An Obligation for PAs and NPs to Read the Newest Book in Critical Care

 by Bob Blumm, MA, PA-C, DFAAPA 

 Today, in the year 2012, there is a cry that sounds throughout all medical institutions that deliver critical care: it is a cry for knowledgeable individuals, regardless of rank (MD, DO, NP or PA) to bring their skills and dedication to the critical care units of their hospitals. When attending an American College of Surgeons (ACS) two hour presentation on this subject about ten years ago, I discovered that the physicians involved were double boarded and were most commonly supported by NPs and a fewer number of PAs. I had written an article in the last year of publication of the Physician Assistant Journal encouraging PAs to enter this specialty prior to the meeting with the ACS. Sometimes our cries fall on deaf ears or there is little interest, but the field has exploded and there are not nearly enough physicians to staff this area, and institutions throughout the United States are calling upon our professions.

I consider some of the administrators and directors of medical staffs took some heat for opening the doors for this larger group, but the fact remains that with open doors, hospitals are still short staffed and have hired some individuals who do not possess the training or experience to adequately fulfill this role. NPs have proven that they were up to this challenge and the rationale was that many were ICU/CCU nurses before they became NPs. PAs, likewise, have proven that they are adequately prepared for this responsibility as this is part of the daily responsibilities of Cardiothoracic PAs as well as Neuro-surgical PAs and many surgical PAs. We have been involved in this demanding and urgently needed specialty for more than ten years and many Chiefs of services state that “if you removed their name tags you would not be able to distinguish one profession from another.”

The name of the new book is “Integrating Nurse Practitioners and Physician Assistants Into The ICU: Strategies for Optimizing Contributions to Care.”

The editors are:
Ruth M. Kleinpell, Ph.D, RN, FCCM
Walter A. Boyle lll , MD, FCCM
Timothy G. Buchman. MD, Ph.D., MCCM

This book contains 11 chapters starting with 21st Century Challenges and then moves to Shaping the Next Critical Care workforce. Chapter 3 demonstrates the NP model at Sloane Kettering, followed by Billing, Reimbursement and Productivity. There will always be the need to train individuals who are prepared for this giant step upward, therefore the following chapter discusses the Orientation Programs. With the Joint Commission continually protecting the patients and their care, the next chapter deals with a very subjective matter: Credentialing and Privileging for NPs and PAs. We move forward in this text to Assessing Outcomes and then Integration of the NP and PA in the Pediatric ICU. The last three chapters focus on Forming Centers for Advanced Practice, Expanding the Role for NPs and PAs in the ICU and Beyond, and the Administrative Considerations for Maximizing the Integration of NPs and PAs Into the ICU. This represents a banquet for administrators, directors, service chiefs, and all medical staff, which includes the NP and PA.

The appendix of this book is worth the price alone as it focused on the nuisances of this type of specialty. This book is published by the Society of Critical Care Medicine and is available today by contacting them or Amazon. As I mentioned, there is no hospital library that should be without this volume and all senior staff members need to absorb the materials to fully appreciate that there is light at the end of their dark tunnels in staffing their critical care areas. I only wish I were 20 years younger so that I would have the opportunity to be involved in this valuable and rewarding service to our patients.  

 

 Do those few words have recognition for you? These are the words that accompany advertisements concerning the New York Lottery. It is urgent that I redefine these words for you as your entire career future for next year is tied up in this comment. There are many issues that are presented by resolutions in the AAPA HOD. These issues are extremely important to PAs as they will reflect on certain approaches to health care. This HOD meets in Toronto in the month of May. Prior to this there is an election of AAPA Officers and Board Members. In order to vote, you must be a member. Therefore you can’t win, if you don’t play. There are many who could care less about these elections as demonstrated by the poor election numbers over the past five years and the attitude of grassroots PAs that it doesn’t matter anyhow. This, unfortunately, is untrue.

I get as angry as everyone else when I write a letter and do not receive one back. I feel like I just kissed a cheek and the person turned their face. Soon I become infuriated and say;”I’m not going to be rejected again and therefore, that’s the last kiss. Members of the AAPA have sensed this over the past year and are forming the same attitude. Please listen to me; it would be a mistake not to take advantage of this opportunity in this year’s election. Why? The issues, conversations that we have had and are having with the “title change.” There are a dozen other reasons why this board will need the confirmation of many more people than it has had in the past and only you have the power to respond to the voting mechanism that is sent to you. Once and for all I want to cast a ballot and focus on what my elected board does because after that year, after presenting issues and receiving help or rejection, I too will follow the crowd that says, "it’s not worth my dime." This is a last ditch effort to see my academy work for me, the grassroots PA. I think they have heard the message that we need and want responses and this is not 1990 when a rich, staff led organization, told us what our concerns are and should be. This is the year of the Dragon and we are putting fire under the next board.

I want to see a board that understands our position that responds to us although we may be coming from different ideologies. I want to see a board that represents me as a PA and the profession as we engage in government. I want job assurance for the future and equal rights. I can have none of these things if I have not voted for the correct people. I have sent out a letter to those that used to be part of the Medical and Surgical Congress to forward to the presidents of the specialty organizations. I have asked their boards to ask about seven questions so that these specialty group boards can endorse specific candidates, not based upon friendships and good looks but upon integrity. We who are the fourteen members of the Name/Title Change have already sent our questions and will endorse as a committee. Yes, we can control this election and also bring it from its dismal past of less than 3,000 last year to something that is representative of its membership, which is declining.

I ask you to join me and other leaders who believe in this last opportunity, get your dues money in now, vote for you leaders and do not dismiss the endorsements of your boards. We are engaged in this proposition with knowledge of many of the issues and a burning desire that requires some action, a poll of the profession and the establishment of an Ad Hoc Committee. Thank you.

A citizen of our wonderful country would need to be blind or deaf to be in a situation where they were unaware that the Republicans are seeking a candidate to run against the incumbent President Obama. Concurrently this is the time the AAPA is declaring the nominees for election in the upcoming year and I am sure that the AANP is involved in the same labors. Elections are serious and it amazes me that so often we know so little about the candidates and how they feel on issues of great importance. As Americans, we need to know where our candidates stand on health care, national defense, welfare, social security as well as foreign and domestic affairs. Would we even attempt to pull a lever without knowledge of these issues? The same holds true in PA and NP politics. What does the candidate believe regarding issues concerning healthcare in America, utilization of the PA and NP workforce, reimbursement issues, research, and for the PA, a change to the name associate?  THE NP side also continues to look at the DNP degree and their programs and content. What do our candidates believe? Are they willing to buck the tide and stand with the grassroots members of their profession? Take the “Associate” issue for PAs, more than six thousand PAs have asked for a change in our name but is anyone in leadership listening or are they quick to toss the ball to another entity to escape personal accountability? The membership of ALL organizations desire to be heard and also to see our requests both responded to and acted upon. Will the newly commissioned professional leaders perform this responsibility or will they look for “more important” issues and neglect the 6,000?

Leadership can be exciting, rewarding, stimulating and an experience in personal growth and development. A leader in an organization is a caretaker and has a responsibility to the profession and to its members. They cannot close their ears to the cries of the members nor can they close their eyes to petitions and comments, letters and facts that are delivered officially to the BOD on behalf of dues paying members.  Why pay dues or consider membership if the leadership refuses to respond? In some cases, leaders who were written by members never answered them.     

Good leaders accept their failures and defeats in some issues so that they may achieve success and triumphs in other areas. Leaders strive to win the battles but are more focused on final outcomes and what may be needed five and ten years from now. Perhaps because the role of leadership is filled with a multiplicity of emotions, it can be understood why and how styles and skills can differ among individual personalities. I have personally observed two leadership styles over the past several decades: the strong leader and the strong, sensitive leader. I am of the firm belief that volunteer organizations must have the latter in order to maintain membership and productivity. Observe the following two styles. Which do you prefer?

The Strong Leader

1.     Is concerned with what is best for them.
2.     Creates an atmosphere where membership is totally dependent upon their decisions.
3.     Controls from without using tactics such as restrictions, rules and regulations.
4.     Invariably has an: ”I’m superior, you’re inferior attitude” that alienates others.
5.     Interprets questions as personal criticism.
6.     Takes no risks and tends to pass the ball to others.
7.     Limits the growth of other leaders by deterring the actions of others and by not training anyone else for the job.

The Strong Sensitive Leader

1.     Is considerate of membership and others on the team.
2.     Aims to create a plurality of leadership within the group which will ultimately make them unnecessary.
3.     Influences from within by encouragement, inspiration and motivation.
4.     Respects all members, old and new, Hears their comments and responds.
5.     Is willing to discuss actions and reasons for actions.
6.     Delegates and allows for success or failure.
7.     Desires power with leaders, encouraging input, feedback, ideas and participation.
8.     Liberates other leaders by encouraging new ideas and participation in a process where all are heard. Equips other with the tools to accomplish their tasks.

So who and what are we seeking in candidates or as officers in our professions?

We are seeking visionaries who are action-oriented and energetic, who are not afraid of adversity or challenge. We are looking for those individuals who accept these concepts willingly for the good of the order. Genus is not a requirement, but rather the requirement should be the insatiable hunger to see the profession grow and flourish both today and tomorrow and in the decades to come. We require future leaders who have a strong belief in our professions, our future and will enable us to resist all others who would try to limit our privileges. We need leaders who will stand against ANY powers that feel that they can make decisions for our profession. We need those who will not accept compromise or mediocrity in place of the pursuit of excellence. We need to know how people see the problems our profession has and how they will solve them. That’s what we need to be thinking about before we check off our ballots and vote for our future.

Today the largest majority of Americans are taking some type of herbal medications. They have followed the Pied Piper wherever he has marched, in streets, on ad boards, in magazines and journals, on TV and radio ads, on net sites, observing the comments of famous musicians and actors, from providers of health care, there is nowhere that this modality has not been spoken of. Even this site and sister sites such as Clinician1.com proudly extol the virtues of herbals in the health care diet. I am a believer, to an extent, in alternative medicine but am also aware that sometimes these good guys can be deleterious to us prior to surgical procedures and when taking other medications. Therefore, our responsibility is to find the offenders or those that can possibly cause harm and share the information with our patients and our colleagues and perhaps ask the makers of these supplements to aid us in this campaign.

Considering the fact that more than 60 million Americans are taking these supplements, it is only reasonable to believe that your patient is among this heterogeneous group.  When the patient is visiting this becomes yet one more question that should be asked at a time when people are looking over our backs when we spend excess time. The problem relates to whether we are intimidated by those people or whether we care to deliver a certain standard of medicine. It is also a question of professional liability as drug interactions and a proper history are incumbent upon the clinician prior to a pre-operative physical exam. How long do you think it will take prosecuting attorneys to do the math and compile evidence that we have fallen short of the mark in this area and will weave a web that encourages a jury to find our brand of medicine abhorable? There are internet sites that can help us gain information such as (www.ncamm.nih.gov) and www.fda.gov/medwatch) The information lies at our fingertips and it’s time to let our finger do the walking or possible face the consequences.

The stores such as Barnes and Nobel and the internet sites such as Amazon.com have many Herbal Encyclopedias available and they are a worthwhile purchase and a daily fifteen minute read for general information as well as specifics when we are dealing with prescribing for our patients. When we boast that our specialty or profession is a commitment to seeking new knowledge daily, this too is a part of the commitment. I thought I would just use this as a word of advice for the New Year.

Recently, I was a speaker at the NPA of NYS and spent a couple of hours in their exhibit hall. I have written on this subject a couple of weeks ago but today I will focus on a treasure that I unexpectedly came upon. There was a lone bookseller and his brother, an emergency room director, who were standing behind a table with about fifty books, all of which shared the same title. I picked it up and started through the first ten pages to be properly introduced and the salesman brother asked what I thought of the book. I made a suggestive comment that I was an expert on some of these subjects and wished to look at the chapter related to one of my areas of expertise. To my amazement (I have no idea why I was amazed) this chapter shared all of my personal expertise and then added a few points that I had failed to include in my own study. I was permitted to take the book to my room and give it a real test run, and it delivered on every subject that I studied. This book was based upon the physician’s protocols and agreements with his NPs and PAs and his book was called aptly, Nurse Practitioner Acute Care Protocols and Physician Assistant Acute Care Protocols. I believe that this should be in the personal library and lab coat pocket of every clinician who practices Urgent Care, emergency Medicine, Family Practice and beyond. It’s not a cookbook but a systematic manner in which to correctly diagnose and treat patients who present with certain complaints. Many of us have treated common problems in a common manner and have almost forgotten that with EBM there came new approaches and a widened differential diagnosis. This book is meant to focus on the varied differentials and to assist us in our approach to either rule in or rule out potential life threatening problems.

We are now entering the season of Hanukkah and Christmas and during these holidays we share gifts. There is no better protocol book to purchase for a colleague of friend or family member who is a PA/NP than Acute Care Protocols. You can begin with Cardiovascular and observe patient care scenarios for chest pain protocol, cardiac dysrhythmia protocol and Hypertension protocol. It moves steadily to CHF and Syncope/Presyncope protocols. You will discover Adult/Acute Bronchitis Protocols. Want to know the stepwise approach to /CVA/TIA, there is a protocol that can be observed. The GI system is handled from the mouth to the anus and the endocrine protocols make this educating, fun and correct. Ophthalmology, Fractures and Nasal protocols, Motor Vehicle Accidents, strains , sprains, fractures, general and vascular problems Pediatric, Geriatrics and social and Psychiatric. They are all included and are easily followed with time for real time responses from your labs.

In this age of malpractice concerns and a legal department that has discovered NPs and PAs, why be short. These lawyers read the same books and sometimes are more prepared that the experts. I don’t want to defend my actions but would rather render the proper care flopping good protocols and guidelines and then mixing and matching. This book has the power to protect you and your patients as well as the supervising or collaborating physicician which make us all winners. Dr. Correll has done a great job and has 28 years of working with NPs and PAs. Think of this book during this holiday season. While you are thinking, it’s a perfect time to consider that Personal liability Insurance Policy. It is no longer a case of who should purchase this insurance but rather of who can afford not to purchase. Next moth I’ll alert you to a strange phenomena that is occurring across this land concerning these policies. Don’t fail to look before you leap as this will be the most important decision of your medical careers.

NEW YORK (Reuters Health) - A new survey of surgeons suggests many fail to discuss their patients’ wishes in case a risky operation goes awry, and even more would not operate if patients limited what could be done to keep them alive.  Such medical wishes, called advance directives, outline what can and cannot be done if patients are unable to decide for themselves, but the restrictions are debated among doctors.

“(Surgeons) feel the advance directive basically ties their hands behind their back, and they’re not given the tools to get them through the surgery,” said Dr. Margaret Schwarze, one of the survey’s authors and an assistant professor at the University of Wisconsin School of Medicine and Public Health.  She and her colleagues asked 912 surgeons who regularly perform risky operations 14 questions on how they discuss a patient’s advance directives and whether they influence their decision to operate.

The survey’s results, published in the Annals of Surgery, found that more than four out of every five surgeons discussed which forms of life support the patients would like to limit. But only about one half specifically asked about the patient’s advance directive, which can include restricting the use of feeding tubes and ventilators to keep a person alive.   “I think some surgeons just don’t discuss advance directives because they think it’s so irrelevant,” said Schwarze.

Over one half of the surgeons said they would not operate if an advance directive limited what could be done to keep a patient alive after surgery.  The researchers said such instructions can also cause tension between the surgeon and the patient, because it shows the patient may be unwilling to accept the therapies that come with high-risk operations.  Compared with brain surgeons, heart surgeons were much more likely to decline an operation.

According to the researchers, brain surgeons may see removing life support as a reasonable decision, because their surgical complications can cause brain damage.  Schwarze told Reuters Health it’s not uncommon for heart surgeons to use techniques like CPR after an operation, and restrictive instructions may get in the surgeon’s way.

“I think it’s important for patients to discuss their values and goals with surgeons before a big operation,” Schwarze added in an email to Reuters Health. “It’s also incredibly important to discuss this with family members or someone who may need to make decisions.”  However, she added that surgeons should also address the advance directive to get rid of potential confusion.

Dr. Peter Angelos, professor and chief of endocrine surgery at the University of Chicago Medical Center, agreed that family members should be involved in the discussion.  “An advanced directive is frequently a vague general statement, but in fact, every case is going to be a very specific situation,” said Angelos.  He added that family members who aren’t involved in a patient’s conversation with the surgeon can be at a loss after the operation.

The 900 responses were from 2,100 randomly selected heart, brain and vascular surgeons in the U.S.
The study is accompanied by an editorial, which the journal declined to make available even though the survey’s results are online.

SOURCE: http://bit.ly/t9SVLr       Annals of Surgery, online December 1, 2011

  Please do not construe from the title of this article that it is meant only for the EM clinician. Clinicians will discover these presentations in family practice and in the urgent care setting as well as in the orthopedic office. My personal passion for writing this is to demonstrate that the diagnosis may be hidden if we are in a specialty setting, and that elusive diagnosis may be life threatening. I wish for you to consider the following three scenarios and apply your skills to seeking the answer that is correct not the one that is obvious. Give it a try as this little example of mental gymnastics cannot injure you but make you a better provider.

Scenario 1- An otherwise sedentary 43 year old female has decided to begin exercise due to her recent 20 pound weight gain. Two weeks ago she has a UTI for which her PA treated her with Levaquin 500 mg qd. Today she has gone to the tennis club and has played two games of tennis. During the game she suddenly developed a pain in the right lower ankle region while simultaneously hearing a “pop.” She enters the ER Fast Track area in a wheelchair with an elevated ankle that has ecchymosis and grade 3 edema and a cold foot.

Scenario 2- A 53 year old business executive from a large Manhattan firm has decided to visit a friend for the Christmas holidays. Seeing a large pile of logs he decided he would chop wood for the morning fire. After having an oversized Starbucks coffee and feeling quite energetic from the caffeine rush, he found an oversized ax in the shed and started to carry large logs to the chopping block to begin his work. He developed a strong swinging motion and brought the ax to his side and then straight down on the log. After 45 minutes of this activity, he suddenly developed a severe pain to his left shoulder that radiated down his left arm. The pain became so severe that he states;”it took my breath away.” The patient was driven to the ER by his host and was sent to Fast Trak with shoulder and elbow pain.

Scenario 3- A 36 y/o fireman from Buffalo, NY was engaged in the firefighters tournament, which was being held on Long Island. Unable to make the trip with his Hook and Ladder Company by plane due to his fear of flying since 9-11, this contestant drove the entire night non-stop except for coffee and to relieve himself. At 11 AM Fireman Woody has been admitted to the ER and triaged to Fast Track for pain and swelling of the knee and calf while rapidly climbing the tower. Apparently, while carrying the hose, his knee buckled and now he has pain and swelling from the knee to the ankle.

Read the scenarios and take a few minutes to think of a diagnostic plan. Perform the exam and explain your actions to yourself. Mention the physical assessment techniques that you would perform as well as any additional testing you would perform including medications that you would order. What is your final diagnosis? If you wish you can send it to this author and I will respond. Hopefully I will not be inundated with responses.

We initiated this essay with the presentation of the Physician/PA team, segued into new ideations that are not all embraced by everyone immediately as they represent change. People become comfortable living in the present and consider it unnecessary work and money to make changes that are perceived as a sudden outburst by a few people. This newest focus on the name we were initially called and the first national debate was discovered as starting in 1996 and today there are six thousand PAs that have called for action.

Our second portion of the essay focused on what these PAs expect of their physicians in a responsible relationship. We are now flipping the coin to ascertain what exactly the physician expects of the PA. Education:

1.    Core knowledge- There is the expectation that the PA has a basic compendium of core knowledge in the sciences and knows the reasons for disease and its prevention as well as having the ability to use science and evidence based knowledge to create a differential diagnosis.

2.    Aptitude- The PA should have the ability to utilize various communication sources such as conferences, journal reading and internet research to help the team to move forward, This area is important because everyone profits from physicians, NPs, PAs, secretaries, and technicians and the patient. PAs are considered as part of a strong organized team working together with goals and time frames.

3.    Thoroughness- Whether it be related to a medical practice or a surgical practice there is the need for continuity, for additional diagnostic testing, for referrals to appropriate specialties and to generate a synopsis of these facts for occasional presentations relating to office management and protocol..

4.    Continued Medical Education- Medicine evolves from day to day and it is essential to attend a yearly PA meeting as well as the specialty meeting of the physician. In addition it is expected that the PA will read new and relevant information that applies to the caseload of the practice and to share information and evidence based studies that reflect more modern and proven methods to prevent a disease and lessen its ability to injure the patient.

5.     There are a small number of physicians and groups who will encourage their PA to take a residency program that has didactic and clinical training. My physician partner sent me to his mentor at Johns Hopkins early in our relationship to learn the fundamentals of the physician or professor that he admired. I was later sent to Vienna, Austria to study under Professor Hans Bruck, a famous Austrian surgeon for three weeks. I have joined Dr. Acker at one week meetings of the Pan Pacific course every two years so that we could split our time more effectively and bring home twice the information. This type of activity is interpreted as the physician has trust in their associate PA.

2. Attitude:

A. The physician wants the PA to treat the practice as it were his or her own. There must be a consideration for all of the parameters that the physician considers because this relationship is meant to be like a marriage and both people will profit. Dr. Acker, my supervising physician and I have been working together for 39 years and I took a two year hiatus to join the corporate world and discovered that the trust that developed between Dr. Acker and myself was more important than corporate titles without appreciation.

B. First impressions count. The first impression of the practice and the professionalism of the office are determined by the physician/PA/NP Patient relationship. This supersedes the physician/PA relationship. Proper respect for the patient who is the customer is first and the ability to integrate similar clinicians into a practice setting and work cohesively is important to the overall success of that practice site.
My physician described our relationship when becoming a recipient of the Paragon Award for the Physician/PA Team as a calling not a vocation- not a sinecure to earn a living.

C the PA practices with the understanding that he/she will always be the associate.
    He described this as the priest to someone’s bishop
    Subordinate yet having full ability to demonstrate their approach.
    Control of ego- if the associate thinks that he/she indeed is more proficient than the physician, then the associate should apply to medical school.

To assume in medicine is to court disaster and therefore fastidious and zealous attention should be given to every patient and their problem.

D. Relationships

1. A perfect relationship between a physician and a PA is built on trust.

2. Longevity- these relationships are meant to be enduring, not unlike a marriage. One should not switch teams as one would with running shoes.

3. Profit sharing- incentives and financial remuneration should be fairly distributed based upon the success and expansion of the practice.

D. What do patients expect of the Physician/PA team?

1. The patient must feel that the physician has complete trust or faith in the PAs ability to treat his/her patients.

2. The PA is knowledgeable and qualified to treat each patient problem with sensitivity, taking the time to listen and to maintain the similar approach as the supervising physician.

3. The physician and the PA have an excellent relationship with sharing of ideas and with evident mutual respect.

These are the ingredients for successful physician/PA teams.
                                     Please Send A Copy To Friends & Colleagues

Please Send A Copy To Friends & Colleagues