You are an NP/PA on an ambulance!

[Giant81]

I'm envisioning something like this. I live in a rural area that hardly has paramedics so I suspect we won't get NP/PA's anytime soon but here's my scenario.

Farmer working on machinery, slips, slices arm open, it's bleeding pretty good, but bleeding is controled by the time NP/PA shows up.
evaluate patient, clean wound, numb, suture, wrap, provide Rx for antibiotics and pain meds, print off sheet with signs to keep an eye out for and tell them to follow up with their PCP. roll back to garage. Saves the PT a trip to the ED, saves ED staff time with a fairly routine trauma, win/win.

Granted this is with little knowledge of a paramedics SoP, and I'm not sure if a paramedic can use butterfly stitches to close a wound and advise a PT to go to Urgent care or see his PCP within the next 24hr if possible.

 

[zzyzx]

Why not just have the Farmer take himself to the ED? If he controlled the bleeding himself, why even call 911?

In a rural area, it is hard enough to find MD's, PA's, and NP's to staff clinics. It does not seem efficient or cost effective to take one out of a clinic where they can see many patients.

There are good reasons why doctors stopped doing house calls many decades ago.

 

[medicsb]

Oooh, I want to play.

You are an NP or a PA working on an ambulance. Imagine that it is a trial program like the one in Orange County, CA.

How would you handle the following 911 calls:
1) Which would you treat and not transport (with referral to PMD)?
2) Which would need an ER eval?
3) Which would be a likely hospital admission?

1) 35 y/o diabetic (Type I) with a fingerstick glucose of 400; ran out of his insulin. Asymptomatic.
I don't trust "asymptomatic" in a type I DM pt. I'd want a BMP and urinanalysis. So to the ED. 12 lead on scene. Don't really need an ambulance.

2) 55 y/o c/o hypertension, BP 245/120, asymptomatic. Was a relative's house and tried their automatic BP. Does not take any anti-hypertensives and has not seen a doctor in years.

Most would be very uncomfortable with that BP. We can talk all we want about it being asymptomatic, but you probably have to throw something at them. Perfect world they'd get a script for HCTZ and referal to PCP. Realistically they're probably going to get a 12 lead, CXR, BMP, CBC, and urinalysis. Someone will probably throw hydralazine at them.

2) Patient involved in a fight. C/o a "fight bite." He punched someone in the mouth and has lacerations on his hand. "Do I need to see my doc to get antibiotics or will I be okay without?"

Thorough cleansing, close exam for tendon injury, loose approximation, and ABx.

3) Diabetic (Type II) who takes metformin, glypizide, and an insulin was found ALOC by his wife. Blood glucose 20. After you administer dextrose, he is fully alert and oriented.

Perfect world: direct admit to observation unit (otherwise to the ED).

4) Twenty year old with a sore throat x 3 days. Also fever. No SOB and vital signs stable. Says she can't deal with the pain anymore; no OTC meds working.

Decadron IM and walk it off, you big baby.

5) 7 y/o SOB with Hx asthma. Pt is acting age appropriate and does not appear to be in acute distress. Mild retractions noted and tachypnea; bilateral exp wheeze. SpO2 95% after breathing Tx.

Retractions and tachypnea? To the ED unless you're going to sit for hours on scene waiting for them to turn around.

6) CHF'er who has frequently visited the ER and is well known to the staff. C/o just not feeling well, generalized weakness, increased dyspnea on exertion. Vital signs stable; no acute distress. Denies chest pain. 12-lead shows paced rhythm.

To the ED, needs work up. Probably getting admitted at least to obs.

7) Pt was running on the beach when she stepped on and broke a bottle. Has deep lac on foot requiring suturing. Bleeding controlled.

To ED, need Xray to assess for FB.

8) 27 y/o syncopal episode at work. Vital signs stable; asymptomatic. No prior Hx.

If there's concern for bleeding somewhere or if it was exertional and/or sudden, then to the ED.

9) 35 y/o c/o fever, malaise, cough x 3 days. The cough is productive with green phlegm. SpO2 99% and stable vital signs. C/o mild SOB but is in no acute distress.

Take some motrin, fluids, and stop being such a baby. Leave at home. (Turn all the lights on in the house because this guy is probably afraid of the dark.)

10) New first-time parents of a 20 day old with fever 102. Vital signs are stable and the baby does not appear to be in any distress.

To the ED. Baby gon' get needle'd.

11) Auto mechanic c/o injection-gun injury to his hand. Pt was using a high-pressure grease gun when it injected grease into his hand. Minimal pain. No loss of function. Pt states he called because his co-worker told him that the grease could enter his blood stream and cause a stroke.

To the ED (one with access to hand surgeon).

12) 3 y/o with fever x 2 days. Mother states that she has given him Tylenol several times but his fever keeps coming back. No coughing, no retractions, no signs of respiratory distress. Child is smiling at you and interacting normally with mother. All vital signs are WNL except that temperature is 102 and pt is a little tachycardic.

Give the tylenol regularly (or alternate w/ motrin), makes sure she maintains hydration. Advise mom to put on her big girl pants and stop being such a ninny.

13) 28 y/o male with chest pain and SOB. Pain increases with deep inhalation. 12 lead unremarkable. Pt is mildly tachycardic and tachypneic but not in any acute distress. Lung sounds clear to auscultation. SpO2 99%.

Needs a D-dimer and CXR. To the ED.

14) 15 y/o with testicle pain x 1 hour. No penile discharge or dysuria.

To the ED. Needs testicular US.

15) 2 y/o fell off high chair onto hard kitchen floor. Pt has hematoma to occipital region of his head. Pt is acting age appropriate and was crying immediately after the fall. No vomiting. Mother asks, "Does he need a cat scan? Can we let him sleep?"

PECARN the kid. Dispo per that.

 

[GloriousGabe]

If I was a PA or NP on an ambulance the first thing I would do is get off the ambulance as it certainly doesn't pay the same amount as I would working in a clinic or hospital.

 

[Brandon O]

Thorough cleansing, close exam for tendon injury, loose approximation, and ABx.

Loose approximation? Not familiar with that approach. Is that a compromise with secondary intention?