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

aka American ER Doc Gone Walkabout… 003

LITFL Editior’s note:

You might want to check out previous installments of ‘American ER Doc Gone Walkabout‘ by Rick Abbot before reading on:

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…

Let’s try something next week that’s more fun, and that we all love: Psychiatry consultants! (Give him some oral Seroquel, he’ll stop screaming within a day or two….)

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Comments

  1. Nurse Ratched says

    Mmmm…. This is a contentious issue amongst some in the nursing fraternity. While I can see the argument that ‘scut work’ delegated to nursing staff can free up senior medical officers to do other (hopefully more important) things, I have witnessed the occasional MO taking advantage of our generosity and sitting back to wait for the numbers before actually laying eyes on the patient. Sometimes these routine tasks force Drs to examine their patients more thoroughly. In the end, nurses still have to clean up the sh$t and empty the bedpans in ED. We can’t delegate these tasks because there often isn’t anybody to delegate them to!

    • Rick Abbott says

      I know that scenario too well: triage note says RLQ (RIF in Australian) pain, order the labs and CT and you don’t actually have to talk with or lay hands on the patient, and can stay glued to the cricket on TV. All good things have their downside.
      And, for training purposes, the junior doctors need to learn the techniques of cannula insertion, etc. (For me, it was 30 years since I had been in the position of doing that particular procedure, and had to decide whether to re-learn it for 3 months, or just bail and ask for help -- I bailed.)
      But, in pure practicalities, for truly technical procedures -- even as technical as ultrasound guided peripheral cannula insertion -- can be taught to a paramedic/technician in a short time and increase the staffing and ER throughput much more quickly than training and hiring an additional doctor or nurse.
      And, I bet they can do the bedpan thing, too.

  2. Antipodean Medical Student says

    Having spent some time training in both countries I think much of the difference in doctor’s roles comes from their expected scope of practice. The Australian system expects residents to work in rural and remote settings where allied health staff may not be available. In the scenario of a trauma occuring on a relieving term, knowing basic procedural skills may be critically important and so emphasis is placed on becoming proficient in these skills even in tertiary centres. In comparison, many US doctors will spend their entire careers in hospitals that are supported by mid level providers who are experts in procedural work.

    • Rick Abbott says

      For training, the students and residents do need to know how to efficiently and properly insert an intravenous cannula -- the manipulative skills are a stepping stone to the more demanding tasks of ultrasound guided lines and central lines.

      However, in the States, even when I’m working at a small rural hospital the nurses (no IV technicians) are doing all the blood draws and cannula starts -- and have far more experience and skill than I do. If they’ve failed, it’s on to an ultrasound guided proximal or central line by me.

      1 Doc, 5 nurses, 2 non-EMT technicians, and a clerk on each shift -- plus a mid-level for 12 hours a day can run through 80-100 patients a day. Admittedly quite low acuity. If the Docs were doing more of the technical procedures, we’d need double coverage.

      The only setting where I personally placed peripheral lines in the last 30 years have been: field work with ambulance and mountain rescue crews, and a very brief career doing house-call emergency medicine to the rich and famous (Oh, Doctor -- I just flew my Lear Jet from sea level to Aspen, and now I have a headache.)

  3. Minh Le Cong says

    Hi Rick. I enjoy your articles on the Australian vs US health care systems, from an ED viewpoint.
    I am particularly impressed you tuned into a Rugby game! I would not be concerned you were not aware of the Australian national anthem…I find many overseas still regard Sydney as the capital city of Australia.
    In terms of who does minor procedures in the ED, at least. I think you have to be flexible. If its busy, it might be better to do it yourself as part of seeing the patient. If its not so busy then it does not matter who does it as long as it gets done.
    I support the concept of nurse practitioners or physician assistants. It has only been rolled out this year nationally and is still a political hot potato. We have a long way to go compared with the US on this issue.
    Part of the problem is that the government heavily committed in training more doctors during the last election campaign. With almost double the amount of new doctors graduating over the next few years, mid-level non-doctor providers have been sidelined on the political front. Keep up the commentary!

  4. says

    Thanks Rick for an interesting perspective. I am fortunate enough to work as a Registered Nurse in a NSW Emergency Department that has specialist Advanced Clinical Nurse roles (or as I like to call them “Emergency Nurses”).
    These nurses have additional training and work with about 40 approved protocols (“Chest pain”, “Shortness of breath suggestive of pneumonia”, “Urinary retention” etc..).
    Importantly these protocols have high-level buy-in from radiology, pathology and management to CYA (Cover You Ass) and only came about after years of trials and evidence collection (time to analgesia etc..). Most of the protocols are directed at relieving pain and have been in place for more than 10 years in our department.
    We all cannulate, collect, order and send pathology, suture, plaster, order and interpret x-rays, collect ABG’s and administer S8 drugs for both adult and paediatric patients BEFORE they have their first ED doctor contact.
    What’s the trade off ? We are assisted by Emergency Department Support Officers (like wardsmen) who make the beds, stock the trolleys and do patient transfers- they perform the non-nursing duties that allow me to spend more time at the bedside. And, no longer do I stand at the end of the bed and say “Sorry, you’ll have to wait for the doctor to see you…”

    • Rick Abbott says

      I presume that all are more satisfied with your system: the patients, the nurses, the doctors, and the wardsmen -- it really allows, IMHO, everyone to step up a notch in what they do, to the benefit of all.

      I got the vibes that many of our LGH nurses were disappointed that they were in a position of not being allowed to do what they knew needed to be done, and which they were quite competent to do -- whether it involved starting the orders that needed to be entered, or performing some procedure that they were competent to do, but wasn’t on the list of merit badges that they had accumulated.

      Over the past 35 years, I’ve seen it evolve from a very informal agreement as to what limits could be pushed, to an acknowledged but still pretty informal system, to a very regimented and defined, but quite expanded set of roles for all the players in the lineup.

      Best wishes for the New Year.

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