Who’s gonna insert that cannula, place that urinary catheter, whatever?

American ER Doc Gone Walkabout Episode 003

Very noticeable was the amount of routine tasks that the Doctors — senior and junior — seemed to do in Tassie. IV starts (cannula insertions), blood draws for lab (pathology), foley catheter insertions, splints, etc.

I haven’t done a routine blood draw, or started a peripheral IV (had a hard time remembering the “insert a cannula” terminology), or placed a foley catheter in 35 years. By the time our US nurses and techs have concluded that they can’t get a cannula inserted, it’s time for an IO, femoral, or central line. And, for a 3 month stay, it didn’t seem likely that trying to relearn those skills was going to be high yield.

Our first line or defense in the US are the “techs” – EMT’s and Paramedics working in the ER.They do many of the routine tasks – moving patients about, drawing bloods, inserting cannulas, applying splints and sometimes casts, wound care and preparation for suturing, placing urinary catheters (males do the males, female techs do both males and females). Some of our techs have become proficient at more complex procedures — inserting difficult cannulas under real-time ultrasound guidance (and will train our junior doctors in the technique), inserting intraosseous cannulas, etc. Many of them are wise enough and confident enough to be a great help with assuring that background tasks go well when the senior doctors are multi-tasking (deeper and faster on that CPR, don’t forget that you need 3 amps of calcium gluconate to equal an amp of calcium chloride, watch that tube while we’re rolling the patient, monitoring during procedural sedation).

As you might imagine, with the advanced tasks, there is a great deal of variability from one hospital ED to another, and from one individual to another, as to how this will be approached and what is permitted.The techs improve efficiency, help with teaching, and are a gigantic asset to practice.

Moving on to the nursing staff:Nursing scope of practice seemed somewhat restricted compared to home – at least in the procedural realm. If my understanding of casual conversations was correct, the nurses face a “merit badge” system of certifications and recertifications that becomes quite onerous, and many of the nurses don’t have the motivation to keep up on all the available certifications.

So, none of our LGH nurses inserted male urinary catheters (though many had done it in the past), or difficult adult or any pediatric intravenous cannulas, etc.

In reality, this had the advantage that, because we seemed to be generally better staffed on the doctor level than on the nursing level, assigning those tasks partly to doctors evened out the workload somewhat. Very noticeably missing in the land of Oz, were the “mid-level” practitioners: physician assistants and nurse practitioners (PA and NP).In US ED’s – large and small – the mid-level manages much of the urgent care and minor emergency business (and because of our disorganized medical care system, we’ve got a lot of that). In some settings, the PA also does a significant portion of the care of sicker and more complex patients – in direct conjunction with the supervising doctor – doing the basic history and physical, ordering lab and imaging studies, contacting consultants, handling much of the paperwork. In essence functioning in the role of intern or junior resident with close supervision of the attending (consultant) physician. Many of the minor procedures – suturing, incision and drainage of abscesses, etc. – are also handled by the PA’s (some technical procedures, like drainage of peritonsillar abscesses are done only under direct supervision). We don’t have enough trained doctors to go around, and can train mid-level practitioners in one fourth the time of training a doctor, so these practitioners provide a large amount of flexibility in keeping up with rapidly changing staffing needs. They greatly improve the efficiency of our attending staff physicians and are widely used in large teaching hospitals as well as in non-teaching hospitals of all sizes.

All of our consulting specialty services use mid-levels extensively, again how much depends on the hospital, and often our first contact will be with the PA. For instance, a significant head injury being admitted to neurosurgery might be admitted by the neurosurgical PA, and the neurosurgeon himself might only be involved directly if a surgical procedure is required. Similar with gastroenterology and many others. If, like many American ED Docs, you don’t drain Quinsy (no American ED Doc knows that word) yourself, the ENT PA may show up to drain it for you.

Correct me if I’m wrong, but my perception in Tassie was that much of the slack in physician staffing was taken up by junior doctors — many of them originating in, and with basic training obtained in — other countries of the world.

My last observation for today, my greatest surprise while in Australia: I tuned in to a Rugby game on TV and was astounded when the national anthem was sung — it wasn’t Waltzing Matilda…

Next time:  Consultants, HTFU and the depressing state of US healthcare