SIDE EFFECTS

Seems that I spent a lot of time discussing side effect issues with medications with patients this week.  I get that people are concerned about what’s going into them and what badness  might happen, but they forget to ask about the positive things that might happen as well.

There are risk/benefit ratios for everything we do in life, be it something we say to someone, something we eat or drink, some action or inaction, all can result in positive or negative effects.  Medications are no different.  Everything we do medically is calculated, based on evidence, training and experience.  We cross reference this with what is wrong with the patient, what they’re taking, what other problems the person has, and what other medication they are taking.  The more the person has going on and is taking, the harder the decision becomes.

Then there comes the other problem of mis/disinformation and plain old ignorance about what various medications do or don’t do and the frequency of said issues.  The internet is a great thing if used properly…however, many people have a habit of not reading good sites.  Another problem is Dr’s Mom and Friend Who Knows Everything (yet has no medical training) – I often hear people saying that their friend or mom says that they need this, that and everything else.  Rarely true.

Back to the problem at hand – person comes in with complaint X and is found to have diagnosis Y.  Treatment options include A,B,C and D…however patient is deathly allergic to A, and  C and/or D aren’t likely to be effective without B.  Since I can’t make someone do anything against their will (well, almost anything), my job now is to let the person know what I think is best for them and why.  I don’t hand hold – I’m blunt about options and what I think the best ones are for that person at that time.  I’m also blunt about concerns about minutiae that may or may not happen, especially side or adverse effects that happen one in a bazillion times – and for some reason, most people think that those will be the ones that happen to them.  You have to be blunt in the ER because you can’t hold onto folks that don’t need to be there.  Some folks will all of a sudden develop a decision making disorder about what’s really a minor issue and blow it all out of proportion, expecting family to convince them, as well as me, that this is in their interest.  Luckily for me in this case, I’d had a similar intervention and was able to speak from experience from both sides of the fence and we got down to business shortly thereafter.

Side effects or adverse effects occur sometimes, but not near as often as people think.  Ask your questions, sure, but also ask balanced ones, “Like what are the benefits as well as the risks?”.

Sean K

 

 

 

 

My Week…and a Rant About Resuscitation

I just finished my recertification in Advanced Cardiac and Pediatric Advanced Life Support this week.  Over three evenings myself and several other people went through a few lectures and plenty of practice resuscitations on adult and child mannequins.  I’ve taken ACLS many times over the years and have watched as the algorhythms and guidelines have changed and been simplified each time I did it.  I also remember one thing rarely changed though in most of the times I took it – we rarely had any of our “patients” live.

Over the years, despite all science and training and public service announcements, people still die from heart attacks and sudden cardiac arrest.  Automated External Defibrillators have increased the incidence of lives being saved at time and point of arrest (and I personally know some folks that are alive today for that very reason), as well as having paramedical personnel more readily available to help when people are struck down, but despite what all the old episodes of ‘ER’ will tell you, the vast majority of cardiac arrest victims still die.

When an arrest victim is brought in, a pile of people descend upon them to try their damnedest to squeeze blood around the body and get air in and out of the lungs.  They stick needles into veins to get drugs in to try and stimulate the heart back into beating properly or even at all.  They repeatedly push, well really pound, on their chest.  CPR is a brutal, yet necessary, thing to try and get blood to the heart muscle and the brain so that the patient might have any hope of surviving.

These days, we will sometimes invite family into the resuscitation bay so that they can witness not only how hard people are fighting for their loved ones’ lives, but what that person is actually going through.  Their are times when some (not all) people are needlessly put through this process…folks with very advanced or terminal illnesses, the very frail or aged.  Some of these folks may have had “the talk” with their doctors abut how they want to be treated after a certain point in their lives or illnesses, but their families sometimes, at that moment, cave in to the emotions of the time and want all stops pulled to save their family member.  The unfortunate thing about that is the potential suffering that the patient may in fact go through as the result of a successful resuscitation may be worse than they’ve already been going through what with bruised chest, fractured ribs and the like added to whatever else may be ailing them.  I remember as a young medic one of my officers telling me about a code he was at…the fellow was a religious person and offered a prayer for the patient in question while the resuscitation went on.  This patient, while successfully resuscitated, ended up living in constant pain for another few short days.

I am not anti-resuscitation by any stretch of the word.  I’ve worked full out on a number of folks over the years, witnessed a precious few where we literally made Lazaruses out of some folks, however, the net result is still in favour of fate, Mother Nature, and the various gods that oversee us.  To paraphrase a TV physician, everything we do in medicine is to slow down the inevitable that is programmed into our DNA – humans are machines with a shelf life and a limited extended warranty plan for those that are able to pay in time and effort to look after themselves.  Sometimes we can reverse the process in mid-cycle, sometimes we can’t.  I always tell patients that there are certain laws in the physical realm we can bend to a point -the laws of genetics being some of them.  I liken those laws to the Law of Gravity like this – if you jump out of an airplane, regardless if you have a functioning parachute or not, you’re going to hit the ground eventually; the only difference is how fast and hard.  Same goes with our bodies – if we look after them, it becomes like a parachute of sorts.  If we have bad histories in our families of say, early heart disease, we can ensure that we don’t tempt fate by making sure we don’t smoke, eat reasonably well, get periodic check ups, exercise regularly, keep blood pressure a stress in check, etc ad nauseum.  If you choose to play chicken with fate though and jump without a functioning chute or reserve, you might just end up in an ER having the proverbial BIG ONE or worse, having the proverbial BIG ONE and several folks pounding on your chest.

I think that all people should give some thought to what they want done to them if their hearts and breathing fail them and make sure that your primary care givers and your families are aware of your wishes.  Have these written down somewhere and revisit them as often as things in life change.  Some of us joke about tattooing our chests with “DNR” or “Do Not Place Hands or Pads Here”…but it’s not a joke to be doing a full code on someone who has little to no hope of anything like a meaningful life IF we even manage to bring them back.  That takes a toll on families, the patient and the caregivers involved.  So have that talk.

 

SO WHY FED THROUGH THE FIREHOSE?

I’m going to jump on in here.  So, what is a PA?  What do we do?  What are we not?

To paraphrase the website for The Canadian Association of Physician Assistants, PA’s are highly trained health care professionals that work in collaboration with a physician or group of physicians as an extender of their capabilities.  They provide a high quality of care to patients in a variety of settings and under varying levels of direct and indirect supervision.  Their scope of practice is dependant upon their supervising physician’s specialty and comfort levels with the procedures they’re able to perform.  In order to receive the post-nominal of CCPA (Canadian Certified Physician Assistant), a national certification exam must be passed and a minimum number of continuing education credits must be logged annually.

PA’s in Canada were originally from the military or trained in civilian programs in the US, where PA’s have been practicing since the Vietnam War…and those original PA’s were largely ex-military medics.  The Canadian Armed Forces program at CFB Borden, Ontario,  evolved into a two year program, much like our American counterparts’ schooling.  This program became the model for 3 other ones at civilian universities.  They are at the University of Manitoba, McMaster University and a consortium of the University of Toronto and the Northern Ontario School of Medicine.   There are PA’s currently working in Manitoba, Ontario, New Brunswick, Alberta, and in remote mining/drilling camps.  PA’s are regulated by the Colleges of Physicians and Surgeons in Manitoba, New Brunswick and Alberta.  Military PA’s in Canada are chosen from the Medical Technician trade to become PA’s as a matter of normal career advancement, and generally have a minimum of 8-12 years experience before starting school.  Civilian Canadian schools have varying degrees of requirements for type and duration of prior health care experience, whereas most US institutions require a minimum of 1000hrs.

The two years of school are quite gruelling.  The first year is basic medical sciences, study of diseases at all life stages, the various major medical specialties, physical examinations entailed with each organ system, occupational and population medicine for the military folks and special population medicine for the civilian programs.  Part of our occupational health in the military included basic preventative medicine skills, including kitchen and building/quarters inspections.  Second year is full of clinical rotations – family medicine; internal medicine; pediatrics; general, urologic and orthopedic surgery; psychiatry; obstetrics and gynecology; ear/nose/throat medicine and surgery; emergency medicine; trauma medicine and surgery.  There is a lot of knowledge to take in all at once – hence the title “Fed By The Fire Hose”…I always felt all I was doing was just studying for the next exam.  You open wide, and either hold your ground and drink or get blown away.  My class lost 3 people along the way and another failed the final round of exams.

Once I graduated, I wrote my national certification exam and was posted to Victoria BC.  While there, I had the opportunity to take my Basic and Advanced Diving Medicine courses offered through the CF School of Operational Medicine in Toronto and worked off and on in the undersea medicine field and primary care at CFB Esquimalt.  PA’s also are able to take the Basic Aviation Medicine and Flight Surgeon’s courses as well.

PA’s were embraced by Manitoba roughly 10 years ago to help assist physicians and patients alike to decrease waiting lists for surgeries and in emergency department waiting rooms.  Currently, PA’s in Manitoba are practicing in emergency medicine, orthopedic, general, plastic, neurologic, and cardiothoracic surgery, oncology, family medicine, internal medicine and psychiatry.  I was originally hired to work as a pilot project in a small town as the main provider in a family medicine clinic and a personal care home with my supervising physician normally about 30 km away – we had direct supervision hours a couple times a month and I did some ER shifts to add to that.  My charts were audited and signed off electronically via the electronic medical record shared with our clinics.  He’d help with tougher cases and with those that I wasn’t legally allowed to prescribe medications for.  I worked there for three years before taking my current position working solely in emergency medicine for the past year.

My job at work is to see patients of all acuity levels in my ER – I’ll interview, examine, order appropriate labs and imaging, initiate treatment.  I’ll discuss what’s happening with my attending of the day, and then discharge, admit and refer as needed.  This includes prescribing necessary medications within my formulary – I legally cannot sign for hard narcotics for prescriptions leaving the hospital.  I can do certain procedures – suturing, casting, removal of foreign bodies, catheters, IV’s and other invasive line insertions, manage airways.  When I was in family medicine, I had normal office hours where I saw appointments, managed people’s chronic and acute health issues and looked after the residents of a small personal care home that was attached.  If I encountered something unusual or out of my scope, my supervising physician was immediately available by phone or text.  As noted earlier, my supervising doc would also come out periodically to see patients outside of my scope for prescriptive authority or for those that needed a second set of eyes.

I suppose lastly I should answer that question of “What are we not?.  I’m not a Nurse Practitioner – they are RN’s that have completed extra training, have their own licenses and scopes of practice.  While some PA’s may at one time have been RN’s, they aren’t NP’s.  Our licenses are tied to a contract of supervision with a physician/physician group.  Another frequent question I get is “When are you going to be a doctor?”.  I answer never unless I feel really masochistic and decide go to medical school and that my training is actually complete.  Lastly, I make a point of introducing myself by my first name and that I’m a PA working with Dr X…I’m not allowed to let people think that I am in fact an MD, and in fact correct people that call me “Doctor”.

Here are links to two Canadian PA websites.

Canadian Association of Physician Assistants

Physician and Clinical Assisants of Manitoba

 

Will talk with you all later.

Sean K

 

 

 

 

Welcome

My name is Sean Kelcey. I’m a Physician Assistant currently working in in Emergency Medicine in a semi-rural hospital in Manitoba, Canada.  Prior to that, I worked in Family Medicine in a small town and was in the Canadian Armed Forces as both a medic and a PA. I started this site to give my profession more visibility, discuss what PA’s can bring to both the public we serve and our potential employers, and to dispel myths. Please feel free to comment on my various posts…however, as this is a private site, there is some decorum expected as to how you comment.  Keep it clean, not abusive or slanderous.  I’m not here to start a flame war with other professions – medicine is a team sport and there is a never ending supply of work for us all.