Critical Care in the ED for Physician Assistants

You’re an advanced practitioner in a traditional emergency medicine role. You’re starting to see chest pain, belly pain, shortness of breath, GI bleeds and neuro cases. You’re starting to see the cases you got into this business for. You want to make a measurable impact; you want to keep growing. If you’re this kind of advanced practitioner, our upcoming series is for you. It’s for the provider who wants to take their game to the next level. These providers want to take care of really acutely sick patients.

When a patient with a systolic pressure of 60 comes in, you want to have the confidence and competence to manage that. You have someone who comes in with angioedema and they’re losing their airway. You want to grow to a position where you can manage that patient. That’s what this series is going to be about. It’s giving you the confidence, competence, and tools to manage these acutely ill patients.

My name is John Bielinski and I’ve been a PA for 23 years. I managed acutely ill patients for the majority of my career, running critical access emergency rooms. I was a lone wolf, the sole provider, so I had to learn ACLS like the back of my hand. I had to learn airway control because I didn’t have anybody but me. I had to chest tubes and LPs. I had to learn central lines. I had to learn these techniques because, quite frankly, my patients demanded it. This is really important for you to understand.

If you work in emergency medicine, you need to understand that your patients didn’t have a choice. When someone gets sick, it’s not their choice. You’re on call, on duty, so you have a responsibility. Advanced practitioners have the responsibility of optimizing our game within the capacity that we work.

If you work in urgent care, in an emergency room, you may think, “There’s always a doc next to me.” You want to be positioning yourself for your next job. When this job dissolves or you want to grow, will you be ready for the next gig? I want to start talking about how you position yourself to be taking care of acutely ill patients. What did I do? How did it happen to me?

Well, I was slowly indoctrinated to sick patients when I worked as a hospitalist. When someone got sick, I would get that call. I got the call for the 20 beat run of V-tach and the very sleepy COPDer with an O2 saturation of 86%. I had to manage those rapid response calls but I also knew that I could call a Code Blue and the ICU team would come.

ACLS Protocols

If you want to grow into a position where you’re taking care of really sick people, you have to master ACLS protocols. You have to know doses and you have to know when to start over. The only way that I got good at ACLS was becoming an instructor. If you want to go to the next level, you have to become an ACLS instructor so you can learn the algorithms like the back of your hand.

I had the privilege of being an ACLS instructor for a long time. I also became an instructor for an American Heart Association course called ACLS EP, or Advanced Cardiac Life Support for the Experienced Provider. That’s for people who really know their algorithms. It takes you to the next level and lets you teach about things like toxicologic arrests, electrolyte emergencies, environmental emergencies like life-threatening asthma, weird cardiac stuff like WPW, and right-sided heart infarctions.

The axiom of learning holds true here. You see one, do one, teach one. You see a V-tach arrest, you run a V-tach arrest, and then you teach a V-tach arrest. When you’re analyzing another person’s assessment of a V-tach arrest, you can critique them in a loving way that makes them a better clinician. At the same time, you’re kind of preaching to yourself. When you can teach ACLS, you learn how to apply them very specifically, in good detail. If you want to get really good at taking care of acutely ill patients, consider becoming an ACLS instructor. Contact a local agency. They’re always looking for good instructors.

Airways

When I was working in a traditional emergency room, I got really comfortable with the airway right away. Even though I was just a new graduate PA, I got good at the airway in any code-like situation that came in. Even though the doc was running the code, I would make sure that suction was set up, the tube was on, the catheter was ready, and it was turned on. You always want the whistling noise of the suction going in the code room because when someone starts vomiting, you can’t set up the suction then. It has to be ready, or else you’re whipping the patient on their side and it’s really concerning.

One of the things that I always did was ask the docs if I could help with the airway on any codes that come in. I suggest you do the same if you’re working in a traditional emergency room. That means Ambu bagging if there’s not a respiratory therapist available. It means asking the doc what kind of tube they want and getting those tubes set up. Is it seven and a half or an eight tube? Get the stylet put in. Get the 10 cc syringe hooked up to the endotracheal tube. Get the end-tidal CO2 detector ready.

When I did a trauma rotation at the Albert Einstein College of Medicine ER in Philadelphia, there was an airway team and a circulation team. I took it upon myself to be the airway guy. That means I had to know how to use nasopharyngeal and oropharyngeal airways. Know when they’re indicated. Know when cricoid pressure may be helpful for the doc when it comes to intubation. Know that bagging somebody is a good thing. If you can bag them effectively, you can prolong their life for a long time. You also need to understand that if you bag them for a while, some air is going into the stomach. We have to be very careful about what we’re doing in this situation. If we want to prevent the patient from vomiting and aspirating, an NG tube may be indicated. You want to ask those questions.

The Psychology of Critical Care

In the 15+ years I ran critical access emergency rooms, when I knew a code was coming in, I considered the worst-case scenario. What’s the worst-case scenario in a code? It’s not that the patient dies because most of the patients are going to die. Remember, when it comes to resuscitation, there are a few outcomes. Ultimately, in the emergency room, I just want the return of spontaneous circulation and I want to preserve it. Quite frankly, I want someone else to fill out the death certificate. If a code comes into my emergency room, I want to stabilize them to the best of my capacity and then get them to somebody else.

That’s not the optimal goal though. We want our patients to have good neurological functions so that they can walk out of the hospital. I found that as an ER PA working critical access emergency medicine, I couldn’t worry about that secondary outcome. I just have to do the best I can with what I have. What are the odds that someone is really going to have a good neurological outcome and leave the hospital? In my experience, a good neurological outcome discharge is about 2%. That means only one out of 50 patients that I see are going to have a good neurological outcome when they leave the hospital. They’re going to be able to spend Christmas with their family and be coherent.

I have to realize that the chance of a very successful optimal resuscitation is low; it’s 2%. So what’s the worst-case scenario in a resuscitation? It’s not that the patient dies, it’s not. The worst-case scenario is that the patient dies and you were a basket case in the process. You didn’t give good orders, you didn’t follow good structured algorithms. At the end of the code, the patient is dead and everybody’s flustered. Everybody’s thinking, “Man, I hate when John’s on because he’s a basket case in a code.”

When you’re running a code, take a deep breath. Breathe out and relax a little bit because you have to be a code leader. You have to be crisp, concise and methodical. You don’t get jacked up because that’s the worst-case scenario. Colleagues, every code is practice. Every cardiac arrest is practice for the next one. Make sure you’re doing really good CPR or holding whoever is doing CPR accountable. Make sure the transitions are smooth. You want to get good at assessing the rhythm. You want to get good at defibrillation, if necessary. You want to be better at your medicines, at clear communication, at giving an order and making sure it’s back channeled to you. When you’re going to defibrillate, you need to say, “I am going to defibrillate; nobody touch the patient. All is clear, everybody’s clear.” You don’t want anybody to get hurt in the process, whether it’s through defibrillation through an IV needle stick or through emotional stress.

Every single code you want to be three or five percent better than your last. Why? Because a 78-year-old with colon cancer who comes in in cardiac arrest is a very different code than a 12-year-old pulled out of a swimming pool. We want to be optimized for that 12-year-old pulled out of a swimming pool.

As a code leader, your first step in running a code is to be really calm. When I was a young hospitalist and I started running codes, I would run to the codes. I would race to the codes and it was really counterproductive for two reasons.

1. I’d be out of breath and hyper sympathetic and jacked up.
2. I was at a teaching hospital with foreign medical residents who were super fast. They’d always beat me to the bedside. I talked to a PA friend of mine with a lot of experience. I said, “I get so disappointed because all these people are at the code.” She goes, “John, here’s the deal. Don’t run to the code, don’t run anymore. Just walk with intention. Wait until the crash cart gets there because the residents always beat the crash cart. When the crash cart comes, just take the paddles off the defibrillator, walk in the room with the defibrillator paddles extended saying, ‘Excuse me, excuse me, excuse me.’ The residents jump out of the way just like they were defibrillated and then you’re front and center for the code.” That was super helpful for me.

When I would go on a shift in a critical access hospital, I’d say a prayer before going in because you never know what’s coming through that door. You never know when there’s going to be an airway closing up in front of you that requires a surgical airway. You have to prepare yourself mentally for that. You have to mentally prepare yourself and your team for the acute stroke patient who comes in with acute right-sided weakness that happened 15 minutes ago. Do you know how to manage that? Do you know how to assess them? Do you know how to scan them? Do you know how to push TPA or get them to definitive care? You can’t be the person who delays that.

If you’re a PA or NP who wants to increase your game and transition into the role of really taking care of critically ill patients, take a deep breath and prepare appropriately. Often, paramedics are really good at this because they’re used to being the code team on the streets. Advanced practitioners transitioning into this role will need to grow their knowledge base to be a code leader. Getting to the point that you can run a code if you need to makes you more valuable.

The next post in this series will cover the primary and secondary assessment. Stay tuned for more growth. I plan on doing a whole series on how to increase your critical care in the emergency room. In October of 2019, I taught an advanced emergency medicine conference at Yellowstone National Park on critical care in the emergency room. The content was so powerful that we recorded all of it into a Category 1 CME video series. It will be available for advanced practitioners looking to take their game to the next level.

More CME from CME4Life

We have three different categories of CME at CME4Life designed to support advanced practitioners in emergency medicine:

1. We have an urgent care curriculum. This will teach you the tools of efficient and effective care. You’ll learn how to get your psychology right, as well as head to toe assessments for things like conjunctivitis, otitis media, sinusitis, epistaxis, and anterior epistaxis. This is the kind of patient who you don’t think needs to be admitted.
2. We have our demystifying emergency medicine curriculum. I’m super, proud of this curriculum. It’s the best stuff I’ve ever developed. There are two hours of clinical lab medicine and two hours of how to assess a pulmonary patient, including chest radiograph interpretation. Part three is an advanced EKG interpretation workshop. Part four is abdominal pain and headaches.
3. We have our Black Belt EKG program. If you need help with EKG interpretation, I’ve come up with a bunch of systems, a bunch of mnemonics, for chest pain and EKG interpretation.

We also have an advanced emergency medicine curriculum. This really looks at critical thinking. We give you case studies and ask, “What would you do now? What would be optimal thinking now?”