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Physician Extenders (was RE: trauma-list Digest, Vol 54, Issue 16)
Harper, M Jane M.Jane.Harper at osfhealthcare.orgMon Dec 17 16:30:30 GMT 2007
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That's actually one of the biggest differences between PAs and NPs - we are independently licensed to practice and in ¾ of the states are not required to have physician *supervision*, but rather *collaboration*, a relationship in which the physician is not automatically legally responsible for acts of the NP. We are held to the same reasonable and prudent standard as other nurse practitioners with the same education and experience - I would no more treat a 10 year old trauma patient than I would expect a pediatrician (or pediatric NP) to treat an 80 year old. In some states (of which Illinois is one), prescriptive authority for controlled substances - but not all legend drugs - is delegated by a physician to a nurse practitioner, and his/her name appears on our prescription pads. However, we are still independently held to a reasonable and prudent standard, and the physician would only be legally responsible for our foulups if the physician had a reason to expect we might be incompetent in that particular area but delegated it anyway. As Lorick said, every relationship is different, whether it's NP/physician or PA/physician. And every state has its own legal wrinkles. But I don't *believe* that any state allows PAs to hang out their shingles in an independent practice the way NPs can in several states. How is this pertinent to trauma? Since we are independently licensed, we cannot be considered purely the physician's agent and therefore could not act in his/her *stead* the way PAs can in some settings. (It's also much more difficult in many institutions to get NPs credentialed for procedures such as endotracheal intubation, chest tube thoracotomy, and central line placement because we *do* have independent licensure and less of a known quantity than the PA, whose scope of practice seems in many cases to be clearer.) Jane ---------------------- Jane Harper, PhD(c), RN, ACNP, CCNS, CNRN, CCRN Rockford, IL m.jane.harper at osfhealthcare.org _____ From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Lorick Fox, PA-C Sent: Monday, December 17, 2007 10:15 AM To: Trauma & Critical Care mailing list Subject: RE: Physician Extenders (was RE: trauma-list Digest, Vol 54, Issue 16) Pret, This actually is a potentially "interesting" question. In most states (as far as I know), the acts of a PA are generally considered to be legally the acts of their supervising physician and that physician is responsible for appropriate delegation and monitoring of the PA's functions. Some states define the PA scope of practice as that of their supervising physician, subject to that physician's judgement. Many require a job description, or something along that line, at the time of approval of the license, but some do not. Often, it is the hospital credentialing process that is most restrictive. For a period in Maryland, prior to prescribing privileges being explicitly granted, there was a time (1979) that we ended up with an Attorney General opinion that said that as the PA was acting as an agent for the physician, a hospital nurse was authorized AND required to accept PA written orders exactly as they would if the MD wrote them (i.e. if there was something they would question from the MD, they could call the MD to verify, otherwise, they were required to accept the order as that of the MD). This was before PA's were even credentialed - they were simply considered surrogates. Cardiac surgery PA's often are credentialed to open chests in emergencies. I suspect in many states, a PA licensed to a trauma surgeon would be legally considered the same as the physician for in-house patients. However, since no institution has ever credentialed a PA to take a patient to the OR solo (although there at least used to be states where that would theoretically be legal if a doc was so dumb as try to delegate same), I think that the in-house presence of the surgeon for a Trauma Center is assured. The AAPA (rightfully) makes a big deal of PA/MD or DO "partnership". Every such partnership is to some extent unique because every physician and every PA have their own strengths and weaknesses. For example: I don't have fancy level suturing skills - when I was covering an ER in 1981, my supervising physician refused to come in for cardiac arrests because "you know more about it that I do", but asked (directed) me to refer significant facial lacerations either the PCP or surgeon. (I admit, that was a bit weird, and was based in part on the fact that the first cardiac arrest I managed there was "pronounced" by two very senior physicians who came to the ER to watch me; I declined to accept that judgment and the patient walked out of the hospital a week later.) Every State has it's own PA law, and it has been a LOT of years since I was the Chairman of the Judicial Affairs for the American Academy of PA's, but I suspect this represents the legal position in most cases. Lorick At 04:43 PM 12/17/2007, you wrote: Hey, Lorick. Well said. As List veterans will attest, I'm wrong with astonishing frequency about a breathtaking variety of stuff. But if only for my own edification, I'd be eager to hear from someone with connections to the ACS VRC before abandoning my half-witted interpretation of reality. During our earliest consultations with the College in the 1990's, we were strongly cautioned against having boarded medical intensivists cross-covering our traumas, even over short terms, even with a surgeon as backup. Surely, then, there are surveyors who would frown on a PA covering nights. And good luck meeting Leapfrog. Sorry if I'm muddying things. It's what I do. I'm ready and grateful for any enlightening smackdown that awaits. Pret -----Original Message----- From: trauma-list-bounces at trauma.org [ mailto:trauma-list-bounces at trauma.org <mailto:trauma-list-bounces at trauma.org> ] On Behalf Of Lorick Fox, PA-C Sent: Monday, December 17, 2007 9:18 AM To: Trauma & Critical Care mailing list Subject: Re: Physician Extenders (was RE: trauma-list Digest, Vol 54, Issue 16) I understand what Pret means, but for clarity: Always have to have the surgeon in place for trauma admissions. However, I can assure you that many PA's manage SICU, MICU, CCU patients routinely, with the physician in the OR, at home or otherwise occupied. They don't provide SOLE management, but they provide initial/primary management, with the MD fine tuning (or making the "no good answer" decisions), either in person or via phone. St, Joseph's wasn't a trauma center (that was next door) but we had at least 30 ICU beds that I was the primary call person for between 2000 and 0800 for the year and half I survived that. The post CABG patients were primarily managed by the surgeon from home, but he would ask us to see them if there was question or they needed cardioversion/new line/airway management/etc. If there was a surgical decision to be made, however, either the cardiac surgery PA or the surgeon would come in (often without my involvement at all - they could open chests, I couldn't). "Manage ICU patients" was certainly in my state approved job description in both Georgia and Virginia. Lorick At 03:54 PM 12/17/2007, you wrote: Our general/trauma extenders assist in the OR, round with the attendings on all inpatients (inc ICU), do a variety of procedures (chiefly wound care, tubes, and lines), and handle much of the day to day documentation. Our trauma surgeons also staff a busy general surgery practice, so there's a wide variety of work to be done. The PA's (there are no NP's in trauma at the moment, but our recruitment is non-discriminatory on that account) do not take call, and are not assigned to the trauma response team as such; however, when they're on site (weekdays mostly), at least one of them is usually accompanying the trauma attending, and thus tags along and acts as an extra set of hands, further freeing the surgeon to direct the resuscitation. I don't think you'll find a Level I or II center which lists "management of ICU patients" in the PA/NP job description. Functional realities notwithstanding, you've got to have a doctor (almost certainly a surgeon, and further, a boarded intensivist) directly responsible for ICU care. It's part of the verification requirement. In my observation, our PA's get more OR and procedure time than most. I'm aware of plenty of practices wherein the extenders are used for clinical and clerical infrastructure (i.e., scut work). But then, ours were selected in large part for their surgical experience, and have enormous operative credibility. We've been immensely fortunate in our hiring, and have a team of surgeons that admires and supports the unique surgical capacities of its assistants. All of which is to say that in a great many programs, and for any number of PA's and NP's, one person's scut work is another's indispensable role in a comprehensive system of patient care. I have no doubt that the use of extenders in trauma centers will continue and increase; but I can't see there ever being a standardized job description across the profession. Pret Bjorn, RN EMMC Trauma Program (ACS Level II) Bangor, ME USA -----Original Message----- From: trauma-list-bounces at trauma.org [ mailto:trauma-list-bounces at trauma.org < mailto:trauma-list-bounces at trauma.org <mailto:trauma-list-bounces at trauma.org> > ] On Behalf Of czuehlke at frontiernet.net Sent: Friday, December 14, 2007 5:50 PM To: trauma-list at trauma.org; trauma-list-request at trauma.org Subject: Re: trauma-list Digest, Vol 54, Issue 16 Greetings list members, This is directed toward those that are in Level I and II centers (or other high volume centers). How many of you use physician assistants on your service? For those that have residents and fellows, what is the role of the PA during pt care? Does the PA take call? Do the PAs manage patients in the SICU? Do you see a change in demand for PAs in trauma care? Hi, In the one trauma centers I work in the PA sees just the mildly ill patients and places sutures and or staples in patients. The PA is never seen in the trauma rooms nor is he/she in a place where there are serious medical conditions. NP's are treated exactly the same way. At the other hospital newly named trauma center level II for 2010. It does not use NP's or PA's at all. Carol Eisenbrandt Quoting trauma-list-request at trauma.org: > Send trauma-list mailing list submissions to > trauma-list at trauma.org > > To subscribe or unsubscribe via the World Wide Web, visit > http://list.mistral.net/mailman/listinfo/trauma-list > or, via email, send a message with subject or body 'help' to > trauma-list-request at trauma.org > > You can reach the person managing the list at > trauma-list-owner at trauma.org > > When replying, please edit your Subject line so it is more specific > than "Re: Contents of trauma-list digest..." > > > Today's Topics: > > 1. Nearly Famous! (tuganddawn at talktalk.net) > 2. Physician Assistants in Trauma (Michael Krowka) > 3. Re: Physician Assistants in Trauma (Ronald Gross) > 4. RE: Physician Assistants in Trauma (Brian E. Fletcher) > 5. Re: Nearly Famous! (Krin135 at aol.com) > > > ---------------------------------------------------------------------- > > Message: 1 > Date: Thu, 13 Dec 2007 20:56:15 -0000 > From: <tuganddawn at talktalk.net> > Subject: Nearly Famous! > To: <trauma-list at trauma.org> > Message-ID: <000a01c83dca$9b0826f0$4752f259 at 049682920380> > Content-Type: text/plain; charset="iso-8859-1" > > Hello to everyone. > > Before I begin may I wish all of you wherever you are and whatever > your beliefs a very Merry Christmas and a pleasant and event free > New Year. > I am a Paramedic/Firefighter working in the UK and have > recently been asked to consider appearing in a documentary series > about the ambulance service speciffically dealing with concerns > about the increase in calls, abuse of the service and out of hours > GP service effects. > A few months ago I would have been completely against this idea > but recent reforms, behaviour of management and treatment by other > health care professionals has made me consider the potential > benefits of exposing certain ignored aspects of my service > (including the appalling lack of professionalism, training and > negligence by many Paramedics). > I wonder if the list might offer any insights they have about the > ethics and problems faced with this sort of media exposure > especially when one considers the uncontrolable environment we work > in. I would also appreciate any advice about how to deal with these > "cutthroat" sensationalist media types! > In any event, thanks for your time and trouble and I hope to hear > your responses. > > Yours with kindest regards > > Tug Crumpton > > ------------------------------ > > Message: 2 > Date: Thu, 13 Dec 2007 16:00:59 -0700 > From: Michael Krowka <mkrowka at gmail.com> > Subject: Physician Assistants in Trauma > To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org> > Message-ID: <C38707BB.3C00%mkrowka at gmail.com> > Content-Type: text/plain; charset="US-ASCII" > > Greetings list members, > > This is directed toward those that are in Level I and II centers (or other > high volume centers). > > How many of you use physician assistants on your service? > > For those that have residents and fellows, what is the role of the PA during > pt care? Does the PA take call? Do the PAs manage patients in the SICU? > > Do you see a change in demand for PAs in trauma care? > > > > Michael D. Krowka > EMT-P > > > > > ------------------------------ > > Message: 3 > Date: Thu, 13 Dec 2007 19:17:30 -0500 > From: "Ronald Gross" <Rgross at harthosp.org> > Subject: Re: Physician Assistants in Trauma > To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org> > Message-ID: <47618535.7FF1.00B9.0 at harthosp.org> > Content-Type: text/plain; charset=US-ASCII > > Michael, > > We have 4 PAs and one APRN on service. Contact me off-line and I > would be happy to discuss....... > > Ron > >>>> Michael Krowka <mkrowka at gmail.com> 12/13/2007 6:00 PM >>> > Greetings list members, > > This is directed toward those that are in Level I and II centers (or other > high volume centers). > > How many of you use physician assistants on your service? > > For those that have residents and fellows, what is the role of the PA during > pt care? Does the PA take call? Do the PAs manage patients in the SICU? > > Do you see a change in demand for PAs in trauma care? > > > > Michael D. Krowka > EMT-P > > > -- > trauma-list : TRAUMA.ORG > To change your settings or unsubscribe visit: > http://www.trauma.org/index.php?/community/ > > > > ------------------------------ > > Message: 4 > Date: Thu, 13 Dec 2007 19:44:10 -0500 > From: "Brian E. Fletcher" <bfletcher at columbus.rr.com> > Subject: RE: Physician Assistants in Trauma > To: "'Trauma & Critical Care mailing list'" > <trauma-list at trauma.org> > Message-ID: <20071214004410.BJDP22267.hrndva-omta06.mail.rr.com at BRIAN> > Content-Type: text/plain; charset="us-ascii" > > We have 10 Nurse practitioners. We manage the step down ICU, floor > patients, and respond to traumas. We essentially function like a resident, > performing primary/secondary assessment, FAST, central lines, Chest tubes, A > lines, suturing etc. We also have an NP clinic and an attending clinic. The > NP clinic sees lower acuity patients and we also assist in the attending > clinic. Hope this helps. > > Brian > > -----Original Message----- > From: trauma-list-bounces at trauma.org [ mailto:trauma-list-bounces at trauma.org < mailto:trauma-list-bounces at trauma.org <mailto:trauma-list-bounces at trauma.org> > ] > On Behalf Of Michael Krowka > Sent: Thursday, December 13, 2007 6:01 PM > To: Trauma & Critical Care mailing list > Subject: Physician Assistants in Trauma > > Greetings list members, > > This is directed toward those that are in Level I and II centers (or other > high volume centers). > > How many of you use physician assistants on your service? > > For those that have residents and fellows, what is the role of the PA during > pt care? Does the PA take call? Do the PAs manage patients in the SICU? > > Do you see a change in demand for PAs in trauma care? > > > > Michael D. Krowka > EMT-P > > > -- > trauma-list : TRAUMA.ORG > To change your settings or unsubscribe visit: > http://www.trauma.org/index.php?/community/ > > > > ------------------------------ > > Message: 5 > Date: Thu, 13 Dec 2007 20:39:34 EST > From: Krin135 at aol.com > Subject: Re: Nearly Famous! > To: trauma-list at trauma.org > Message-ID: <c73.2076a517.349338d6 at aol.com> > Content-Type: text/plain; charset="US-ASCII" > > > In a message dated 13-Dec-07 14:57:36 Central Standard Time, > tuganddawn at talktalk.net writes: > > I wonder if the list might offer any insights they have about the ethics and > problems faced with this sort of media exposure especially when one > considers the uncontrolable environment we work in. I would also > appreciate any > advice about how to deal with these "cutthroat" sensationalist media types! > In any event, thanks for your time and trouble and I hope to hear your > responses. > > > > Tug: > > good luck with your project. > > You might have better luck posting to the EMS-L using instructions found at: > > List FAQ: http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2007-December/_HTTP://EMS-L.ORG <http://ems-l.org/> <http://ems-l.org/ > _ (http://EMS-L.ORG <http://ems-l.org/> <http://ems-l.org/ > ) > Unsubscribe: _EMS-L-UNSUBSCRIBE at EMS-L.ORG_ > ( mailto:EMS-L-UNSUBSCRIBE at EMS-L.ORG < mailto:EMS-L-UNSUBSCRIBE at EMS-L.ORG <mailto:EMS-L-UNSUBSCRIBE at EMS-L.ORG> > ) > (subscribe should be _EMS-L-SUBSCRIBE at EMS-L.ORG_ > ( mailto:EMS-L-SUBSCRIBE at EMS-L.ORG < mailto:EMS-L-SUBSCRIBE at EMS-L.ORG <mailto:EMS-L-SUBSCRIBE at EMS-L.ORG> > ) ) > Manage: _ HTTP://EMS-L.ORG/MAN-EMS-L.HTM < http://ems-l.org/MAN-EMS-L.HTM <http://ems-l.org/MAN-EMS-L.HTM> > _ ( http://EMS-L.ORG/MAN-EMS-L.HTM < http://ems-l.org/MAN-EMS-L.HTM <http://ems-l.org/MAN-EMS-L.HTM> > ) > Post to list: _EMS-L at EMS-L.ORG_ ( mailto:EMS-L at EMS-L.ORG < mailto:EMS-L at EMS-L.ORG <mailto:EMS-L at EMS-L.ORG> > ) > List Manager: _LISTADMIN at EMS-L.ORG_ ( mailto:LISTADMIN at EMS-L.ORG < mailto:LISTADMIN at EMS-L.ORG <mailto:LISTADMIN at EMS-L.ORG> > ) > Moderator: _MODERATOR at EMS-L.ORG_ ( mailto:MODERATOR at EMS-L.ORG < mailto:MODERATOR at EMS-L.ORG <mailto:MODERATOR at EMS-L.ORG> > ) > > Or one of the various Yahoo Paramedic groups... > > ck > Charles S. Krin, DO FAAFP > > > > **************************************See AOL's top rated recipes > ( http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004 < http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004 <http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004> > ) > > > ------------------------------ > > -- > trauma-list : TRAUMA.ORG > To change your settings or unsubscribe visit: > http://www.trauma.org/index.php?/community/ > > End of trauma-list Digest, Vol 54, Issue 16 > ******************************************* > -- trauma-list : TRAUMA.ORG To change your settings or unsubscribe visit: http://www.trauma.org/index.php?/community/ -- trauma-list : TRAUMA.ORG To change your settings or unsubscribe visit: http://www.trauma.org/index.php?/community/ LFFox, MPAS, PA-C Distinguished Fellow, AAPA CCA, American College of Cardiology Associate, Society for Critical Care Medicine Associate, Underwater and Hyperbaric Medical Society Lorick Fox, MPAS, PA-C SEAVIN/Peace Vector IV Unit 64903, Box 1201 APO, AE 09868-4903 (cell) +20-18-230-4448 (landline) +20-45-240-9450 www.lorick.org <http://www.lorick.org/> < http://www.lorick.org/ <http://www.lorick.org/> > -- trauma-list : TRAUMA.ORG To change your settings or unsubscribe visit: http://www.trauma.org/index.php?/community/ ============================================================================== The information in this message is confidential and may be legally privileged. 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