Jordan, Paediatric Emergency Medicine PA
Jordan is a University of Toronto PA program Graduate , and Canadian Certified Physician Assistant working in Paediatric Emergency Medicine at Toronto’s Sick Kids Hospital.
What is Paediatric Emergency Medicine?
We see anybody under the age of 18, so right from birth for example difficult labor and birth from a midwife at home, all the way up to their 17th and 364th day on this planet.
We are very much the safety net on everything ranging from the sniffles to abdominal pain, to kids who have been hit by a car.
We’ll see anything that comes in our door and a lot of the times because we are that tertiary care centre, we are considered the expert location.
We’ll get a lot of parents and families who are frustrated and they come to us for answers because they’ve had a hard time or lack of resources in their community. We’ll see those patients that sometimes other doctors need extra help on and they refer onto us. We see those patients who sometimes think that they weren’t getting enough care in other locations. And we’ll see those patients who live really close to us.
Sometimes the patients who come in just need that reassurance, but oftentimes they do need a lot of interventions, whether that’s IV fluids and antibiotics, whether it’s setting a broken bone or whether it’s advanced imaging, CT scans and ultrasounds, everything and anything under the age of 18 is a fair game for us.
How is treating kids different than treating adults in Emergency Medicine?
Generally kids are healthier. Obviously the more you age, the more co-morbidities you’re likely to have, and the more illnesses and drugs you accumulate as you move through life.
With that being said, we do see actually a fair number of complex children and they tend to be sicker and they have a lot of more things like genetic disorders and metabolic disorders. These are the kids that sometimes don’t make it all the way to adulthood.
There is also different pathologies that occur in children than in adults. For instance when a child falls, they’re going to break their elbow, they’re going to get a supracondylar fracture. And that’s what happens to a kid, not the same for an adult as they get hurt in different ways. They get different kinds of conditions and they present differently as well.
The case we often see is appendicitis. Everybody knows appendicitis is this abdominal pain and fevers and vomiting and that might just not be true in the three year olds or that toddler group. They will sometimes just have very vague complaints. Kids do present a little bit differently.
Working in the ER at Toronto SickKids Hospital as a PA
Structure of the Emergency Department
In the SickKids Emergency Department there are four areas in the emergency department. We have our East and West area, which are higher acuity areas.
Ideally East is supposed to be for more those complex chronic patients.
The West Area is for the ultra high acuity patients, though that doesn’t always happen. Sometimes we have to flow them from one to the other. We also have our trauma area in the emergency department which houses up to four patients. Hopefully we never have to reach that but it’s happened with big accidents such bus rollovers and other incidents that have multiple casualties.
We also have our urgent care area where we see the, some of the lower acuity patients. A lot of the times our lower acuity patients come in because we see many patients.
We have such a high volume of patients but one out of every many patients in that low acuity area is actually going to have something that is sinister and sneaky and is actually very urgent and needs some emergency intervention.
How do PAs work in the Paediatric ER Department?
We have six Physician Assistants at Toronto SickKids Emergency Department. I was actually the second cohort of PAs to be hired. I was really fortunate that I had an amazing group, Julia and Claire, who came in right before me and they really helped establish the Physician Assistant role in the department and established directives for us as well. Then there is my cohort, which includes Emma and myself. Then we just hired two more PA’s in the last year – Brayden and Elise.
We work mostly during the peak hours that patients come in, that would be the morning and the after school as well as evening hours. The PAs work both weekends, evenings and holidays because the emergency room never quits. Occasionally we’ll have to do an overnight shift, but those are thankfully quite rare for us.
And we’ll do one or two overnights per month. The Peds ER PAs spend time in all of the different areas. I spend about 75% of my time, I would say in the urgent care side and probably 25% then in the more emergent side, it’s just a matter of where our patient volumes are.
One of the roles of the PA in our department is to be flexible and to keep an eye on where the wait times are for patients. The Peds ER has to always see though the most acute patient first. And you’ll end up with patients waiting who are still emergent and on the high acuity side, but they’ve been there for several hours then they might move the PAs over to see those patients as well.
Common Conditions Seen in the ER
We also see Abdominal pain and constipation, appendicitis, common fractures like your supracondylar, and your clavicular fractures. Those are really our bread and butter type of things along with stomach flu and every other type of viral illness under the sun.
Rare Conditions seen in the Peds ER
Because Toronto SickKids Hospital is a tertiary care centre, we see a lot of rare conditions. Some of the better known rare conditions, things like cystic fibrosis, which is still actually an ultra rare disease when you look at the actual incidents in the population. But other things like Moyamoya and genetic disorders that aren’t even listed on UpToDate yet.
We see a ton of different presentations and different levels of prevalence.
What procedures do you perform autonomously?
We will perform laceration repairs. We do a lot of laceration repairs in the emergency room we’ll also do body retrievals, kids love sticking things in their nose and their ears and we’re the ones that will help get that out.
We also do reductions of nursemaid’s elbow (radial head subluxation) and other simple relocations. Because our patients are kids, we are a little bit sensitive about. A lot of our kids need some anxiolysis for that and because of the PA scope in Ontario, we’re not able to order medications like my Midazolam, or fentanyl, which is routinely for procedures in the Peds ER. When those medications are involved, we have to have a physician involved as well.
In terms of Casting and splinting, we’re really lucky that our nurses probably do a lot of our casting. We do some of the circumferential casts if the need arises, we don’t do a lot of slab. And we’ll also do cast removal in addition to other procedures.
Are you prescribing medications and initiating management as well?
We had our medical directives established about a year and a half ago now. The medical directives we have are quite broad, they allow the PAs to initiate fluids, order antibiotics, blood work, x-rays, ultrasounds and all of that is within our scope.
The PAs start the management, especially if it’s something that we’re very familiar with autonomously and then after some of those results start to come back we’ll review with our physician in more detail.
My Schedule in Peds ER
The PAs do eight hour shifts and we try to stay on as best as we can in one section of the emergency department when we are there. Obviously if need dictates, we will flow ourself from one area to the other area but we try to stay in one part of the department.
On average, I try to see around 15 and 16 patients in my eight hour shift. On average I do four shifts a week, for some weeks, we’ll work three shifts, some I will work five.
Typically I try to see about three patients per hour that I’m there. It can vary a lot especially on days where everybody’s having cough and there’s a terrible stomach flu going through a daycare I might be able to see some extra patients because I know that there’s a terrible stomach flu going through the daycare.
A patient is very classical for it – they’re not the hydrated, and we can do some counselling with the parents. Some days it’s obviously a lot slower when we have more complex patients come in, for instance when we have a sickle cell patient come in and they’re having chest pain or they’re presenting with neurologic symptoms and we’re starting to worry about a stroke or other complications.
Orienting a new PA Hire to Peds ER
The Orientation for the new Physician Assistant hires at SickKids Hospital Paediatric ER actually lasts for about a month. The new hires get the normal HR orientation e.g. What to do in the case of a fire, how you find your pay stub, etc.
And then the new hires pair up one of an experienced, senior PA. The new PA hires do a little bit of shadowing over about the first week or so. And then the senior PA starts to act as a preceptor going in and reviewing some of the patients, talking about some of the learning points with them.
We also have tons of resources that the hospital provides us both like written material like textbooks and Canadian Pediatric Society Guidelines as well as actual hands on didactic sessions.
We get our Advanced Pediatric Life Support class taken care of (PALS). We get hands on teaching for ultrasound with our focus fellows. Teaching and orientation works really well the new PA hires, both from the physician side and the senior PA side in order to help us succeed in our role.
Impact of a PA Working in the Peds ER
What patients can expect when being seen by a PA
When a patient sees me, they can expect to get a history and physical exam started. I will go in, I introduce myself in my role as a PA and then we take the history. I’ll perform a physical exam and then depending on the complaint, I usually start some investigation.
For instance, I explain that I think the patient needs a catheter because they are three months old and I am worried about a UTI and they’re not able to pee for us yet. It might be a chest x-ray or an ultrasound or something else like that and it might be blood work. I explained the role of the investigation and the rationale behind it. We will get that going if there’s anything to treat. For example, for laceration repairs I will start with management and for us that means some topical analgesics for the patient.
Depending on the complaint, patients can expect me as the PA to get pretty far before I start to involve my supervising physician.
If the child looks on well or if it’s a complex complaints or something I haven’t came across before, then I get the physician involved early and they’ll come in, they’ll introduce themselves and how we work as a team and the supervising physician will help guide me through the management of my patients.
If it’s something that I’ve seen before and I’m comfortable managing, they might see my supervising physician at the end of our meeting before discharge to ensure that one I didn’t miss anything and that this child does look well and to answer any questions that the parent might have about the care of their child. We work as a team in hand-off, very closely to each other but it depends on what the patient is actually coming in for as to what they can expect when they see me and do some counseling and answer questions for the parents.
What supervising physicians can expect when working with a PA
A supervising MD should hopefully expect that a PA eases their cognitive load, helps clear some of those patients and really helps with the flow of the department.
As a PA, I can help manage some of these lower acuity patients and then have the physician come in. The physicians then shift to focusing on those more acutely ill patients.
I would also help hope that the physician can trust me to do a little bit of teaching and help with the residents and fellows, not necessarily reviewing, but doing some of those procedural things that, cause I’m there a lot.
And while we’re in a big teaching hospital, we have lots of residents and clerks and fellows that come and go, but the PAs are a constant. I would hope that they would also let me be involved in some teaching and pass on some of my knowledge procedurally and experientially that I have to the learners that come in.
How PAs interact with Nursing Staff
I love our nursing staff. We have the best nurses and again, I’m biased but, our nurses are always on the ball. They’re fantastic. If one of our nurses say that they are worried about a patient, I’m worried about a patient as well.
We have a great relationship – we teach each other back and forth and there is always something new to learn from them. I hope that they learn from me and take things away as well.
The Impact of Having PAs in a Busy Peds ER Department
One of the biggest impacts that I think the PA group has had is really standardization of practice.
Toronto SickKids Hospital has a big Emergency Department – there’s close to 50 supervising physicians actually signed onto my PA medical directives. Some of them work a lot and some of those physicians of them might only work once a month or once every other month.
Between all the Peds ER Physicians there is variation in practice and obviously everybody practices a little different. Medicine is not an algorithm -it is an art, but having the PA’s there to standardize how we diagnose UTI’s, how we interpret ECG, how we call x-rays and recall families for positive blood cultures has really helped patient flow.
“I think we’ve also allowed our doctors to shift their focus to some of our more acute patients, and the physicians come in for all of the patients that the PAs see, but they have that cognitive space freed up for those acutely ill patients, those complex need patients, and I think that’s been a big benefit to them as well as to the patients themselves.”
Reflecting on PA Practice
What I enjoy about working in Paediatric ER
I love the kids. I don’t think I can go back to adult medicine and I think SickKids sold me on pediatrics.
“The kids are amazing, they’re resilient and brave, especially the ones that have these chronic medical needs and they’re really familiar with the healthcare system from such a young age. You see that resilience and that determination in them.”
The staff at Toronto SickKids Paediatric ER has a great culture. I loved the culture of emergency medicine and I love the culture of pediatrics and this combines the best of both.
Going through the different specialties in second year PA school, I found each one had their own culture and there were parts of it I liked the parts of it I disliked. And I just found that the willingness to learn the compassion of the PAs and paediatricians, and the eagerness and the novelty of emerge all combined really well into that Peds Emerg piece for me.
It keeps things fresh and it keeps things interesting. I have a different day every time I go into shift and that’s something I absolutely love about my job.
Challenges of working in Paediatric ER
Some of the challenges are some of the things that I love, sometimes it’s emotionally exhausting dealing with kids. Whether it’s the two year old who just won’t stop crying because he’s sick, whether it’s an emotionally exhausting conversation that you have to have with parents about their child being a newly diagnosed diabetic or a new leukemia patient. It can be emotionally exhausting at times. We have a really great support system set up at work for when we’re feeling that. I’d say that’s probably the biggest challenge of my job on a day to day basis.
Sometimes shift work can also be exhausting. I work late nights and evenings and weekends and holidays. I don’t work all of them. We have a big enough group of PAs that we trade amongst ourselves. I’m not doing family medicine where I have a nine to five job and I knew that coming in to the job in Peds ER, it was a compromise that I was willing to take in order to do Emergency Medicine because I fell in love with it.
But it’s exhausting. I can see myself moving out at some point in the distant distant future into something more nine to five.
How I see my practice changing over the years
Hopefully I see a continuation of the trust I’ve developed with my supervising physicians continue to grow. Whether that means increasing scope or whether that means I’m seeing a wider breadth of patients. That’s how I would like my next few years at SickKids to go. I’d also love to be involved in more of their teaching aspects and some of their research aspects as I find that fascinating. Obviously since I’m doing my Masters in Medical Education, I obviously find that fascinating, but I would love to be more involved in that and that’s the route I’m hoping to go with my future career
Reflecting on the Decision to Become a PA
I love it. I never had a doubt after the first day of PA school. I love that I get to be hands-on with patients and be on the front lines. I love that I get to work in this amazing team with my supervising physicians and the nurses. I love that I get to work with kids all day. I think that’s amazing. Yeah. I’ve never regretted my decision to become a PA.
POCUS in PA Practice
What is POCUS?
POCUS is ultrasound that is performed at the bedside by a non radiologist. We use it a lot in the Paediatric Emergency because we want to save kids from radiation and for cognitive offloading. That means I can save them a chest X Ray, that would be fantastic.
It also helps with Cognitive offloading in that if I put the probe ultrasound probe onto a child and I see a pneumonia, I don’t need to worry about why they are short of breath anymore. I see the issue and I can focus my attention to treating instead of solving a mystery.
Lastly, POCUS helps with our patient flow. Sometimes to get a patient to go outside the department is not safe because they’re unstable, or the imaging department is backed up’ed or overworked – it might be half hour, 45 minutes that the patients are gone.
And to be able to improve patient flow and by virtue of helping them faster by reducing patients in the waiting room as well, that’s super beneficial to us. And that’s great.
Learning POCUS
POCUS is a skill that PAs can absolutely can take on. You get competent or working. TA’s learn. There’s a couple different ways.I’m really fortunate because the hospital I work at has an ultrasound fellowship and they’ve allowed me to tag on, not as an official fellow, but they’re all amazing at teaching and they’ve let me take onto their rounds and through teaching lectures and through bedside rounds. And then we have some formal modules in place in order to ensure that we’re competent and we have some online evaluations that are, are all of our scans get reviewed by an expert to ensure that they’re meeting standard.
Other ways that PA’s can get competent in ultrasound is through Scarborough General Hospital. Their emWave POCUS team actually has a ultrasound fellowship available for PAs. PAs that are practicing are welcome to apply to that fellowship. And that’s one way that they can get competent in emergency medicine. There’s also lots of courses that are available outside. There’s the, you start courses, Sunnybrook Hospital hospital. There’s a couple of courses. I think there’s some courses through the Canadian association of emergency physicians that PAs are eligible to take. It really depends on where you’re working and what exactly you want to do with this skill.
Final Notes
PA is definitely a growing profession. Every year U of T graduates close to 30 30 PAs, McMaster graduates just under that. And the military will also have some PAs retire from active duty into the civilian side. It’s definitely a growing profession and as more and more residents are starting to do their education with PAs in Canada, the need and the demand for PAs I think is going to grow with that. And even in pediatrics, because everybody comes through SickKids, we’ve seen that in the community. People are starting to get more and more interested in PAs in the community outside of the hospital centre.
