competence in the i n i t i a l evaluation. Thus if a consultation is needed in a surgical s p e c i a l t y , t h e P A h a s t h e experience to collect d a t a needed for the consultant's e v a l u a t i o n of the patient. T h i s e n a b l e s t h e P A to organize the p a t i e n t ' s care, i n c l u d i n g radiographic a n d l a b o r a t o r y assessments. Duties performed at MHMC also include d a i l y t h r o a t c u l t u r e i n t e r pretations a n d i n i t i a t i o n of t h e patient recall process and t r e a t m e n t as indicated. A b n o r m a l l a b o r a t o r y results also are reviewed for completeness of d i a g n o s i s a n d p o s s i b l e reevaluation. A t N C B H the e m p h a s i s is reversed, b u t the goals are the same. At MHMC t h e P A ' s s u r g i c a l technique c o m p l e m e n t s a s t a f f w h o s e basic focus is i n t e r n a l medicine; a t NCBH, the PA's medical skills com-. p l e m e n t t h e s u r g i c a l s t a f f ' s skills. The experience g a i n e d in recognition and stabilization of p o t e n t i a l l y serious medical illnesses is added to t h e a r m a m e n t a r i u m of t h e surgical staff. For example, t h e elderly p a t i e n t who falls and suffers a scalp l a c e r a t i o n is not only sutured, b u t is also investigated as to the etiology of the fall. The i n i t i a l e v a l u a t i o n is p e r f o r m e d with an a p p r o p r i a t e physical examination, laboratory studies, and therapy without shuffling the p a t i e n t between different services and philosophies. In this m a n n e r , a patient will not have suffered deterioration or d e l a y regardless of which component of the EMS acts as first provider. T h e P A does n o t r e p l a c e t h e medical or surgical service, nor is he a s u b s t i t u t e for the depth of a n a l y s i s associated with consultative services. The P A a t t e m p t s to b r o a d e n the interests a n d s k i l l s of t h e p h y s i c i a n p r o v i d e r a n d b r i d g e s t h e g a p between s u r g e r y and medicine. In this s e t t i n g , he h a s b e c o m e a n E M S specialist capable of h a n d l i n g a complex i n t e g r a t i v e role. In large emergency s e r v i c e s , n o t r u n b y g e n e r alists or e m e r g e n c y physicians, care is often f r a g m e n t e d into the work of surgeons, internists, pediatricians and g y n e c o l o g i s t s , a m o n g o t h e r s , with v a r y i n g degrees of interservice cooperation. A n o t h e r aspect of t h e P A ' s res p o n s i b i l i t i e s is p a t i e n t e d u c a t i o n .
9:2 (February) 1980
Often in a b u s y E M S p a t i e n t education is neglected for more "critical issues." One e m p h a s i s of P A t r a i n i n g is to t a k e the t i m e to t a l k to p a t i e n t s a n d to e x p l a i n f u l l y w h a t h a s occurred. The p a t i e n t m u s t know the n a m e of t h e disease and the n a m e s of medications, as well as t h e r e l a t e d major actions and side effects.
EDUCATION Since t h e opening of NCBH, the E M S h a s been a t r a i n i n g site for P A students. The coordination of education is s h a r e d by t h e staff P A s and several full-time attending staff m e m b e r s . The P A ' s r e s p o n s i b i l i t i e s include acting as a liaison between t h e h o s p i t a l a n d P A p r o g r a m s , arr a n g i n g s t u d e n t schedules and, most importantly, achieving adequate s t u d e n t s u p e r v i s i o n a n d education. I m p o r t a n c e is given to the developm e n t of r e s p o n s i b l e a n d c o m p e t e n t m i d d l e level h e a l t h care providers. P A s t u d e n t d u t i e s a n d responsibilities a r e precisely defined, a n d include t a k i n g histories and performing physical e x a m i n a t i o n s as well as f a c i l i t a t i n g the flow of patients. The students may request laboratory tests a n d perform v e n i p u n c t u r e after consultation. Additionally, certain p r o c e d u r e s , such as i n s e r t i n g perc u t a n e o u s i n t r a v e n o u s lines, nasogastric tubes and Foley catheters, d e b r i d i n g a n d s u t u r i n g soft t i s s u e wounds, a n d o b t a i n i n g electrocardiog r a m s and a r t e r i a l blood gases, a r e p e r m i t t e d only u n d e r d i r e c t supervision. A l t h o u g h a n effort is m a d e to develop a responsible health care p r o v i d e r who can t h i n k independently, all p r o c e d u r e s done by P A students are authorized prior to perform a n c e a n d closely s u p e r v i s e d . A l l s t u d e n t c a s e s a r e p r e s e n t e d to a g r a d u a t e P A or p h y s i c i a n and t h e c h a r t is u l t i m a t e l y r e v i e w e d a n d c o u n t e r s i g n e d by t h e p h y s i c i a n p r i o r to p a t i e n t admission or discharge. W h i l e the second y e a r of P A student t r a i n i n g is p r i m a r i l y clinical, efforts a r e made to allow t i m e and arr a n g e schedules so t h a t students can a t t e n d lectures. The EMS staff conducts, on a daily basis, lectures cove r i n g d i v e r s e topics in e m e r g e n c y m e d i c i n e . In a d d i t i o n , w e e k l y lect u r e s by the a t t e n d i n g staff a r e held exclusively for the P A students, a n d c o v e r a s i n g l e d i s e a s e process, i t s pathophysiology, differential diagnosis, and t r e a t m e n t . The PAs' p r a c t i c a l skills a r e enhanced by weekly lectures given e i t h e r by senior house staff m e m b e r s
Ann Emerg Med
or by a t t e n d i n g staff. These physicians believe t h a t by i n v e s t i n g seve r a l hours of lecture time, t h e y avoid being called for u n n e c e s s a r y consult a t i o n s a n d are a s s u r e d of getting an a c c u r a t e d e s c r i p t i o n of a p r o b l e m when a consultation is necessary.
RESULTS, PROBLEMS, BENEFITS P h y s i c i a n acceptance of the PA as a fellow professional has been excellent. Most of the a t t e n d i n g physicians and residents at MHMC were a l r e a d y f a m i l i a r w i t h the P A concept and are g e n e r a l l y h a p p y to have additional personnel a v a i l a b l e to help m a n a g e p a t i e n t care. I n a d d i t i o n , there is no sense of competition for t h e e x c e e d i n g l y l a r g e p a t i e n t load. I n i t i a l l y , the NCBH a t t e n d i n g surgical staff was concerned about the P A c a p a b i l i t i e s and how i n d e p e n d e n t l y the P A could function. R a p i d l y the role evolved, and the P A is looked on as a c o l l a b o r a t o r a b l e to m a n a g e most surgical EMS problems. The most crucial step in developing confidence is t h a t of r e a s s u r i n g t h e surgeon t h a t t h e PA will c o n s u l t imm e d i a t e l y if a problem arises. These a t t i t u d i n a l i n t e r a c t i o n s h a v e been s t u d i e d e x t e n s i v e l y by o t h e r s , ls-2° Once t r u s t was established, a strong r a p p o r t emerged. I n i t i a l l y t h e p e r c e p t i o n of t h e E M S PAs by the n u r s i n g staff was m o r e v a r i a b l e a n d more d e p e n d e n t on t h e individual n u r s e t h a n on the institution. However, more of this ini t i a l r e s i s t a n c e was e n c o u n t e r e d in the NCBH EMS than at MHMC, where P A s h a d a l r e a d y functioned in s u r g e r y . The PAs were accepted as middle level health practitioners, and a strong r e l a t i o n s h i p was establ i s h e d w i t h p h y s i c i a n s a n d nurses. Certain nurses perceived that PAs would be placing t h e m s e l v e s between the physician and nurse. This led to degrees of reluctance both in working with t h e PAs as equal m e m b e r s of the h e a l t h care t e a m and, m o r e concretely, in accepting t h e i r w r i t t e n orders for medications and therapies. The conflicts at N C B H were resolved b y an N C B H m e d i c a l b o a r d r u l i n g which stated t h a t a P A order is in essence the same as an order from the PA's supervising physician. We t h i n k t h a t this p r o b l e m h a d its orig i n s in m i s c o n c e p t i o n s a b o u t PAs, t h e i r t r a i n i n g , a n d t h e i r l e g a l res p o n s i b i l i t i e s a n d p r i v i l e g e s . As these problems were aired, the PA/RN difficulties were resolved. Differences were more stylistic t h a n philosophic, and p e r s o n a l i t y clashes b e g a n to resolve as each group ap-
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9:2 (February) 1980
Often in a b u s y E M S p a t i e n t education is neglected for more "critical issues." One e m p h a s i s of P A t r a i n i n g is to t a k e the t i m e to t a l k to p a t i e n t s a n d to e x p l a i n f u l l y w h a t h a s occurred. The p a t i e n t m u s t know the n a m e of t h e disease and the n a m e s of medications, as well as t h e r e l a t e d major actions and side effects.
EDUCATION Since t h e opening of NCBH, the E M S h a s been a t r a i n i n g site for P A students. The coordination of education is s h a r e d by t h e staff P A s and several full-time attending staff m e m b e r s . The P A ' s r e s p o n s i b i l i t i e s include acting as a liaison between t h e h o s p i t a l a n d P A p r o g r a m s , arr a n g i n g s t u d e n t schedules and, most importantly, achieving adequate s t u d e n t s u p e r v i s i o n a n d education. I m p o r t a n c e is given to the developm e n t of r e s p o n s i b l e a n d c o m p e t e n t m i d d l e level h e a l t h care providers. P A s t u d e n t d u t i e s a n d responsibilities a r e precisely defined, a n d include t a k i n g histories and performing physical e x a m i n a t i o n s as well as f a c i l i t a t i n g the flow of patients. The students may request laboratory tests a n d perform v e n i p u n c t u r e after consultation. Additionally, certain p r o c e d u r e s , such as i n s e r t i n g perc u t a n e o u s i n t r a v e n o u s lines, nasogastric tubes and Foley catheters, d e b r i d i n g a n d s u t u r i n g soft t i s s u e wounds, a n d o b t a i n i n g electrocardiog r a m s and a r t e r i a l blood gases, a r e p e r m i t t e d only u n d e r d i r e c t supervision. A l t h o u g h a n effort is m a d e to develop a responsible health care p r o v i d e r who can t h i n k independently, all p r o c e d u r e s done by P A students are authorized prior to perform a n c e a n d closely s u p e r v i s e d . A l l s t u d e n t c a s e s a r e p r e s e n t e d to a g r a d u a t e P A or p h y s i c i a n and t h e c h a r t is u l t i m a t e l y r e v i e w e d a n d c o u n t e r s i g n e d by t h e p h y s i c i a n p r i o r to p a t i e n t admission or discharge. W h i l e the second y e a r of P A student t r a i n i n g is p r i m a r i l y clinical, efforts a r e made to allow t i m e and arr a n g e schedules so t h a t students can a t t e n d lectures. The EMS staff conducts, on a daily basis, lectures cove r i n g d i v e r s e topics in e m e r g e n c y m e d i c i n e . In a d d i t i o n , w e e k l y lect u r e s by the a t t e n d i n g staff a r e held exclusively for the P A students, a n d c o v e r a s i n g l e d i s e a s e process, i t s pathophysiology, differential diagnosis, and t r e a t m e n t . The PAs' p r a c t i c a l skills a r e enhanced by weekly lectures given e i t h e r by senior house staff m e m b e r s
Ann Emerg Med
or by a t t e n d i n g staff. These physicians believe t h a t by i n v e s t i n g seve r a l hours of lecture time, t h e y avoid being called for u n n e c e s s a r y consult a t i o n s a n d are a s s u r e d of getting an a c c u r a t e d e s c r i p t i o n of a p r o b l e m when a consultation is necessary.
RESULTS, PROBLEMS, BENEFITS P h y s i c i a n acceptance of the PA as a fellow professional has been excellent. Most of the a t t e n d i n g physicians and residents at MHMC were a l r e a d y f a m i l i a r w i t h the P A concept and are g e n e r a l l y h a p p y to have additional personnel a v a i l a b l e to help m a n a g e p a t i e n t care. I n a d d i t i o n , there is no sense of competition for t h e e x c e e d i n g l y l a r g e p a t i e n t load. I n i t i a l l y , the NCBH a t t e n d i n g surgical staff was concerned about the P A c a p a b i l i t i e s and how i n d e p e n d e n t l y the P A could function. R a p i d l y the role evolved, and the P A is looked on as a c o l l a b o r a t o r a b l e to m a n a g e most surgical EMS problems. The most crucial step in developing confidence is t h a t of r e a s s u r i n g t h e surgeon t h a t t h e PA will c o n s u l t imm e d i a t e l y if a problem arises. These a t t i t u d i n a l i n t e r a c t i o n s h a v e been s t u d i e d e x t e n s i v e l y by o t h e r s , ls-2° Once t r u s t was established, a strong r a p p o r t emerged. I n i t i a l l y t h e p e r c e p t i o n of t h e E M S PAs by the n u r s i n g staff was m o r e v a r i a b l e a n d more d e p e n d e n t on t h e individual n u r s e t h a n on the institution. However, more of this ini t i a l r e s i s t a n c e was e n c o u n t e r e d in the NCBH EMS than at MHMC, where P A s h a d a l r e a d y functioned in s u r g e r y . The PAs were accepted as middle level health practitioners, and a strong r e l a t i o n s h i p was establ i s h e d w i t h p h y s i c i a n s a n d nurses. Certain nurses perceived that PAs would be placing t h e m s e l v e s between the physician and nurse. This led to degrees of reluctance both in working with t h e PAs as equal m e m b e r s of the h e a l t h care t e a m and, m o r e concretely, in accepting t h e i r w r i t t e n orders for medications and therapies. The conflicts at N C B H were resolved b y an N C B H m e d i c a l b o a r d r u l i n g which stated t h a t a P A order is in essence the same as an order from the PA's supervising physician. We t h i n k t h a t this p r o b l e m h a d its orig i n s in m i s c o n c e p t i o n s a b o u t PAs, t h e i r t r a i n i n g , a n d t h e i r l e g a l res p o n s i b i l i t i e s a n d p r i v i l e g e s . As these problems were aired, the PA/RN difficulties were resolved. Differences were more stylistic t h a n philosophic, and p e r s o n a l i t y clashes b e g a n to resolve as each group ap-
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