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.”
– JORDAN LEVINTER, CCPA, CANADIAN PA IN PAEDIATRIC EMERGENCY MEDICINE
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.
Nursemaid’s elbow, also known radial head subluxation.
Reduction technique for nursemaid’s elbow
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.