Patient approach
Emergency medicine practitioners have one overarching goal for each patient: to answer the question, “Does my patient have a threat to life, limb, or sight today?” Emergency departments (EDs) are structured to provide life-saving services to patients in acute need. Determining which patients are in acute need, however, can be less than obvious. A woman with a classic presentation of gastroesophageal reflux may have a myocardial infarction. A man with a complaint of a mild cough and a low-grade fever may have a pulmonary embolus. Someone with a very concerning facial droop may simply have a Bell’s palsy rather than the stroke she feared when she saw her face in the mirror.
The purpose of the ED workup is to provide the correct disposition for each patient. Your preceptor will perform a focused history and physical examination, followed by clinical investigations designed to determine whether the patient is “sick” or “not sick.” To an emergency medicine physician assistant (PA) or doctor, “sick” means there is a possibility that the patient will die today. Although a patient vomiting repeatedly from a hangover may appear sicker than a new atrial fibrillation patient who complains of generalized fatigue, in reality, the new atrial fibrillation patient is sicker and demands a more careful workup. Each patient is evaluated to see if he or she needs hospitalization or whether his or her concerns can be safely worked up on an outpatient basis after discharge.
Emergency medicine practitioners do not necessarily make a diagnosis for the patient in the ED. The goal is to provide life-saving care and then to send the patient to the most appropriate environment for the rest of his or her care. For example, patients with hypotension from severe sepsis will be admitted to the intensive care unit (ICU) regardless of the source of the infection. If the source of the infection can be determined in the ED, that is certainly helpful to the medical staff; however, not knowing the source does not preclude the emergency medicine team from providing appropriate initial care and handoff to the medical team. Patients with multiple traumatic wounds will be taken to the operating room or transferred to the nearest trauma center, even if the staff in the ED do not have time to characterize all the injuries.
When you are seeing a patient, keep these questions in mind:
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Does the patient appear seriously ill?
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Is the patient unable to participate with my history and physical examination?
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Does the patient have vital signs that indicate she or he may be dying?
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Does the patient, although appearing well now, have symptoms that are consistent with a life-threatening pathology (e.g., chest pain, unilateral weakness)?
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Does the patient appear to be dangerous toward me or any other member of the staff?
If the answer to any of these questions is “yes,” you should seek help from your preceptor sooner rather than later. No one will criticize you for seeking help early. If the patient is not as sick as you feared, you will simply be instructed to continue with your assessment and be ready to present the patient to your preceptor in a few minutes.
Finally, a word about honesty. Experienced emergency medicine practitioners know to listen carefully, sympathetically, and respectfully to the patient but to also be a bit suspicious about elements of the patient’s story that potentially do not make sense. Did she really break her jaw by falling out of bed, or is it more likely that she is the victim of domestic violence? Why does this patient’s opiate pain medication always seem to be “stolen” from his car only a few days after his last prescription was written? Could he be selling the pills or so addicted that he is taking far more than the prescribed dose? Is it possible that my 16-year-old female patient with nausea is pregnant despite her denying sexual activity?
A typical day in emergency medicine
PAs in emergency medicine have great variety in the level of responsibility they carry. Some PAs in rural EDs are the sole provider in the ED and are responsible for all aspects of care for all patients, with physician supervision at a distance. Other PAs work solely in the urgent care or fast-track parts of the ED, seeing primarily patients with more minor complaints. Many PAs see all types of patients under the supervision of a board-certified emergency physician. The supervision can be quite close for less experienced PAs or looser for more experienced PAs, depending on the laws of the state, the regulations of the hospital, the requirements of the department of emergency medicine, or the preference of the supervising doctor working with the PA that day.
That said, emergency medicine PAs have the opportunity to see a wide range of medical and surgical conditions. It is not unusual for a PA to simultaneously care for an oncology patient, an orthopedic patient, a cardiology patient, and a psychiatry patient. Sometimes one patient can have issues from all of these specialties! PAs evaluate patients from the beginning, determine what testing they need, carry out the testing, interpret the results, and provide an appropriate treatment. A typical shift might include a pelvic examination, suturing a laceration, transferring a patient to an ICU, interpreting an electrocardiogram, reading a chest radiograph, and dealing with eight complaints of abdominal pain. In all cases, the PA’s role is to determine whether the patient is sick and to provide stabilizing or curative treatment.
Expectations of physician assistant students on emergency medicine rotations
After seeing a few patients with your preceptor to understand how things work at the particular ED, you will typically be sent to see patients on your own. You will be expected to obtain a relevant focused history and an appropriate examination from the patient. Typically, preceptors will ask students to avoid performing pelvic, rectal, or breast examinations so that a patient does not have to undergo these examinations more than once. You should defer these examinations until after you have presented the patient to your preceptor. After you have seen the patient, you should think about what you would like to do for the patient (further evaluation or treatment) and get ready to present the history and physical examination findings and your plan to your preceptor. You will watch for your patient’s results to come back and present them to your preceptor along with your recommendations for the next step as the patient goes through his or her ED workup.
In the setting of a busy ED, you can be of great help to the team by keeping up with your patient’s laboratory and radiology results, by learning where supplies are and being willing to help collect supplies for procedures, and by helping patients with comfort needs when you have a spare moment. Review the principles of sterile technique before the rotation so that if you are fortunate enough to be asked to assist with a lumbar puncture, chest tube, or central line, you will not contaminate the field or impair the PA’s ability to do his or her job ( Fig. 26.1 ).
