In Today’s Edition:

• Study shows the positive impact and contribution of PAs

• New Tennessee law allows international medical graduates to bypass US Residency

• Missouri tackles provider shortages with a new medical license category: The Assistant Physician (AP)…that’s not confusing at all

• Protect your Asthmatics!

• More on malaria and how to protect your family

• Bug spray tips to repel ticks

• Clinical conundrums: Test your knowledge on altered mental status (AMS) with this case based exercise

🩺 APP Trending News

Study shows the positive impact and contribution of PAs

A new systematic review investigated the impact and perceptions surrounding Physician Associates or Assistants (PAs) working in the Emergency Department (ED). The results show that both Doctors and patients hold favorable opinions of PAs. Data also indicates PAs significantly contribute to the healthcare team, as evidenced by reduced waiting times, shorter lengths of stay, improved clinical outcomes, and decreased rates of patients leaving without being seen. Information we probably knew, but now, it’s science. 👌

New Tennessee law allows international medical graduates to bypass U.S. Residency

Tennessee pioneers legislation that allows international medical graduates (IMGs) to bypass the traditional U.S. residency requirement (which is repeating a residency in the US). “Competency” will be reviewed and the physician must have completed 3 years of post-graduate training in their country of origin. With the state opening its doors to a diverse pool of physicians from around the world this will help to fill shortages in underserved and rural areas. It will be interesting to see how this new law affects healthcare and outcomes in Tennessee. The implications and controversies in enacting this new law will undoubtably raise some interesting debates! 🧐

Missouri tackles provider shortages with a new medical license category: The assistant physician (AP)… and other states are following suit

Some states are taking action to mitigate the projected primary care physician shortage. Annually, the number of residency positions available falls short of the number of medical school graduates in the U.S. and Canada. Given the number of graduates without work, Missouri has implemented the introduction of Assistant Physicians (APs). The law allows APs to practice primary care in underserved areas under the supervision of a licensed physician through a collaborative practice agreement so they may utilize their skills acquired in school. The model is catching on as several other states including Arkansas, Kansas, Utah, Arizona, Louisiana, and Idaho, have enacted similar laws to enable assistant physicians to bridge the waiting period between graduation and securing a residency position.

⚙️ The More You Know

Summer Hazards Blaze On 🔥 🦟

Protect your Asthmatics!

Smoke from Canadian wildfires continues to cause air quality alerts for more than a third of the US population, affecting over a dozen states from the Midwest to the East Coast. Over 120 million people in major cities like Chicago, Cleveland, Detroit, and Indianapolis, have had to alter their daily routines to keep themselves and their pets safe from the fine particulate matter in the air as it poses health risks to people who suffer from asthma and heart disease.

How to protect your family from Malaria

Last week, we shared news about confirmed malaria cases acquired in the U.S. We have found some additional recommendations from the Florida Department of Health. A few safe summer pointers from the link above themed “Drain and Cover” include:

• COVER doors and windows with screens to keep mosquitoes out of your house or repair broken barriers.

• DRAIN standing water to stop mosquitoes from multiplying

  • Drain water from garbage cans, house gutters, buckets, pool covers, bird baths, pet bowls, boat covers, etc. Basically, drain or dispose of anything that can hold onto standing water after sprinklers, dew, or rain collects. Let’s face it, literally any outdoor object can become a mosquito breeding not so fun fest!

• COVER skin with clothing or appropriate repellent

  • Wear long pants and shirts when possible - especially during sunrise and sunset when mosquitos are most active.

  • Repellent - Apply mosquito repellent carefully!

    • Check the labels! Always use repellents according to the label. Repellents with DEET, picaridin, oil of lemon eucalyptus, para-menthane-diol, 2-undecanone, and IR3535 are effective.

    • Best practice: use mosquito netting to protect children younger than 2 months old.

    • Do not apply under clothing, use over clothing or exposed skin as indicated

    • Do not apply permethrin directly to skin.

    • Ensure repellent is safe for children and age appropriate:

      • Mosquito repellents containing lemon eucalyptus oil or para-menthane-diol should not be used on children under the age of three years.

      • DEET is not recommended on children younger than two months old.

      • Don’t apply repellents to the hands of children…this is parenting. Apply to your hands then transfer to children’s skin/clothing as indicated.

Bug spray tips to repel ticks

Bug spray will come in handy now that we know ticks literally stick to hosts passively, using static electricity. Last week, Recent Biology published a study all about the ability to ticks to stick to hosts. It found that static charges of animals result in strong electric fields when close to vegetation that literally pull ticks across the air (think multiple body lengths. Yuck! Maybe dryer sheets should be added to those camping supplies.

💡Inspiration for Aspirations

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📈Future APPs

This week we bring you information from Drexel University. Did you know they have the oldest PA program in the country?

The Physician Assistant program is the oldest program in Pennsylvania and one of the largest in the country. It provides a master of health science degree and the option for Doctor of Health Science (DHS) degree. The pass rate is above the national average and all students are provided with a clinical experience in an underserved and/or unrepresented area.

The Nursing program offers multiple programs including RN-BSN-MSN program and the Nurse Practitioner program including 9 different track options. It also has options for advanced roles for Clinical nurse leaders, Nurse educator and Nurse Anesthetist including a doctoral option. There are also PhD options available. The program offers highly interactive methods and online option. The employment rate was 100% within 6months of graduation for all MSN graduates.

🧪Clinical Conundrums: Because We Love a Challenge!

Let’s Pick Your Brain!

Test your knowledge on altered mental status (AMS)

Clinical Case: A 75 yr old male is brought into the ER by family with complaints of multiple falls, and worsening mentation. The patient has a history of arthritis and heavy alcohol use.

After you have performed a thorough physical exam, excluding a focal neurological deficit (i.e. stroke), you obtain normal imaging and basic labs including a CBC w/ mild macrocytic anemia and low-normal leukopenia), mildly elevated LFTs and normal ammonia level. Tox screen is negative including ETOH.

His initial glucose was 64 which was corrected. His heart rate is 54 and blood pressure is notably “soft.” His temperature is 96.3 per bladder thermometer. He has a normal EF on your POCUS but exhibits non-pitting facial, hand, and pre-tibial edema. Your differential at this point could include:

• Adrenal crisis

• Septic shock

• Meningitis/encephalitis

• Hypothermia of exposure, sepsis, or other etiology (think about structures affecting our temperature regulation)

• Hypoglycemia due to liver dysfunction, insulin OD, or other etiology

• Cerebrovascular accident

• Drug intoxication (e.g. carbon monoxide, clonidine, beta-blocker or calcium channel blocker).

• Malnutrition

• Exposure

• Severe hypothyroid state (myxedema coma)

• The list goes on….

You recognize that the pitfalls of missing irreversible causes of altered mental status are broad. While you admit this person for further work-up and empirically treat septic shock you can administer something else…

Take the poll! We will reveal the answer and expand on the differential and key points with resources next week!

🔎ICYMI

Last week we brought you a ‘Happy Independence Day’ bundle of news:

• California sues DNP for using the term “Doctor” in clinic

• Got protection? Safe and effective sunscreen tips

• Locally acquired malaria cases in Florida and Texas

• Firework safety tips. You are welcome ER staff

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