APCblogit

LAST CHANCE FOR DXA

YOUR HELP IS NEEDED TODAY: SENATE VOTE EXPECTED WEDNESDAY

The Medicare package introduced on Friday in the Senate does not include relief from the drastic Medicare payment cuts for DXA tests. While Senate leaders seriously considered including some help for DXA providers, a remedy for the DXA cuts did not make it into the final package. When the legislation is voted on by the Senate later this week, a package of amendments will be offered on the Senate floor that will make last minute modifications to the bill.

Securing some relief for DXA as part of this package of amendments will be our last best hope to achieve some fix for DXA this year.Over the past 18 months, you have repeatedly answered our calls for help by sending over 12,000 emails to members of Congress asking for relief from the DXA cuts. We are coming down the home stretch and we need you, your staff, and your colleagues to call or send an email today.

Even if you have contacted your Senators‚ offices already, it is very important that we bring this issue to the attention of senate offices that are in a position to act quickly. The task is simple:

To send an email to your US Senator, click here:http://www.ISCD.org/advocacy

Or call your Senator’s office. Let the staff person know that you are a constituent calling on the DXA/osteoporosis testing issue. Tell them DXA was under discussion as part of the Medicare package and is an important health care issue in your community. Urge the Senator to support osteoporosis care by going to Senator Baucus and asking that the DXA cuts be addressed in the final floor amendment.

IT IS VERY IMPORTANT THAT SENATE OFFICES HEAR ABOUT DXA EARLY THIS WEEK SO THAT THEY CAN ACT IN A TIMELY WAY. THANK YOU FOR YOUR HELP.

If you have any questions, contact ISCD Legislative Counsel Donna Fiorentino at dfiorentino@iscd.org.

Great news about Advanced Trauma for Life Support course!

By Bob Blumm, PA-C

Beginning in October 2008 with the release of the 8th Advanced Trauma for Life Support (ATLS) course manual, “physician extenders”—including Advanced Practice Clinicians (APCs, nurse practitioners and physician assistants)—who complete the ATLS course will receive cards to document their participation. Published since 1980, the American College of Surgeons' ATLS course is taught in hospitals and institutions worldwide.

“The doctor who first attends to the patient has the greatest opportunity to impact outcome,” according to the ATLS Web site (http://www.facs.org/trauma/atls/information.html). Now APCs can be recognized as accredited providers of this critical care.

This change in philosophy is almost 15 years in the making. Five years ago the best we could hope for as nonphysicians was inclusion of 25% nonphysicians in the course, which teaches only 16 students at a time—and this was at the discretion of the regional trauma director. A letter would be given after completion of the entire ATLS program that the APC attended the course. We have repeatedly requested the same certifying card that is given to doctors. At last, the opposition has relented. APC’s are an important and integral member of the team and this recognition is long overdue.

Do you agree that certifying NPs and PAs is a great idea whose time has come? Will documentation that you have successfully completed the ATLS course positively affect your practice? Post a comment to tell us your thoughts about this important development.

Bob Blumm, an APCToday Editorial Board Member, is an instructor for the Trauma Evaluation And Management (TEAM) course, a program for medical students and NPs and PAs in emergency trauma departments. This is a preparatory program for the full ATLS course with certfication. He will be offering a TEAM workshop on Thursday, May 15, at NPACE in Orlando, and is available to teach the course through national or state associations.

Malignant Hyperthermia: The Surgical Team’s Worst Nightmare

By Bob Blumm, MA, RPA-C
President, Association of Plastic Surgery Physician Assistants

At the end of March Stephanie Kuleba, an 18-year-old Florida girl undergoing corrective breast augmentation surgery, died as a result of what doctors are calling a fatal reaction to anesthesia. Hearing about this tragic situation brought back my own memories of a case of malignant hyperthermia (MH), one that had a very different outcome.

Back in the mid-1970s, my supervising physician (SP) and I entered an OR to say hello to a colleague. My SP put his hand on the foot of the patient, who was under anesthesia, and noticed that she felt quite warm. The anesthesiologist asked the circulating nurse to place a rectal thermometer in the patient; it registered a whopping 105 degrees.

The patient’s temperature continued to rise steadily. Steam began to emit from the crystals in the anesthesia canister. What followed next has left an indelible picture in my mind because of the actions of the personnel in the room, the discovery of a wonder drug, and the teamwork that saved this patient from death.

The anesthesiologist recognized the event as a possible MH. Surgery was discontinued and the dressing was put in place. All inhalation drugs were stopped and pure100% oxygen was initiated. A second peripheral line was started and a central line was placed while the nurses gathered ice and packed the patient securely.

Iced saline irrigation was placed down an NG tube, an iced enema was given, and cold IV fluid was administered. The patient’s body temperature continued to rise, and a urinary catheter was placed. My SP got on the phone with his mentor from Johns Hopkins, who recommended that a large bolus of steroid be initiated. The patient’s temperature climbed to 107 degrees.

The anesthesiologist suddenly remembered that a new drug specific for MH had just entered the hospital pharmacy. The medicine, dantrolene sodium, was brought to the OR, where the anesthesiologist began a bolus and then an infusion. The patient’s temperature began to drop steadily.

She was moved from the OR to the PACU and then to the ICU, where 48 hours later she was articulating perfectly and suffering from no ill effects, with the exception of a slight skin slough from one of the IV sites.

I discovered heroes in this scenario—the anesthesiologist who treated the patient, the new wonder drug, dantrolene, and the entire surgical staff consisting of physicians, PAs, nurses, and surgical technologists who worked together to help save this patient. It was an example of teamwork at its finest.

Malignant hyperthermia is an acute, life-threatening pharmacogenic disorder developing during or immediately after a general anesthetic. It can therefore be appreciated or discovered in the OR and the PACU. It is most common in children, teenagers, and young adults, and is usually associated with a history of familial anesthesia problems or fatalities. It can be encountered in dental offices where general anesthesia is employed, the OR, surgicenters, and office-based OR’s—in fact, anywhere where a general anesthetic is given with both volatile gases and depolarizing agents.

For further information on the presentation and the sequela of MH, go to the Web site of the Malignant Hyperthermia Association of the United States, at www.mhaus.org. This site will round out your education and give you the protocols plus a list of supplies needed in a MH crash cart. In an emergency, call the MH Hotline, 1-800-MH-HYPER (1-800-644-9737).

Adversity Gives Birth to Opportunity and Unity

Thursday, February 21, 2008

Bob Blumm, MA, PA-C, DFAAPA
APCToday Editorial Board Member
President, American College of Clinicians

The headlines read: “LI hospital scrutinized after deaths of patients,” and “MD’s aide is eyed in 3 hosp deaths.” Unfortunately, the press does not always seek the truth before reporting; sensationalism sells newspapers and captivates our attention on radio and TV news.

The setting for these stories is Mercy Medical Center in Nassau County, New York, an entity owned and operated by Catholic Health Services of Long Island which is routinely rated number one in New York State. The issue relates to three patients who allegedly died as a result of the services of a physician assistant (PA) – not an “MD aide.” The accuser in this tale, who charged that the PA improperly performed invasive procedures without adequate supervision, is a licensed surgeon who is a member of the medical staff.

What seems to be missing from the press reports is that the PA in question has a proven track record of providing excellent medical care, while the physician is under disciplinary action from the Medical Board at Mercy (this occurred prior to his allegations to the news media). The hospital has supported the PA in this action and the NYS Department of Health and Office of Professional Medical Conduct is investigating the entire scenario.

The ideal situation would have been a press release after the investigation was concluded. As it stands, the casualties include a devastated PA, bad press for Mercy Medical Center, confused and angry patients and their families, and an unnecessarily tarnished image for PAs.

Can there be a sliver lining in the midst of this conundrum? If there is one, it is the opportunity it provides for unity among the larger community of Advanced Practice Clinicians (APCs), a group that includes PAs and nurse practitioners (NPs). In this worst of times lies the chance to stand together and fight for the integrity of our professions.

This situation has infuriated both PAs and NPs. We are acutely aware of the ricochet effect this can have on how people view us. To counter this possibility, reporters for the NY Times and the NY Post have been deluged with letters from rank and file NPs and PAs, from the public relations committee of NYSSPA (the NY state PA society), and from the ACC (American College of Clinicians).

NYSSPA has a crisis team working on this issue. Greg Bennett, president of the AAPA (American Academy of Physician Assistants), states that his organization will be backing NYSSPA’s position. The ACC will continue to be on the front lines, responding in print and legislatively with the active support of our members.

If more good can be found, it is the opportunity it creates for State and National PA/NP associations to expand their memberships. It is the responsibility of these societies and associations to exam the facts and support their members when incidents like this occur. It is also a chance for leaders of NP and PA organizations to come to the same table to share concerns and advocate for each other.

Have your read the news stories about this situation? Do you have comments or suggestions to offer? Post your comment on this blog, or send an email to apctoday@dowdenhealth.com.