PA’s- making Ada Plumer Proud.

Many years ago, nursing was not allowed to place IVs. Now, in some places, they place ultrasound guided PICCs, and in a handful of places, ultrasound guided central lines.   Nursing can titrate vasopressors, and in some facilities, they run ACLS during codes.


So…. Have you ever experienced or asked “for the doctor (or consultant)?”

Have you ever been concerned and wondered do PA’s provide appropriate care in the ED?

This study is done at the world famous Our Lady of Lourdes in Camden,NJ, with none other than the EM famous Al Sacchetti- and should aim to answer some of these concerns, at least in the pediatric population

Over a 24 month period, over 10,000 patients age 6 or younger were restrospectively evaluated for bounce back rates and broken down into 3 groups based on their provider: attending only care, PA only care, or co-evaluation by both EP and PA.  Here’s the twist- in this department, policy permits PA’s to evaluate treat and discharge patients of any age independent of the attending physician.  There are no specific protocols for assigning specific patients to specific providers, though they do state that PA’s do not perform LP’s in the study department, and that febrile infants <8 weeks were brought to the immediate attention of the attending physician by the triage nurse.  Essentially, the PA seemingly functions at a high level and fairly autonomous.

So what’d they find?  Are you more likely to “bounceback” based on who you’re seen by?

Well, as one would likely expect, a higher percentage of higher acuity patients were seen by the attending physician (85% ESI-2, 70% ESI-3, 60% ESI 4/5.), and the younger the patient, the more likely they were an “attending only” case.

Bounce backs?  Only 0.4% of PA only cases vs 0.6% of attending only cases bounced back and were admitted – not statistically significant – and below the national average of 0.83%.  Only 0.9% of PA only cases were admitted vs 4.1% of attending only cases (and 3.4% of PA/MD cases.  This was statistically significant, and likely reflects higher acuity of the cases the MD is involved in.  There was a higher rate of return visits in MD only cases – 8% vs 6.8% (statistically significant) – but the rate of return for combined MD/PA cases was highest – 9.3%.

Amongst ESI 2,3, & 4s, bounceback rates for EP only eval was consistently higher than PA only eval, and bounceback rates for MD/PA co-evaluation was consistently higher than both PA only and MD only eval.

So, what’s the take home?  For one, its that PA’s can provide high level care without a significant drop off in care… and that in order for medicine to progress, we have to cognitively offload to expand our boundaries.  This may include expanding services to nursing or PAs (as discussed above)…

And here is the most important message:

Dont be that person – if someone (nursing, PCA’s, PA/NP’s, etc) comes to you with a concern – go see a patient.  We’re all on the same team.  Take it as a compliment – as evidenced by this paper it’s likely a complex or clinically ambiguous case with a higher bounceback rate, and who doesnt like a challenge!


GI, Improving Outcomes, Mythbusting

Rethinking Diverticulitis

For those savvy FOAM early adopters that have been referring to diverticulitis as the sinusitis of the colon, this one is for you.

While diverticulitis management (or lack thereof) has been discussed periodically – specifically in regards to antibiotics being of no use in the uncomplicated form of diverticulitis – here comes a new study to suggest we have to at least rethink our referral patterns.

The Danish national registry was mined for a population-based cohort study, for a total of 445,456 included patients over 18 years, of whom 40,496 had a diagnosis of diverticulitis. They then compared other patients in a 1:10 ratio (diverticulitis: no diverticulitis) matched for sex and age within 1 year. Of note, the matched group also did not have a diagnosis of diverticulosis either.

Basically, the risk of developing colon cancer was 4.3% in the diverticulitis group and 2.3% in the matched cohort. This was statistically significant (P <0.001, incident ratio 1.86), and remained when adjusting for confounders (OR 2.20)…

Pro-inflammatory states cause more cancer? Perhaps. We know they cause more thromboembolism and early coronary disease already. Bottom line – while an NNT of 50 is nothing fantastic, we see this condition regularly, so reconsider providing strong follow up to your patient, whether that be PMD or GI, especially if they’re in the age where they are due for a colonoscopy anyway.

Improving Outcomes, Neurology, Pediatrics

CDRs- good for you, patients, and lawyers!

One of my favorite tweets ever is the following from Jeff Kline:

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This paper from Academic Emergency Medicine continues to drive home Kline’s point – evidence based medicine is protective – both for the provider medicolegally, and for the patient to be saved from harm’s way of overtesting.

The author’s reviewed WestlawNext (from what I can tell, the closest thing law has to PubMed), for all cases, jury verdicts, settlements, and arbitrations from 1973 (when CT first was used clinically) until January 2014 for all instances of head injuries in which head CT was NOT performed. After trudging through about 1,000 cases in their initial search, the authors eventually found (only) 60 cases in which a head CT was not performed and a provider was sued because of it. Two abstractors independently determined which clinical decision rules applied to that specific case (PECARN, NEXUS, Canadian CT head rule, etc), and if imaging was warranted. Inter-rater agreement was 99.2% for determining tge presence or absence of decision rule indications for CT in a given case, and 98.3% for which specific decision rule applied to a particular case.

The Results: Only 8 out of the 60 cases involved patients under age 18. Among all patients, isolated subdurals were most common (58% of cases), 32/60 died from their injury, while the rest sustained permanent neurologic deficits. Time from when a CT should have been ordered to deterioration or death was <6 hours in 39% of cases, 6-24 hrs in 36% of cases, and >24 hrs in 25% of cases.

The juicy stuff: in all ten cases in which the provider was found negligent, a CT was indicated. Providers settled in 10/11 cases in which a CT was indicated. In the ONE case in which a CT was not clearly indicated involved an MVC with multiple facial fractures and experienced left sided numbness and was scheduled for CT the following day. For all 8 pediatric patients, CT was indicated.

So, if a CT was indicated, and you didn’t do it, good luck.

What about the other cases? Well, The authors do not go into much detail about the necessity of CT for these remaining cases except saying that there were 27 cases which found the provider not liable. This also leaves a few cases outcomes unaccounted for.

All in all, since 1973, there has been a grand total of 60 cases in which a head CT was not done that evolved into a lawsuit.  Many of these cases occurred before the publication of recommended guidelines. In some ways, that is not quite fair – I’d hate to be brought to court for not doing ECMO on a patient because ECMO found its way into standard practice in 10 years.  Regardless, I take this study as a step in the trend of discussing with decision rules with the patient and their family family & documenting clinical decision rule recommendations to minimize the swinging pendulum of both the over and underwork up of patients.


Would Defensive Medicine Really Stop with Acceptable Miss Rates?

Repeat after me: there is no such thing as zero risk. We all have heard “about that one case” – and sure, there are patients with negative d-dimers & PERC negative that have PEs.  There are “clean cath” patients that die the next week.  Septic patients that do not make a lactate – etc, etc.   And so, this largely hypothetical study, suggests that, if there was an acceptable 1-2% miss rate, physicians would admit 29% less acute coronary syndrome rule outs (based on physician surveys of 259 cases).


I have to wonder whether or not this would play out in practice. We’ve seen that tort reform has not really changed the decision making process, why would an acceptable miss rate? I suspect providers “are just saying that” – and would actually still admit many of these patients. It’s been ingrained in providers from their forefathers that lawyers lurk behind every chart. During training, we have all been exposed to the excessively conservative provider – and I suspect unconsciously they rub off on us. Throw in the human aspect of the torment of missing a catastrophe, and you’ve got overtesting that we will likely continue to do for decades, regardless of attempts to change the medicolegal landscape.