Bouncebacks - Advanced Practice Clinicians

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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Alon M. -

I really love EM:RAP, I mean, I REALLY love it. I listen to it constantly, I watch the videos, read the summaries and recently even spent my Friday night (that is 21:00-23:00 EST) listening to the EM:RAP Live session and I feel that I have been able to deliver better care to my patients because of it. This is why I was very disappointed when I heard Mike Weinstock using the term Midlevel Providers on this month's EM:RAP. This chapter reviewed the dynamics between different practitioners involved in the care of a patient who unfortunately ended up dying. The situation described sounds very familiar to me as I am sure it does to many other listeners. That said, I agree with many other Advanced Practice Clinicians (APC), as we refer to our colleagues in our hospital system, that the term Midlevel is inappropriate, belittles our experience and expertise, and misrepresents our role in the healthcare team. This is not an obscure issue, much has been written about it and the American Academy of Nurse Practitioners (AANP) released statements denouncing the use of MLP and similar terms and considers them derogatory.

I feel incredibly privileged to be able to do what I do for my patients in the ED and know that my actions, and not the letters after my name are what really matters. Nonetheless, I could not help but feel offended when a widely circulated and esteemed educational program used the term MLP, apparently unaware of the controversy.

Mel H. -

Alon - I want to apologize for using an outdated term. We will do our very best to use the APC naming convention since we TOTALLY reply on our colleagues to reduce suffering and save lives - this is a team sport - we are on the same team!

Mike W. -

Alon, I am glad you wrote and apologize for using the term MLP. I agree this terminology is changing, some places faster than others, and I assure you that no offence was intended. As the Medical Director of the ODU PA studies program, I am not only an educator but and advocate for APC responsibilities and privileges. Thx for your input!

Alon M. -

Thank you very much for your prompt reply and apologies. Thank you again for your amazing program, which continues to improve in an ever growing rate and thank you for advocating for APC.

On a side note, I also really enjoy listening to the Foolyboo Shows. Great educational content for those times when I want to take a break from emergency medicine. Please keep 'em coming.

James A. W., M.D. -

I have 2 comments:
1) Mike is right in that when you pick up a case it is yours. If you don't go see it you are just lazy and the ensuing errors are your fault. The second doc should have seen the patient in person at 0100. If she was too busy there is a staffing problem and one should consider a more appropriate job environment.
2) I wonder why the APC is seeing this very complex case. In the 1960s it was established that emergency care was best provided by emergency physicians. This has been the underlying premise of the emergency medicine specialty ever since. Insinuating another person between the patient and the physician is always dangerous and has potential for the problem to which we were just we introduced. Relying on an APC to do more than they are capable of is another form of laziness again bred in being too busy. The business model of replacing physicians with APCs is common but is always questionable, generated by business needs, and is mildly unethical in that patients often do not know the difference in level of provider.

Mike W. -

Thanks James, TAKING OWNERSHIP is key with all handoffs, APC, physician/physician, or EP/specialist. Jennifer summarized it in the segment beautifully - when someone asks for help... you go help!

Rabbott -

If you've seen the movie "Sully", you might have noticed a very brief but important line: "I've got the plane." That brief statement clarified the changing roles as the more experienced and senior Captain took over the hands-on flying of the plane from the (presumably) less experienced First Officer. Nice that the Captain recognized a potentially disastrous situation (OK, not too subtle in the case of the movie), and explicitly clarified that "the plane" was now his. Physicians might learn from this.

Mike W. -

I did see Sully and I agree w the parallel. The captain and first officer work together and this is the best model for success!

Chris W. -

The most important quality in both MLP and MD alike is the ability to communicate. If you are failing at this you are failing at your profession.

If at some point in your career you have not asked a colleague for help or their opinion on a complex case I ask what rite aid urgent care do you work at? If a team member asks you for help you give it. I find James MD comment #2 absolutely insulting. Every institution is different. Every MLP or MD skill set is different. For example at my institution it would be rare to see an attending do an intubation, chest tube, central/dialysis line over the PA and we have one of the most complex patient populations in the country. The question should be asked with every complex patient "do you feel comfortable with the plan/procedure; if not, what can I do? A team approach is critical!

Scott R. -

I'm sorry but there was an elephant in the room that I feel like got skimmed over here. When the APC was talking about the depositions and the first physician had answered "yes" to the question of "Doctor, don't you think if somebody has abdominal pain, tachycardia, and diaphoresis the first thing on your differential should be salicylate toxicity?" SERIOUSLY?!!?!? FIRST thing on the differential. Tox would be on my differential if I got a list of 5 but the specific of salicylate toxicity wouldn't hit a list of 20. I mean sure, if the symptoms were Tachypnea, Tinnitus, and Vomiting. Definitely at the top of the differential diagnosis then. I feel like you could have talked about how depositions could better be handled here too.

Juron F. -

Boom! When I heard that my jaw dropped. I was shocked no one mentioned it yet.

Mike W. -

Agreed:
We must, indeed, all hang together, or assuredly we shall all hang separately. Statement at the signing of the Declaration of Independence (1776-07-04), quoted as an anecdote in The Works of Benjamin Franklin by Jared Sparks (1840).

Xander Merboo -

#1 the overall discussion was outstanding. I really like the take home message that when a PA asks a physician for help, there should be the expectation that the physician will take the patient over without any blowback.

#2 as a very very small aside on the discussion - SEMPA [the PA counterpart to ACEP] has released their policy statement that PAs in the ED should be addressed by the title 'EMPA' and they do not recommend lumping together all advanced practice RNs [CRNA, APRN, CNM, NP] with PAs. In the case where non-physician practitioners are to be lumped together, SEMPA recognizes the term Advanced Practice Provider [APP]. Not that I agree with their nomenclature decision, but they are the main body to support, educate and advocate EM PAs.

Mike W. -

Thx Xander for your comments - this was a wild case and really demonstrated how we all need to work together!

paul f. -

It sounds like Tim did a good job taking care of this patient. At my hospital most admissions are discussed with attending. I can imagine being the night MD and asking about Vitals, did a CT get ordered ( abdomen and ? head) and wanting to review these once they came back as I managed all the other new cases. I would begin to really turn on the "thick slice" thinking once the images were negative. At that point CNS infection and toxic causes would be strongly considered and most toxic screens still add salicylate and acetaminophen. As an attending I would have likely taken ownership of the case in terms of complete reassessment, but it would not have changed the outcome in this case. The case made sense once the salicylate level was available. Because the patient died, it became a good case to review, but I think Tim did a great job. The first MD's testimony concerning salicylate poisoning is ridiculous. I also agree this would have been defensible. Tim, you did nothing wrong!

Cathleen M. -

In listening to this case,....I must say I felt sorry for Tim, PA. It didn't seem he was getting the help he needed in a complex case. Also, the first physician that was deposed seemed to throw him under the bus. The lawyer asked that first physician "if someone has abdominal pain, tachycardia, and diaphoresis, the first thing on you differential should be salicylate toxicity?"---The first physician said "Yes".
I completely disagree---there was no history of salicylate overdose!!! There are numerous diagnoses on the differential list before salicylate toxicity!! The PA was thrown under the bus both on the night the patient was in the ER and during depositions. Tim got the diagnosis and even though he did everything right sometimes there are bad outcomes. Tim, don't let this one case bring you down!

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