A day in the life: Alan Howard, PA-C

I'm a few minutes ahead of schedule; that means it will be donut day in the ED. I swing over to Henry's Doughnuts, the only 24-hour donut store in Gilroy. This pink box of pastries will keep me on the good side of the nurses for my entire shift.

¦ 9:55 AM

I walk into the ED and drop the box of “slow delicious sweet death” in the break room and try to say “hi” to everyone who is in this morning. Because this is a small, rural ED, this takes about 15 seconds. I take my sweatshirt off in the doctor/PA room and grab my stethoscope.

¦ 10:00 AM

I walk down to the lab to speak with the microbiologist about the overnight blood culture results. She hands me a report, and I see that one of two bottles for an older patient is positive. Although this is likely the result of a contaminant, I call the patient and ask how she is doing. She is feeling much better now that she is on the appropriate antibiotics for her bronchitis. I tell her to follow up with her regular doctor and fax the blood culture report to her primary care physician. I start sorting through my stack of overnight radiology and lab reports. For every positive result, such as a urinalysis positive for urinary tract infection (UTI) or a fracture noted on plain films, I look up the chart and verify that the diagnosis was noted and the patient was appropriately treated. Of the 30 reports I sorted through, eight are positive and all have been treated accordingly.

Next, I pull down the patient call-back book. Doctors and PAs write down the names of the patients from the previous day that they want us to contact as a follow-up. One patient had been treated for pyelonephritis, but her nausea and fever returned early this morning. I advised her to come back to the ED for another evaluation; she did and was eventually admitted. Our monthly goal is for each PA to call back two people per doctor per shift. The call-backs increase our patient satisfaction scores; however, some providers perceive the callback as another example of the ED providing primary care. Although I could agree with that in theory, I suspect these call-backs have avoided some morbidity or possibly mortality.

¦ 11:00 AM

With the paperwork completed, I look at the tracking board and realize my first coffee and donut will have to wait. We work with one PA and one doctor at a time, which allows for a considerable amount of flexibility with regard to patient flow. This morning is shaping up to be low-to-medium acuity but high volume for me.

My first patient is a 24-year-old male with a thumb laceration sustained while handling a big piece of sheet metal at work. He needs sutures, a tetanus shot, and to have his Workers' Compensation paperwork filled out. My next patient is a 10-year-old boy who was hit in the face with a soccer ball. He felt nervous and a little tingly after the strike, but had no loss of consciousness, head pain, or neck pain, and he looks comfortable. His mom and I discuss the pros and cons of a CT and unanimously decide one isn't indicated at this time. Next, I see an 18-year-old rugby player who was hit in the head and rendered unconscious for 45 seconds the day before and now presents with headache, blurry vision, and dizziness. This patient warrants a CT, which is, thankfully, negative. He, too, is told to follow up with his primary care provider this week.

¦ 12:45 PM

An 8-year-old girl who fell off a monkey bar set about 5 feet high presents in the ED. She landed on her right arm, and now she can't move it without feeling excruciating pain. I order an x-ray, fully expecting to see a supracondylar fracture. Sure enough, the outdoor gym equipment has claimed another victim. I flip through the patient's chart to see what kind of insurance she has. She has Medi-Cal, California's Medicaid insurance. Gilroy has only three orthopedists and none of them accept her insurance, so she needs a referral to the county hospital about 30 minutes away. I call one of the residents at County and I am told to tell her to drop in at the County orthopedic clinic the next day. If this girl's fracture had been radically displaced or if there was a hint of neurovascular compromise, the on-call orthopedist would have seen her today regardless of her insurance status. I find it disappointing that fewer and fewer doctors are accepting Medi-Cal. Conversely, reimbursement rates barely allow doctors to cover their costs, making it more and more difficult for those that do accept the insurance. As all PAs know, there are no easy solutions.

Next, I see a 5-year-old girl who has had a fever for the past 3 days and started vomiting this morning. A urinalysis shows that she has a UTI. I gave a presentation on UTIs at a bimonthly department meeting about 6 months ago. The hospital's microbiologist provided an antibiogram of UTIs for the previous year that was incredibly helpful. Using those results, as well as current research on the topic, I was able to present a list of antibiotics we should use. This list has allowed for a more uniform approach to treating patients with UTIs. My next patient is a middle-aged woman with chronic back pain who ran out of pain medication, a common but unfortunate complaint in the ED. She tells me that she lives about 30 miles away but “was in the area” and decided to drop by for a prescription refill. Since this is her fifth visit in 10 days, I explain that I won't be writing a prescription for anything stronger than ibuprofen today and would be happy to refer her to a local pain clinic. She grudgingly accepts the referral. An older man is having a gout flare-up after eating seafood. Two little kids present with ear pain; one has otitis media and the other, otitis externa. This is urgent care “meat and potatoes.”

¦ 2:00 PM

Lunch time. I always like having an aura of productivity, so I run to the cafeteria, throw something on a plate, and eat standing up in a back hallway, out of sight of the ED staff and patients. My fear is that one of these days I'm going to asphyxiate on a pork cutlet in front of the hospital announcements board by the back exit.

¦ 2:10 PM

The afternoon starts to slow down a little, but the acuity level has risen. We have a system whereby the PA can start a workup and then either hand the patient off to the attending to complete or follow the patient through to discharge. My attending asks me to follow a few patients through, allowing me to do full workups on one patient with abdominal pain and another with chest pain. The patient with abdominal pain is a 44-year-old woman with sudden-onset epigastric pain. After I review her labs, I order an ultrasound to rule out cholecystitis. Her gallbladder is large and filled with stones, but there are no signs of thickening or infection. My attending and I agree that this is likely biliary colic and she can follow-up with her own doctor. I give her a compact disc with her ultrasound and lab results.

The patient with chest pain has uncontrolled diabetes, hypertension, a history of alcohol abuse, and belly pain that radiates to his back. An extensive workup ensues, revealing a high blood sugar that I treat with IV insulin and fluids. I consult with my attending, who looks at all of the lab results and concurs that the patient is nonacute and can be discharged. Of the 10 medications the patient has with him, no two were prescribed by the same doctor; all came from three different EDs in the neighboring county. My hope for close follow-up with a primary care provider is shaky at best.

¦ 5:00 PM

I discharge about five more kids with coughs and colds, see one more chronic back pain sufferer, and finish the day with a suture removal for a patient I saw in the police blotter the day before. He is much nicer to me than he was to the officer who arrested him for drunk and disorderly conduct.

¦ 6:00 PM

I have seen my last patient, but I have about 2 hours of charting to do at home. I discuss the day with the PA coming in to work the night-shift and gather up my stuff to go home, where an excited 1-year-old and her incredible mom are waiting for me. I find a note with a sticky thumbprint shoved in my box that says, “Thanks for the donuts!” JAAPA

Alan Howard practices in emergency medicine at the Saint Louise Regional Hospital, Gilroy, California. He has indicated no relationships to disclose relating to the content of this article.